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THEORETICAL  AND  PEACTICAL  TREATISE 


MIDWIFERY. 


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THEOEETICAL   AND   PRACTICAL   TREATISE 


MIDWIFERY, 


INCLUDING   THE 


DISEASES  OF  PEEGNANCY  AND  PARTURITION, 

AND 

THE  ATTENTIONS  REQUIRED  BY  THE  CHILD 
FROM    BIRTH    TO    THE    PERIOD    OF    WEANING. 

BY 

P.     C  A  Z  E  A  U  X, 

member  op  the  imperial  academy  of  medicine;  adjunct  professor  in  the 

facult?  of  medicine  of  paris;  chevalier  of  the  supplementary  number  of  the  order 

of  charles  iii;  member  of  the  surgical  society;  of  tpe  biological 

society;  op  the  medical  society  of  emulation;  op  the  anatomical  society; 

non-resident  associate  of  the  medical  society  of  bordeaux;  correspondent  of  the 

society  of    ACCOUCHEURS   OF   BERLIN  ;    PRESIDENT   OF   THE  MEDICAL  SOCIETY 
OF   THE   DEPARTMENT   OF   THE   SEINE. 

APOPTED    BY   THE    SUPERIOR    COUXCIL    OF    PUBLIC    IX3TRUCTI0X, 

AXD    PLACED,    BY    MINISTERIAL    DECISION,    IN    THE    RANK    OF    THE    CLASSICAL 

WORKS    DESIGNED    FOR    THE    USE    OF    MID^\'IFE    STUDENTS, 

IN    THE    MATERNITY    HOSPITAL    OF    PARIS. 

SECOND    AMERICAN, 
TRANSLATED   FROM   THE   FIFTH   FRENCH   EDITION, 

BY 

WM.    R.    BULLOCK,    M.D. 

Mitfcf  iiu  Juniirc^  an&  |0rtg  Illustrations. 


PHILADELPHIA: 
LINDSAY    &    BLAKISTON. 

1860. 


Entered,  according  to  Act  of  Congress,  in  the  year  1857, 

BY    LINDSAY    AND    BLAKISTON, 

In  the  Clerk's  Office  of  the  District  Court  for  the  Eastern  District  of  Pennsylyania. 


pniLA  delphia: 

C.    SHERMAN    &    SON,     PRINTEn:*, 

19  St.  James  Street. 


TO 


DOCTOR    HAYER, 

physician  ix  ordixary  to  the  empekor  ;   member  of  the  institute 

(academy  of  sciences); 

of  the  imperial  academy  of  medicine  ; 

president  of  the  imperial  council  of  hygiene;  president  and 

founder  of  the  biological  society;  physician  op 

the  hospital  of  la  charite;  commander 

of  the  legion  of  honor. 

Crstiranninl  nf  (0ratittih  aul  Mixihn, 

p.  CAZEAUX. 


TExlNSLATOR'S  PREFACE. 


The  second  edition  of  Cazeaux's  Midwifery  was  translated  by  Prof. 
Robert  P.  Thomas,  of  Philadelphia,  in  1850.  A  translation  of  the  fifth 
and  last  French  edition  is  now  offered  to  the  profession  in  this  country. 
The  entire  work  has  undergone  a  thorough  revision  by  the  author,  and 
has  received,  as  will  be  learned  from  his  preface,  alterations  and  additions 
which  make  it,  so  to  speak,  a  new  book. 

To  avoid  repetition,  the  reader  is  referred  to  the  author's  preface  and 
introduction,  where  are  fully  detailed  the  points  wherein  it  differs  from 
other  works,  and  from  previous  editions  of  the  same  work. 

The  translator  has  only  to  add,  that  he  has  endeavored  to  perform 
his  task  faithfully,  and  would  ask  for  the  work  the  candid  attention  to 
which  the  experience  and  position  of  the  author  entitle  it. 

WM.  R.  BULLOCK. 

W'lLMiXGTox,  Delaware, 
August  17th,  18.57. 


PREFACE. 


When  a  book  readies  its  fifth  edition,  a  preface  is  hardly  needed,  for, 
bj  that  time,  the  object  of  the  work  is  sufficiently  well  known.  The 
present  is  more  particularly  intended  for  the  use  of  students  of  medicine 
and  midwife-students,  although  general  practitioners  may  also,  perhaps, 
gain  something  by  its  perusal,  for  I  have  endeavored  to  make  it  a  con- 
densed summary  of  the  leading  principles  established  by  the  masters  of 
our  art,  and  for  that  purpose  have  drawn  from  all  the  works  published, 
down  to  the  present  day.  My  position  in  the  lying-in  hospitals  has 
enabled  me  to  test  the  value  of  the  doctrines  put  forth  by  former  authors  ; 
and  I  have  adopted  as  true  all  which  my  daily  experience  has  confirmed, 
and  have  rejected  unhesitatingly,  from  whatever  source  they  came,  all 
such  as  were  disproved  by  the  numerous  cases  brought  under  my  observa- 
tion, confining  myself  to  quoting  without  comment,  those  whose  value  I 
have  been  unable  to  determine. 

Although  this  work  resembles,  in  its  general  arrangement,  most  of 
those  published  on  the  same  subject  in  France,  it  differs  from  them 
essentially  in  the  main,  for  I  have  adopted  almost  wholly  the  views  of 
Professors  Naegele,  P.  Dubois,  and  Stoltz,  which  are  not  found  clearly 
expressed  in  any  of  our  classical  books.  I  have  also  extracted  freely 
from  the  learned  treatise  of  Professor  Velpeau,  whose  vast  erudition  has 
greatly  facilitated  my  bibliographical  researches ;  from  the  course  of  my 
former  teacher.  Professor  Moreau ;  from  the  excellent  articles  of  Desor- 
meaux,  of  Duges,  and  of  Guillemot ;  from  the  classical  works  of  England 
and  America,  such  as  those  of  Burns,  Campbell,  Merriman,  Ramsbotham, 
Dewees,  Meigs,  and  Rigby ;  and  from  the  treatises  of  Peu,  Delamotte, 
Levret,  Smellie,  Baudelocque,  Gardien,  and  Capuron.  I  have  also  con- 
sulted with  advantage,  the  manual  recently  published  by  my  friend,  Dr. 
Jacquemier,  also,  the  memoirs  of  Simpson,  Tyler  Smith,  Depaul, 
Devilliers,  &c.  Lastly,  it  will  be  seen  how  highly  I  value  the  eminently 
practical  writings  of  Madame  Lachapelle.     In   a  word,  I  have  selected 


X  P  11  E  F  A  C  E. 

from  all  sources,  whatever  bears  the  impress  of  truth.  In  the  sciences 
of  observation,  a  new  work  is  necessarily  enriched  by  the  labors  of  all 
antecedent  writers  ;  and  therefore,  its  greatest  merit  consists  in  collect- 
ing the  scattered  materials,  and  forming  out  of  them  a  body  of  doctrine, 
Avhich  it  illustrates  in  the  clearest  and  simplest  manner  possible.  Such 
is  the  end  I  have  endeavored  to  attain  ;  and  the  medical  public,  and 
students  especially,  must  judge  whether  I  have  succeeded  in  the  attempt. 

But  few  quotations  have  been  made,  though  their  number  might 
have  been  greatly  increased ;  but  I  wished  to  avoid  the  charge  made  by 
most  students  against  one  of  our  best  classical  works.  However,  I  have 
felt  bound  to  refer  to  living  authors  whenever  I  have  introduced  a  new 
theory,  or  any  particular  procedure,  which  emanated  from  them ;  and 
besides,  as  the  professorate  may  be  deemed  a  mode  of  publicity,  I  have 
respected  the  right  to  the  original  ideas  which  I  have  heard  emitted  by 
Professor  Dubois ;  and  his  name  will  be  found  scrupulously  associated 
with  all  the  opinions  emanating  from  him. 

Notwithstanding  a  spurious  copy  published  in  Belgium,  and  several 
translations  into  foreign  languages,  the  four  large  editions  of  the  work 
first  published,  were  rapidly  exhausted.  So  favorable  a  reception  made 
it  obligatory  upon  me  to  neglect  nothing  which  could  render  the  fifth 
edition  worthy  of  the  reputation  of  its  predecessors.  I  have  reviewed 
and  corrected  all  parts  of  it  with  scrupulous  care.  The  numerous  addi- 
tions made  in  1850,  have  been  retained;  of  these,  may  be  noted  the 
chapters  devoted  to  the  study  of  1.  The  secretory  apparatus  of  the 
genital  organs ;  2.  Of  the  structure  of  the  ovaries,  and  of  the  human 
ovum;  3.  Of  the  development  of  the  corpus  luteum ;  4.  Of  the  modifi- 
cations undergone  by  the  mucous  membrane  of  the  uterus  at  the  various 
epochs  of  the  life  of  the  female ;  5.  Of  the  decidua ;  6.  Of  menstrua- 
tion. 

Especially  has  the  pathology  of  the  pregnant  female  been  greatly 
extended ;  in  its  study  I  have  assumed,  as  a  starting-point,  the  modifica- 
tions produced  by  pregnancy  in  the  composition  of  the  blood.  One 
great  fact  appears  to  me  to  rule  the  pathology  of  the  puerperal  state, 
namely,  the  diminution  of  the  solid  constituents  of  the  blood.  This 
diminution,  which  may  be  regarded  as  physiological  (Researches  of 
Andral  and  Gavarret),  since  it  is  observed  in  almost  all  pregnant  women, 
is  very  frequently  so  great  as  to  becpme  pathological.  Different  morbid 
phenomena  are  then  produced,  according  to  the  element  which  is  princi- 
pally involved.  I  have  long  since  shown,  and  my  views  are  generally 
received,  that  chlorosis,  or  puerperal  hydmemia,  is  the  cause  of  most  of 
the  functional  disorders  which  had  previously  been  attributed  to  plethora. 
I  hope  to  show,  in  like  manner,  that  a  series  of  aifections  of  a  hitherto 


PREFACE.  XI 

unknown  origin,  should  now  be  referred  to  a  peculiar  alteration  of  the 
blood ;  an  alteration  consisting  chiefly  in  a  diminution  of  the  albumen, 
and  the  ordinary  symptom  of  which  is  albuminuria.  The  new  views  of 
the  physiology  of  pregnancy,  and  of  the  nature  of  puerperal  diseases 
which  I  have  endeavored  to  establish,  ought,  I  think,  to  modify  essen- 
tially the  treatment  of  these  affections.  To  this  point  I  invite  the  atten- 
tion of  practitioners. 

The  third  part  has  undergone  the  least  change ;  I  ought,  however,  to 
mention  as  entirely  new,  the  chapters  on  the  effect  of  labor  upon  the 
mother  and  child,  especially  that  devoted  to  the  apparent  death  of  the 
new-born  infant. 

In  studying  the  accidents  which  may  complicate  labor,  I  have  availed 
myself  of  all  works  published  of  latter  time,  and  there  will,  accordingly, 
be  found  a  number  of  new  considerations  in  the  accounts  of  hemorrhage 
and  puerperal  convulsions,  and  of  the  indications  to  which  they  give  rise. 

A  sixth  part  has  been  added,  devoted  exclusively  to  the  hygiene  of 
children,  from  birth  to  the  period  of  weaning. 

Lastly,  at  the  end  of  the  work,  will  be  found  an  appreciation  of  the 
use  of  anaesthetics  in  obstetrical  practice. 

It  is  impossible  to  point  out  all  the  less  important  additions  scattered 
through  the  work ;  but  they  are  so  numerous  that  the  fifth  edition  con- 
tains double  the  amount  of  matter  in  the  first.  It  is,  therefore,  so  to 
speak,  a  new  book,  in  which,  I  trust,  will  be  found  collected  all  our  know- 
ledge in  relation  to  the  obstetric  art. 

In  conclusion,  I  may  be  permitted  to  express  publicly,  my  thanks  to 
M.  Coste,  for  his  great  kindness  in  allowing  me  to  study  his  beautiful 
collection  in  the  College  of  France,  and  to  borrow  several  figures  from 
the  magnificent  work  which  he  is  now  publishing. 

November,  1855. 


TABLE   OF  CONTENTS. 


Preface  to  the  American  Edition, 

Preface, 

Introduction,         .  .  . 


PART  I. 

OF  THE  FEMALE  ORGANS  OF  GENERATION. 

CHAPTER  I. 


OF   THE   PELVIS. 


ARTICLE  I. 


Of  the  bones  of  the  pelvis, 

The  sacrum,     . 

Coccyx, 

Coxal  bones  or  ossa  innominata. 


Articulations  of  the  pelvis. 
Pubic  symphysis, 
Sacro-iliac  symphysis, 
Sacro-coccygeal  symphysis, 
Sacro-vertebral  articulation, 


ARTICLE  IL 


ARTICLE  IIL 


Of  the  pelvis  in  general. 

External  surface,    . 

Internal  surface, 

Superior  strait, 

Inferior  strait,  . 

Cavity  of  the  pelvis, 

Base  of  the  pelvis, 

Differences  of  the  pelvis,  according  to 

Uses  of  the  pelvis. 


age  and  sex, 


PAOE 
V 

vii 
xxxi 


18 
18 
20 
20 


22 
22 
23 
24 
25 


26 
26 
27 
29 
31 
33 
35 
35 
36 


XIV 


CONTENTS. 


ARTICLE  IV. 
01  the  pelvis  covered  by  the  soft  parts, 


36 


CHAPTER  II. 

OF   THE   ORGANS    OF    GENERATION. 


SECTION    I. 


Of  the  external  parts  of  generation, 


ARTICLE  I. 


ARTICLE  IL 


The  mens  veneris, 


The  vulva, 

Labia  majora. 

Labia  minora,  . 

Clitoris, 

Vestibule, 

Urethra, 

Hymen, 

Carunculte  myrtiformes, 

Fossa  navicularis. 


ARTICLE  in. 

Secretory  apparatus  of  the  external  genital  organs, 
Class  first — Sebaceous  and  plliferous  follicles. 
Class  second — Muciparous  organs. 
Isolated  or  agminated  muciparous  follicles,     . 
Vulvo-vaginal  gland,  .... 


ARTICLE  IV. 


The  perineum. 


SECTION    IL 


Of  the  internal  parts  of  generation, 


The  vagina,     . 


The  uterus, 

Of  the  neck  of  the  uterus, 
Internal  surface  of  the  uterus, 
Structure  of  the  uterus, 
Ligaments  of  the  uterus,   . 
Bodies  of  RosenmuUer, 


ARTICLE  I. 


ARTICLE  II. 


39 


39 


39 
40 
41 

42 
43 

43 
43 
45 
45 


45 
45 
45 
45 
46 


49 


49 


49 


53 
53 

68 
59 
62 
63 


CONTENTS. 


XV 


Of  the  Fallopian  tubes, 


ARTICLE  III. 


ARTICLE  IV. 


Of  the  ovaries,  .  .  .  .  . 

Structure  of  the  ovaries,    .... 
Of  the  ovarian  vesicles,  .  .  .  . 

Of  the  unfecundated  human  ovule, 

CHAPTER  III. 
ARTICLE  I. 

Modifications  undergone  by  the  ovarian  vesicles, 

Concomitant  changes  of  the  uterus, 

The  corpus  luteum,     .  .  .  .  . 


ARTICLE  II. 


••t? 


Of  menstruation, 


65 


67 
69 
69 
10 


13 

74 
76 


82 


PAET  11. 

OF  GENERATION,     .... 

BOOK  I. 

OF  CONCEPTION,        .... 

BOOK  II. 

OF  GESTATION,         .... 

CHAPTER  I. 

SIMPLE   UTERINE    PREGNANCY. 

ARTICLE  I. 
Anatomical  changes,  ........ 

Changes  in  the  body  of  the  womb. — Volume,  form,  situation,  direction,  thickness 
of  its  walls,  density,  ...  .... 

Alodifications  of  the  neck  of  the  womb,      ...... 

Modifications  of  the  texture  and  properties  of  the  womb, 

Texture,     ••••...... 

Properties. — Organic  contractility,  contractility  of  the  tissue. 

Relations  of  the  uterus  during  pregnancy,  .  .  .  .  . 


ARTICLE  II. 


95 


95 


101 


Changes  in  the  neighboring  parts, 
Changes  in  the  breasts, 


102 

102 
108 
113 
113 
121 
125 


126 
129 


XVI 


CONTENTS. 


ARTICLE  III. 

,  enlargement  of  the  abdomen,  changes 


1,S0 


130 

.   140 

141 

.   143 

146 

.   147 

150 

.   150 

151 

.   166 

165 

Diagnosis  of  pregnancy,     . 

Rational  signs — Suppression  of  the  menses 

in  the  breasts,  pulse,  alterations  of  the  urine, 
Sensible  si^ns. 
Vaginal  touch, 
Abdominal  palpation, 
Active  m>)vements  of  the  child, 
Passive  movements,  ballottcment, 
Anal  examination. 

Auscultation  as  applied  to  pregnancy, 
Sound  of  the  foetal  heart, 
Bruit  de  soufflet,    . 
Table  exhibiting  the  signs  of  pregnancy, 


BOOK  III. 

OF  THE  HUMAN  OVUM,  AFTER  FECUNDATION,    .  .      168 

CHAPTER  I. 

DEVELOPMENT  OP  THE  HUMAN  OVUM. 

ARTICLE  I. 

Changes  of  the  ovum  in  the  tube,  ......      169 

ARTICLE  IL 

Changes  of  the  ovum  from  its  arrival  in  the  womb  until  after  the  development  of 

the  allantoid,  ........  171 

CHAPTER  II. 

OF    THE    DECIDUA,      .  .  .  .177 

Old  theory,  .........      177 

New  theory — The  decidua  is  simply  the  mucous  membrane  of  the  uterus,      .  180 

CHAPTER  III. 

CHANGES  OF  THE  OVUM  FKOM  THE  DEVELOPMENT  OF  THE  ALLANTOID 
UNTIL  FULL  TERM. 


ARTICLE  I. 


Of  the  fcetal  appendages, 
Allantoid  vesicle, 
Umbilical  vesicle. 
Amnion, 
Amniotic  (luid, 
Chorion, 


189 
189 
190 
191 
192 
194 


CONTENTS.  XVll 


ARTICLE  II. 


Of  the  organs  of  connection,  .......      195 

Placenta,  .........  195 

Umbilical  cord,      .........      207 

CHAPTER  IV. 

OF  THE  FCETUS. 

ARTICLE  I. 
Dimensions  and  weight  of  the  fostus  at  the  different  periods  of  intra-utevine  life,      212 

ARTICLE  II. 

Head  of  the  child  at  term,  .  .  .  .  .  .  .218 

Diameters  of  the  head,  .......  220 

ARTICLE  III. 

Position  and  attitude  of  the  foetus,  ......      223 

ARTICLE  IV. 

Functions  of  the  foetus,  .......  226 

Nutrition,  .........  226 

Respiration,      .  •  .  .  .  '  .  .  .  .  280 

Secretions,  .........  232 

Circulation,      .........  233 

Changes  effected  in  the  circulation  after  birth,      .....  235 

BOOK  IV. 

ABNORMAL   PREGNANCIES,  .  .  .238 

CHAPTER   I. 

TWIN    PREGNANCY,  .  .  .  238 

CHAPTER  II. 

EXTRA  UTERINE  PREGNANCY,   .      .      .244 

BOOK  V. 

PATHOLOGY   OF   GESTATION,  .  .  261 

CHAPTER  I. 

DISEASES  OF  THE  PREGNANT  WOMAN — GENERAL  CONSIDERATIONS. 

ARTICLE  L 
Lesions  of  digestion,  ........      263 


XVlll 


CONTENTS. 


Anorexia,  ......... 

Pica  or  nialacia,     ......... 

Vomiting,         ......... 

Discussion  in  regard  to  the  producing  of  abortion   in  grave  cases   of  vomiting 
during  pregnancy,    ........ 

Constipation,  ......... 


Lesions  of  respiration, 


ARTICLE  IL 


ARTICLE  III. 


Lesions  of  the  circulation — Alterations  of  the  blood — Plethora  and   lijdrajmia 
— Varices  and  hemorrhoids,  ...... 

ARTICLE  IV. 

Lesions  of  the  secretions  and  excretions,  . 

Ptyalism,  .  . 

Secretion  and  excretion  of  urine,  . 

Albuminuria,    ...... 

Leucorrhoea,  ..... 

Dropsy  of  the  cellular  tissue,  .... 

Ascites,      ...... 

Dropsy  of  the  amnion,  .... 

Hydrorrhoea,  .  .... 

ARTICLE  V. 

Lesions  of  locomotion,  ....... 

Relaxation  of  the  pelvic  articulations,       ...... 

Inflammation  of  the  pelvic  articulations,        ..... 

Disposition  to  falling,         ....  .... 

ARTICLE  VL 

Lesions  of  innervation,  ....... 

Lesions  of  the  sensorial,  affective,  and   intellectual    faculties — Vertigo,   giddi- 
ness, syncope,  ........ 

Pruritus  of  the  vulva — Itching  of  the  skin,  ..... 

ARTICLE  Vn. 


Abdominal,  lumbar,  and  inguinal  pains, 
Uterine  pains,  .... 


26.3 
264 
265 

271 
274 


274 


275 


286 
286 
287 
288 
296 
297 
299 
302 
306 


308 
308 
310 
310 


311 

311 
313 


314 

315 


CHAPTER  II. 

DISPLACEMENTS    OF    THE    UTEKUS. 
ARTICLE  I. 


Prolapsus  uteri. 


317 


CONTENTS. 


XIX 


Faulty  directions  of  the  uterus, 
Retroversion,  .  . 

Anteversion,     . 


Uterine  obliquity, 
Lateral  obliquity, 


Causes, 
Symptoms, 

Diagnosis, . 

Prognosis, 

Delivery  of  the  after-birth. 

Treatment, 


ARTICLE  n. 

ARTICLE  IIL 
CHAPTER  IIL 

OF   ABORTION. 
ARTICLE  L 

ARTICLE  II. 
ARTICLE  IIL 
ARTICLE  IV. 

ARTICLE  V. 
ARTICLE  VL 


CHAPTER  IV. 

OF   DISEASES    OCCURRING   DURING   PREGNANCY. 


Epidemic  diseases,  .  . 

Sporadic  diseases, 

Chronic  diseases,    . 

Surgical  affections. 

Ulceration  of  the  neck  of  the  uterus, 


PART  III. 

OF  LABOR  IN  GENERAL, 

BOOK  I. 


321 
321 

327 


329 
329 


330 


336 


340 


344 


345 


349 


356 
358 
360 
365 
366 


Of  premature  labor, 
Of  retarded  labor, 


371 


371 
374 


XX 


CONTENTS. 


BOOK  II. 

OF  NATURAL  LABOR  AT  TERM, 


3Y6 


CHAPTER  I. 

CAUSES    OF   LABOR, 


3Y6 


CHAPTER  II. 


PHYSIOLOGICAL   PHENOMENA   OF    LABOR. 


Precursory  signs,    .  .  .  . 

First  stage  of  labor, 

Second  stage,  .  .  .  . 

The  pain,  or  contraction, 

Dilatation  of  the  os  uteri,  . 

Of  the  glairy  discharges. 

Bag  of  waters,         .... 

Of  the  duration  of  labor, 

Effect  of  labor  upon  the  mother  and  child, 


.   385 

386 

.   387 

388 

.   392 

393 

.   394 

396 

.   399 

CHAPTER  III. 

OF  THE   MECHANICAL   PHENOMENA    OF    LABOR. 

ARTICLE  I. 

Of  the  presentations  and  positions,  ......      402 

Table  of  presentations  and  positions,  ......  404 

Classification  of  Naegele,  Stoltz,  and  P.  Dubois,    .....      409 

ARTICLE  II. 

Of  the  vertex  presentation,    ........      412 

Causes — Diagnosis — Mechanism — ^Prognosis,  ....  413 

ARTICLE  III. 

Face  presentation,  ........      431 

Causes — Diagnosis — Mechanism — Prognosis,  ....  432 

ARTICLE  IV. 

Presentations  of  the  pelvic  extremity,        ......      444 

Causes — Diagnosis — Mechanism — Prognosis,  ....  445 

ARTICLE  V. 

Presentations  of  the  trunk,  .......      456 

Causes — Diagnosis — Mechanism — Spontaneous  version — Spontaneous  evolution 

— Prognosis,       .........      457 


CONTENTS.  XXI 

CHAPTER  IV. 

OF  THE   NECESSARY  ATTENTIONS   TO  THE  WOMAN   DURING  AND   AFTER 

LABOR. 

ARTICLE  I. 
Of  the  attentions  to  the  woman  during  labor,         .....      467 

ARTICLE  IL 
Of  the  attentions  to  the  child  during  labor,  .....      477 

ARTICLE  in. 
Regimen  of  women  in  labor,  .......      482 

ARTICLE  IV. 

Of  the  attentions  immediately  after  labor,  .  .  .  .  .      484 

ARTICLE  V. 

Phenomena  of  the  lying-in  state,    .......      485 

Changes  undergone  by  the  generative  organs  after  labor,        .  .  .  487 

Of  after-pains,        .  .  .  .  .  .  .  .  .491 

Lochia,  .........  493 

Milk-fever, 497 

ARTICLE  VL 
Attentions  to  the  lying-in  woman,  ......      500 

CHAPTER  V. 

OF  THE  ATTENTIONS  TO  THE  CHILD  IMMEDIATELY  AFTER  ITS  BIRTH. 

Debility  or  disease  of  the  child — Apparent  death  of  the  child — Debility  of  new- 
born children,     .........      504 


PART  lY. 

OF  DYSTOCIA,        .  .  .  .517 

FIRST  DIVISION. 

CAUSESOFDYSTOCIA,        .  .  .      517 

BOOK  I. 

OF  LABORS  RENDERED  DIFFICULT,  IMPOSSIBLE,  OR  DANGEROUS,  BY 
DEFICIENT  OR  EXCESSIVE  ACTION  OF  THE  UTERINE  FORCES. 

CHAPTER  I. 

Extreme  slowness  of  the  labor,  .  .  .  .  .  .  518 

Slowness  or  feebleness  of  the  contractions,  .....      520 


Xxil  CONTENTS. 

Relaxation  or  suspension  of  the  pains,  .....  523 

Irregularity  of  the  pains,    ........      524 

Of  Ergot, 526 

CHAPTER  II. 

OF  TOO   RAPID   LABORS,  •  •  .530 

BOOK  II. 

OF  LABORS  RENDERED  DIFFICULT,  IMPOSSIBLE,  OR  DANGEROUS,  BY 
OBSTACLES  OPPOSING  THE  READY  EXPULSION  OF  THE  FCETUS. 

CHAPTER  I. 

DEFORMITIES    OF   THE    PELVIS. 

Of  the  pelvis  deformed  by  excess  of  amplitude,     .....      533 
Of  the  pelvis  deformed  by  excess  of  retraction,  ....  635 

ARTICLE  I. 
Pathological  anatomy,       ........      536 

ARTICLE  II. 
Causes,       ..........     546 

ARTICLE  III. 
Effect  of  contractions  of  the  pelvis  upon  pregnancy  and  parturition, .  .  557 

ARTICLE  IV. 
Diagnosis,  .........      564 

ARTICLE  V. 
Indications  presented  by  deformities  of  the  pelvis,      ....  582 

CHAPTER  II. 

MALFORMATIONS   OF  THE   VULVA   AND   VAGINA. 

Adhesions  of  the  external  and  internal  labia,         .....  588 

Persistence  of  the  hymen,         .......  589 

Smallness  and  rigidity  of  the  vulva,  .  .  .  .  •  •  589 

Resistance  of  the  perineum,     .......  591 

Malformations  of  the  vagina,         .  .  " .  .  •  •  •  592 

Inversion  of  the  vagina,  .......  695 


CONTENTS.  XXIU 

CHAPTER  III. 

TUMORS   IN    THE    EXCAVATION. 

ARTICLE  I. 

Tumors  developed  in  the  botiy  walls,         ......  596 

Exostosis,         .            .            .            .            .             .            .           ■  .            .  596 

Osteo-sarcoma,        .  .  .  .  .  .  .  .  .597 

Deformed  callus,           .*....           ^.            .  597 

ARTICLE  II. 

Tumors  appertaining  to  the  soft  parts,       ......  598 

ffidema  of  the  labia  externa,    .......  598 

Sanguineous  tumors,  or  thrombus  of  the  vulva  and  vagina,           .             .             .  598 

Thrombus  of  the  lips  of  the  cervix  uteri,         .....  606 

Various  other  tumors,         .  .  .  .  .  .  ,  .607 

Tumors  appertaining  to  the  neck  or  body  of  the  uterus,          .             .             .  G07 

ARTICLE  III. 

Tumors  in  the  adjacent  parts,         .             .             .             .             .             .             .  612 

Tumors  of  the  ovary,   .             .             .             .             .             .             .             .  (j  1 2 

Tumors  of  the  Fallopian  tube,       .......  615 

Tumors  of  the  rectum,              .......  615 

Tumors  of  the  bladder,       ........  616 

Tumors  developed  in  the  cellular  tissues  of  the  pelvis,             .             .             .  G17 
Hernial  tumors,      .             .             .             .             .             .             .             .             .618 

CHAPTER  IV. 

OBSTACLES  DEPENDENT  ON  THE  NECK  OR  BODY  OP  THE  WOMB. 

ARTICLE  I. 

Rigidity  of  the  cervix,              .......  621 

Spasmodic  contraction  of  the  cervix,          ......  622 

Obliquity  of  the  cervix,             .......  624 

Agglutination  of  the  external  orifice,         ......  626 

Tumefaction  and  elongation  of  the  anterior  lip,            .             .             .             ,  627 

Abscess  in  the  lips  of  the  cervix,  .             .             .             .             .             .             ,  628 

Induration  with  hypertrophy  of  the  cervix,      .....  628 

Cancer  of  the  neck,             ........  629 

Complete  obliteration  of  the  neck,       ......  630 

ARTICLE  11. 

Obstacles  dependent  on  the  body  of  the  womb,     .....  631 

Anterior  obliquity,        .             .             .             .             .             .             .             .  631 

Posterior  obliquity,  .  .  .  .  .  ,  ,  .632 

Lateral  obliquity.          .             ,             .             ,             ,             .             .             ,  635 


Xxiv  CONTENTS. 

Hernia  of  the  womb,  ........      637 

Prolapsus  uteri,  .......#  638 

CHAPTER  V. 

OBSTACLES   DEPENDENT    ON   THE   FCETUS    OR    ITS   APPENDAGES. 
ARTICLE  I. 


639 
642 


Diseases  of  the  foetus — Hydrocephalus,     ..... 

Hydrothorax  and  ascites,         ....... 

Deformities  of  the  foetus — Emphysematous  condition  of  the  foetus,  .  .      643 

Tumors  of  the  foetus,   ........  643 

Anchylosis  of  the  foetal  articulations,         ......      644 

ARTICLE  II. 

Excess  of  volume  of  the  foetus,  ......  644 

Monstrosities,  .........  645 

Multiple  and  adherent  foetuses,  ......  645 

Multiple  and  independent  foetuses,  ......  647 

ARTICLE  IIL 
Prolapsus  or  falling  of  the  cord,  ......  652 

ARTICLE  IV. 
Shortness  of  the  cord,         ........      657 

ARTICLE  V. 

Malpositions  of  the  child,         .......  661 

Inclined  vertex  positions,  ........  662 

Anomalies  in  the  mechanism  of  natural  labor,  ....  663 

Inclined  breech  positions,  ........  665 

Face  positions,  ........  665 

Trunk  positions,     .........  669 

Complicated  positions,  .......  670 

BOOK  III. 

OF  THE  DISEASES  OR  ACCIDENTS  THAT  MAY  COMPLICATE  LABOR, 
AND  REQUIRE  THE  INTERVENTION  OF  ART. 

CHAPTER  I. 

OF  PUERPERAL  HEMORRHAGE. 
ARTICLE  I. 

Of  the  causes  of  uterine  hemorrhage — Predisposing  causes,         .  .  .  676 

Determining  causes,     ....••••  680 

Special  causes,       ....•••••  "°^ 

Insertion  of  the  placenta  upon  the  lower  segment  of  the  uterus,  .  .  682 

Rupture  of  the  cord  or  of  one  of  its  vessels,  .....  685 


CONTENTS.  XXT 

Shortness  of  the  cord, ........  688 

Rapid  contraction  of  the  uterus,    .......  690 

ARTICLE  11. 

Svmptoms  of  uterine  hemorrhage,       .            .            .            .            .            •  690 
External  discharge,            .             .             .             .             .             •             •             .691 

Internal  discharge,       ........  691 

ARTICLE  III. 

Diagnosis,              .........  692 

ARTICLE  IV. 

Prognosis, ..........  69Y 

ARTICLE  V. 

Treatment,       .........  701 

A  synoptical  table  of  the  treatment,           ......  711 

CHAPTER  II. 

OF    PUERPEKAL    CONVULSIONS. 

Causes,            .........  715 

Symptoms,  .  .  .  .  .  .  .  .  .720 

Terminations, .           ,.             .             .             .             .             .             .             .  725 

Diagnosis, .            .            .        '  ;            .            .            .            .            .            .  728 

Prognosis,        .........  729 

Pathological  anatomy,        ........  732 

Nature  of  eclampsia,  ........  733 

Treatment,              .........  736 

CHAPTER  III. 

OF   RUPTURES    OF   THE    UTERUS. 

Causes,             ........  748 

Symptoms,              .........  752 

Prognosis  and  termination,      .......  754 

Pathological  anatomy,        ........  756 

Treatment,       .........  758 

Ruptures  of  the  vagina,      ........  760 

CHAPTER  IV. 

OF    RHEUMATISM   OF   THE    UTERUS,        .             .  762 

CHAPTER  V. 

OF   CERTAIN   DISEASES   THAT   MAY   COMPLICATE  LABOR,  766 

SECOND   DIVISION. 

OBSTETRICAL    OPERATIONS,     .             .  769 


XXvi  CONTENTS. 

■  CHAPTER  I. 

OF   VERSION. 

ARTICLE  I. 
Cephalic  version,  ....•••••       '72 

ARTICLE  II. 

Pelvic  version,              .             .             ......  776 

General  rules  of  the  operation,       .......  777 

Difficulties  that  may  be  met  with  in  its  performance,                .             .             .  783 

Appreciation  of  version.        ........  789 

Version  in  vertex  presentations,           ....              .             .  7i)0 

Version  in  face  presentations,        .  .  .  •  .  .  .791 

Version  in  breech  presentations,           ......  791 

Version  in  trunk  presentations,    .              ......  792 

Trunk  presentations  with  escape  of  the  arm,               ....  794 

CHAPTER  II. 

OF   THE    FORCEPS. 

ARTICLE  L 
Preliminary  precautions,    ........      799 

ARTICLE  11. 
General  rules  for  the  application  of  forceps,  .....      801 

ARTICLE  IIL 

Special  rules  for  the  application  of  forceps,  .....  807 

Application  in  vertex  presentations,     ......  807 

Application  in  face  presentations,  .......  815 

Application  of  the  forceps  on  the  retained  head,  after  delivery  of  the  body,  .  818 

General  considerations  on  its  employment,  .....  820 

CHAPTER  III. 

OF   THE   LEVER   OR    VECTIS,         .  .  .829 

CHAPTER  IV. 

OF  PREMATURE   ARTIFICIAL  DELIVERY. 

ARTICLE  I. 

Cases  requiring  premature  artificial  delivery,         .....      8.12 

ARTICLE  IL 
Operative  procedures,        ........      838 


CONTENTS. 


XXVll 


CHAPTER  V. 

OF  THE  PRODUCTION  OF  ABORTION, 


846 


CHAPTER  VI. 

OF    THE   EFFECT   OF   BLEEDING   AND    A   DEBILITATING    REGIMEN 

UPON   THE   DEVELOPMENT    OF    THE    CHILD,  .  .      850 

CHAPTER  VII. 

OF    SYMPHYSEOTOMY,  .  .  .  .853 


CHAPTER  VIII. 

OF    THE    CiESAREAN    OPERATION, 

CHAPTER  IX. 

OF   EMBRYOTOMY,      . 


859 


866 


PART  Y. 


OF  THE  DELIVERY  OF  THE  AFTER-BIRTH. 


Of  the  natural  delivery,     . 


ARTICLE  I. 


ARTICLE  II. 


Of  the  artificial  delivery,    .... 

Inertia  of  the  womb,     .... 

Excessive  volume  of  the  placenta, 

Weakness  of  the  cord. 

Irregular  or  spasmodic  contractions  of  the  uterus, 

Abnormal  adhesions  of  the  placenta,  . 

Of  partial  or  complete  retention  of  the  placenta,  . 

Of  putrid  absorption  of  the  placenta, 

Tardy  expulsion  of  the  placenta,    . 

Complete  absorption  of  the  placenta,  . 

ARTICLE  III. 

Of  hemorrhage  before,  during,  or  after  the  delivery  of  the  placenta, 
Causes  of  hemorrhage, — inertia,  .... 

Symptoms,  ....... 

Diagnosis,         ..;.... 

Prognosis,  .  .  .  .  . 

Preventive  treatment,  ...... 


877 


883 
884 
885 
885 
886 
890 
894 
895 
896 
897 


899 
899 
900 
902 
903 
903 


xxvni 


CONTENTS. 


Curative  treatment,  .... 

Use  of  the  tampon,      ..... 

Compression  of  the  uterus, 

Compression  of  the  aorta — Discussion, 

Ergot,         ...... 

Transfusion,      ...... 

Inertia  and  secondary  hemorrhage. 

Active  and  passive  hemorrhage,  but  without  inertia  of  the  walls, 

Hemorrhage  from  the  umbilical  cord, 

Inversion  of  the  womb,  .... 

Rupture  of  the  uterus,         .... 


905 
906 
906 
907 
909 
910 
912 
913 
915 
916 
920 


PART  YI. 

OF  THE  HYGIENE  OF  CHILDREN,  . 


922 


BOOK  I. 

OF  THE  ALIMENTATION  OF  CHILDREN, 


922 


CHAPTER  I. 

OF    LACTATION, 

CHAPTER  II. 

OF   NURSING. 

ARTICLE  I. 

Of  nursing  by  the  mother,  .... 

Precautions  to  be  observed  by  women  who  intend  nursing, 
Rules  to  be  observed  whilst  nursing, 


Of  weaning, 


ARTICLE  II. 


ARTICLE  IIL 


Of  the  regimen  of  mothers,  whilst  nursing,  .... 

ARTICLE  IV. 

Of  obstacles  to  nursing,        ....  .  . 

Of  erosions  and  excoriations,  of  chaps,  fissures,  and  cracks  of  the  nipple, 
Accidents  which  may  obstruct  nursing  by  the  mother, 
Variations  in  the  quantity  of  milk — Agalactia — Galactorrhoea,    . 
Health  of  the  mother,  ....... 

Alterations  in  the  quality  of  the  milk,        ..... 


923 


930 
931 
932 


940 


943 


944 
945 
950 
950 
951 
952 


CONTENTS.  XXIX 

ARTICLE  V. 
Of  mixed  nursing,       ........  954 

ARTICLE  VL 

Of  wet  nursing,      .........      956 

Of  the  choice  of  a  nurse,  .  .....  957 

How  to  regulate  nui-sing  by  wet  nurses,     .  .  .  .  .  .961 

Of  the  regimen  of  wet  nurses,  ......  962 

ARTICLE  VIL 
Of  nursing  by  a  female  animal,     .......      963 

ARTICLE  VIII. 
Of  artificial  nursing,    ........  964 

CHAPTER  III. 

GENERAL   CONSIDERATIONS    RESPECTING    CERTAIN   POINTS   RELATING 
TO    THE    HYGIENE    OF    CHILDREN. 

Clothing,    ..........      966 

Washing — Bathing — Attention  to  cleanliness,  ....  966 

Aeration — Promenades,     .  .  .  .  .  .  ,  .967 

Sleep, -     .  968 


APPENDIX. 

On  the  use  of  anaesthetics  in  obstetrical  practice,  ....      969 


INTRODUCTION. 


Labor  is  that  function  whicli  consists  in  the  natural  or  artificial  expulsion  of 
a  viable  foetus  through  the  natural  parts  of  generation. 

The  term  expulsion  evidently  comprises  three  secondary  Ideas  :  namely,  that 
of  a  body  which  expels,  that  of  a  body  which  is  expelled,  and  that  of  an  opening 
or  canal  through  which  this  expulsion  takes  place.  Hence,  we  may  foresee  to 
what  an  extent  the  structure,  the  position,  the  dimensions,  and  the  relations  of 
these  different  parts,  must  influence  the  degree  of  facility  with  which  this  func- 
tion is  accomplished;  as  also,  how  greatly  a  knowledge  of  this  structure,  and 
these  relations,  must  facilitate  a  comprehension  of  the  forces  brought  into  play 
by  nature  for  the  accomplishment  of  her  work,  and  of  the  mechanism  whereby 
the  expulsion  is  effected. 

Consequently,  the  first  part  of  this  book  will  be  devoted  to  a  description  of  the 
generative  organs  of  the  female;  in  which,  we  shall  first  study  the  pelvis,  and, 
after  having  described  each  of  its  constituent  parts,  shall  consider  it  as  a  whole ; 
carefully  pointing  out  the  peculiarities  that  its  form,  direction,  or  dimensions 
may  offer ;  and  then  passing  immediately  to  an  anatomical  description  of  the  ex- 
ternal and  internal  organs  of  generation.  Most  of  the  leading  authors,  after 
describing  all  these  parts  in  their  normal  condition,  study  their  vices  of  confor- 
mation, position,  &c. ;  but  as  this  method  appears  objectionable,  we  defer  the 
consideration  of  all  those  anomalies,  that  are  justly  viewed  as  causes  of  dystocia, 
to  the  division  in  which  we  treat  of  difl&cult  labors.  For,  by  thus  bringing  to- 
gether the  causes  and  the  effects  they  produce,  we  hope  to  avoid  unnecessary 
repetition,  to  aid  the  memories  of  students,  and  at  the  same  time  to  demonstrate 
more  fully  the  importance  of  a  knowledge  of  these  anomalies. 

The  physiology  of  the  organs  of  generation  is  so  intimately  connected  with 
their  anatomical  arrangement,  as  to  make  it  impossible  to  describe  them  fully 
without  treating  at  the  same  time  of  their  functions.  The  phenomena  which 
they  present  at  certain  periods  are,  beside,  very  properly  considered  as  the  pre- 
ludes of  generation,  rendering  a  previous  study  of  them  indispensable  to  all  who 
would  understand  the  modifications  which  these  organs  undergo  during  the  puer- 
peral state. 

After  having  studied  the  organs  of  the  female  in  the  non-gravid  condition,  we 
shall  examine  the  numerous  and  important  modifications  they  undergo   during 


XXXll  INTRODUCTION. 

gestation ;  and  from  this  examination  we  shall  deduce  the  signs  of  pregnancy, 
and  the  therapeutical  measures  that  may  be  employed  for  the  particular  symp- 
toms to  which  they  give  rise.  The  second  part  will  be  concluded  by  studying 
the  primary  cause  of  all  these  modifications ;  that  is,  the  fcjetus  and  its  appen- 
dages, which  will  be  severally  considered  at  the  diiferent  stages  of  their  develop- 
ment. 

These  preliminary  points  having  been  acquired,  we  shall  then  be  prepared  to 
describe  the  parturition,  in  which  two  orders  of  phenomena  will  be  distinguished  : 
the  one,  being  purely  physiological,  is  an  expression  of  the  vital  actions  brought 
into  play  for  the  expulsion  of  the  foetus;  while  the  other  is  entirely  mechanical, 
and  constitutes  the  mechanism  whereby  this  expulsion  is  effected.  We  have 
devoted  much  space  to  the  description,  and  more  particularly  to  an  explanation 
of  the  mechanism  of  natural  labor;  and  we  hope  to  have  succeeded  in  explain- 
ing certain  facts  connected  therewith,  that  have  hitherto  only  been  pointed  out. 

In  the  fourth  part,  which  is  devoted  to  the  management  of  difficult  labors,  we 
shall  enumerate  in  detail  the  caUses  of  dystocia,  the  mode  of  action  of  each,  the 
signs  by  which  their  existence  may  be  recognized,  the  indications  for  treatment 
they  present,  and  the  means  of  remedying  them. 

In  the  fifth  part,  we  shall  study  the  delivery  of  the  after-birth.  Like  the 
parturition,  this  is  usually  simple  and  natural,  but  it  may  be  complicated  by 
numerous  difficulties  and  accidents  that  require  the  intervention  of  our  art;  and 
hence,  in  order  to  fill  up  properly  the  design  we  have  traced  out,  it  will  be  neces- 
sary to  treat  in  detail  of  the  natural,  the  artificial,  and  the  complicated  delivery 
of  the  after-birth. 

Finally,  in  the  sixth  and  last  part,  we  have  endeavored  to  give,  in  as  condensed 
a  form  as  possible,  such  principles  of  hygiene  as  are  applicable  to  the  physical 
education  of  children  from  birth  to  the  time  of  weaning. 


TREATISE  ON  MIDWIFERY. 


PAET    I. 

OF  THE  FEMALE  ORGANS  OF  GENERATION. 

The  female  organs  subservient  to  generation  are  :  the  ovaries,  the  principal 
function  of  which  is  the  secretion  of  the  ovule  or  female  germ ;  the  Fallopian 
tubes,  designed  to  receive  the  ovule,  and  conduct  it  into  the  cavity  of  the  uterus ; 
the  uterus,  a  kind  of  receptacle,  whose  office  it  is  to  contain  the  fecundated 
germ  during  its  period  of  development,  and  to  expel  it  immediately  afterward 
finally,  the  vagina,  a  membranous  canal  extending  from  the  neck  of  the  uterus 
to  the  external  genital  parts.  Most  of  these  organs  are  situated  within  a  large 
cavity,  the  walls  of  which  are  composed  of  bones  and  soft  parts ;  the  cavity  is 
termed  the  cavity  of  the  pelvis,  ox  pelvic  cavity.  On  account  of  the  importance 
of  the  pelvis  as  an  organ  both  of  protection  and  transmission,  we  shall,  with  it, 
begin  the  study  of  the  organs  of  generation. 


CHAPTER  I. 

OF   THE    PELVIS. 

The  basin,  in  Latin,  pelvis,  is  a  large,  irregular,  bony  cavity,  a  sort  of  curved 
canal,  which  terminates  the  trunk  inferiorly,  and  sustains  it  by  its  posterior  part. 
It  is  placed  directly  upon  the  lower  extremities,  which  afford  it  points  of  sup- 
port, and  to  which,  in  the  erect  posture,  it  transmits  the  weight  of  the  upper 
portions  of  the  body.  Its  position  in  an  adult  of  ordinary  stature  is,  in  general, 
about  the  central  part  of  the  whole  trunk.  In  the  infant  at  term,  and  more 
especially  during  the  intra-uterine  life,  it  is  much  below  this  point ;  and  at  a  cer- 
tain period  of  foetal  existence,  when  the  lower  extremities  resemble  as  yet  but 

2 


18  FEMALE  ORGANS  OF  GENERATION. 

little  nipples,  it  even  occupies  the  inferior  portion  of  the  body.  Especially 
should  the  accoucheur  study  the  pelvis  in  its  totality  and  in  its  relations  with  the 
great  function  which  it  subserves.  Now  as  the  best  way  of  understanding  a 
whole  is  to  decompose  it,  and  study  separately  its  constituent  parts,  we  shall 
proceed  at  once  to  consider  individually  the  bones  which  enter  into  the  composi- 
tion of  the  pelvis. 

ARTICLE   I. 

The  bones  which  together  constitute  the  pelvis  are :  the  sacrum  and  the 
coccyx,  both  placed  behind  and  on  the  median  line,  and  the  ossa  innominata  or 
coxal  hones.  These  last  are  in  pairs,  being  situated  at  the  sides  and  articula- 
ting with  each  other  in  front. 

§  1.  Or  THE  Sacrum. 

This  is  a  symmetrical,  triangular  bone,  which  is  curved  forward  at  its  lower 
part,  and  is  placed  at  the  posterior  part  of  the  pelvis,  where  it  appears  like  a 
wedge,  forced  in  between  the  two  ossa  innominata,  immediately  below  the  verte- 
bral column,  and  directly  above  the  coccyx.  It  is  traversed  longitudinally  by  the 
sacral  canal  (a  continuation  of  the  vertebral  canal),  and,  relatively  to  the  axis 
of  the  body,  it  is  directed  from  above  downwards,  and  from  before  backwards ; 
hence  the  column  represented  by  it  forms  an  obtuse  angle  with  the  lumbar  ver- 
tebrt^,  being  salient  in  front,  and  receding  behind.  This  point  is  called  the  pro- 
montory, or  the  sacro-vertebral  angle.  Besides  this  direction,  the  sacrum  is 
curved  upon  itself  from  behind  forwards,  so  as  to  present  an  anterior  concavity, 
the  hollow  of  the  sacrum  :  this  curvature  is  generally  much  more  marked  in  the 
female  than  in  the  male. 

Anatomists  describe  the  bone  as  having  two  faces,  two  borders,  a  base,  and 
an  apex. 

1.  The  spinal,  or  posterior  face,  is  convex,  rough,  and  very  irregular,  pre- 
senting on  the  median  line  three,  four,  or  five  prominences,  the  longest  of  which 
are  above,  and  continuous  with  the  ridge  formed  by  the  series  of  spinous  pro- 
cesses of  the  vertebra;;  lower  down,  the  sacral  canal  is  terminated  as  a  triangular 
gutter,  being  bounded  laterally  by  two  tubercles,  called  the  cornua  of  the  sacrum ; 
upon  each  side  of,  and  close  to  the  median  line,  a  large  furrow  exists,  at  the  bottom 
of  which  the  four  posterior  sacral  foramina  are  seen,  communicating  with  the 
vertebral  canal,  and  serving  to  transmit  the  nerves  of  the  same  name.  Outside 
of  these  foramina  we  find  a  series  of  elevations,  apparently  analogous  to  the 
transverse  processes  of  the  vertebrae ;  and  above  them  two  irregular  fossrc,  into 
which  the  posterior  sacro-iliac  ligaments  are  inserted. 

2.  The  pelvic,  or  anterior  face,  is  smooth  and  concave,  and  is  traversed  by 
four  prominent  transverse  lines,  the  remnants  of  the  sutures  between  the  difi'erent 
pieces  that  composed  the  bone  in  early  infancy,  and  which  serve  to  separate 
some  superficial,  transverse,  and  quadrilateral  grooves  found  there,  from  each 
other.  Sometimes  the  first  of  these  prominent  lines  is  so  well  marked  as  to  be 
mistaken,  when  practising  the  touch,  for  the  sacro-vertebral  angle. 


OFTnEPELVIS.  19 

The  anterior  sacral  foramina,  four  in  number,  are  found  nearer  the  lateral  mar- 
gins; they  communicate  with  the  sacral  canal,  and  transmit  the  anterior  branches 
of  the  nerves  of  the  same  name.  Beyond  the  foramina  is  an  unequal  surface 
for  the  attachment  of  the  pyramidal  muscles. 

3.  The  borders  of  the  sacrum  may  be  divided  into  two  portions.  1.  The 
superior,  being  very  thick,  presents,  on  its  anterior  half,  a  semilunar  articular 
facet  for  joining  with  the  coxal  bone,  and  on  its  posterior  part  an  excavation, 
and  some  rough  projections  for  the  attachment  of  the  sacro-iliac  ligaments.  The 
other,  or  inferior  portion,  is  quite  thin,  and  is  occupied  by  the  insertion  of  the 
sacro-sciatic  ligaments. 

4.  The  base  is  directed  upwardly  and  a  little  in  front,  and  has  its  greatest  dia- 
meter transversely.  An  oval  facet,  more  or  less  inclined  backwards,  surmounts 
it  at  the  middle,  whereby  the  bone  is  articulated  with  the  last  lumbar  vertebra. 
Upon  each  side  is  seen  a  smooth  surface,  which  is  concave  transversely,  and  con- 
vex from  before  backwards.  These  surfaces  incline  forwards  and  are  continuous 
with  the  iliac  fossje,  being  covered,  in  the  recent  subject,  by  the  anterior  sacro- 
iliac ligaments.  They  are  separated  from  the  anterior  face  of  the  sacrum  by  a 
rounded  border,  which  forms,  as  we  shall  hereafter  learn,  the  posterior  part  of 
the  superior  strait.  The  two  surfaces  constitute  the  ioings  of  the  sacrum.  Be- 
hind, are  found  the  upper  orifice  of  the  sacral  canal,  and  the  two  articular  pro- 
cesses of  the  first  piece  of  the  sacrum. 

5.  The  ajyex  of  the  sacrum  is  directed  downwards,  and  a  little  backwards ; 
presenting  an  oval  facet  for  the  articulation  of  the  coccyx. 

6.  The  sacral  canal,  hollowed  out  in  the  thickness  of  the  bone,  is  the  termi- 
nation of  the  vertebral  canal;  being  triangular  and  broad  superiorly,  it  becomes 
narrow  and  flattened  at  its  inferior  part,  where  it  degenerates  into  a  gutter,  that 
is  converted  into  a  canal  by  the  ligaments.  This  lodges  the  sacral  nerves,  and 
communicates  both  with  the  anterior  and  the  posterior  sacral  foramina. 

The  sacrum,  although  quite  thick,  is  a  very  light  and  spongy  bone.  Besides, 
it  is  pierced  by  a  great  number  of  foramina,  and  traversed  by  a  central  cavity, 
which  serve  to  diminish  its  weight  still  more. 

It  is  formed  of  five  principal  pieces  (false  sacral  vertebrae),  sometimes  of  six, 
and  in  one  case,  seven  were  observed  (Pauw).  In  Soemmerring's  cabinet  are 
three  specimens  which  present  but  four  pieces. 

The  development  of  the  sacrum  is  analogous  to  that  of  the  vertebrae,  and  takes 
place  from  thirty-four  or  thirty-five  points  of  ossification,  arranged  in  the  follow- 
ing manner : — 

1.  Five  of  them,  placed  one  over  the  other,  occupy  the  anterior  and  middle 
parts.  2.  In  each  of  the  interspaces  which  separate  these,  two  small  osseous 
laminae  are  developed  some  time  after  birth,  which  seem  to  form  their  articular 
surfaces.  3.  Ten  are  situated  in  front  and  upon  each  side  of  the  latter,  that  is, 
one  for  each  lateral  portion  of  the  four  or  five  primitive  bones.  4.  And  behind 
them  six  others  are  developed,  between  which  :  5.  There  appear  three  or  four 
that  correspond  with  the  spinous  processes,  or  their  laminfe;  and  6.  Lastly, 
there  is  one  upon  each  side  above  the  iliac  surface,  for  the  articular  facet. 


20  FEMALE     ORGANS     OF     GENERATION. 

§  2.  The  Coccyx. 

This  name  is  given  to  an  assemblage  of  three  or  four,  occasionally  five  little 
bones,  united  with  each  other  on  the  median  line  of  the  body,  and  apparently 
suspended  at  the  point  of  the  sacrum,  of  which,  indeed,  they  appear  to  be  only 
a  movable  appendage,  continuing  its  line  of  curvature  forwards. 

M.  Cruveilhier  declares  that  he  has  known  it,  in  some  cases,  to  form  a  right 
angle  or  even  an  acute  one  with  the  sacrum.  As  a  whole,  the  coccyx  represents 
a  triangular  and  symmetrical  bone. 

1.  Its  spinal,  or  posterior  face,  is  convex  and  irregular,  and  is  only  separated 
from  the  skin  by  the  posterior  sacro-coccygeal  ligament. 

2.  Its  pelvic,  or  anterior  face,  is  smooth  and  slightly  concave,  and  lies  in  con- 
tact with  the  termination  of  the  rectum,  which  rests  upon  it.  Like  the  pre- 
ceding bone,  it  is  marked  by  certain  transverse  grooves,  corresponding  with  the 
intervals  which  had,  for  a  long  period,  separated  its  different  pieces. 

3.  Its  tioo  lateral  borders  are  quite  irregular,  and  are  occupied  by  the  attach- 
ments of  the  anterior  sacro-sciatic  ligaments,  and  the  ischio-coccygeal  muscles. 

4.  Its  slightly  concave  base  presents,  above,  an  oval  surface,  which  articulates 
with  the  apex  of  the  sacrum,  and  behind,  two  little  tubercles  called  the  cornua 
of  the  coccyx. 

5.  The  ajjex  is  rounded,  irregular,  and  sometimes  bifurcated,  affording  attach- 
ment to  the  levator  ani  muscle. 

The  coccyx  is  developed  from  four  or  five  centres  of  ossification,  that  is,  one 
for  each  of  its  parts. 

§  3.   The  Coxal  Bone,  Haunch  Bone,  or  Os  Innominatum. 

This  is  a  non-symmetrical,  quadrilateral  bone,  curved  upon  itself,  as  if  twisted 
in  two  different  directions,  contracted  in  its  middle,  and  of  a  very  irregular  figure. 
The  pair  occupy  the  lateral  and  anterior  parts  of  the  pelvis.  It  presents  an  in- 
ternal and  an  external  foce,  and  four  borders,  for  our  consideration. 

1.  The  external,  ov  femoral  surface,  is  turned  outwards,  backwards,  and  down- 
wards, at  its  superior  part,  whilst  inferiorly,  it  looks  forwards. 

At  its  superior  and  posterior  portion  is  seen  an  unequal,  narrow,  and  convex 
surface,  affording  origin  to  the  gluteus  maximus  muscle,  and  terminated  below 
by  a  slightly  elevated  circular  ridge,  called  the  superior  curved  line.  Beneath 
this,  there  is  a  larger  sui-face,  which  is  concave  behind,  narrowed  in  front  for 
the  insertion  of  the  gluteus  medius  muscle,  and  bounded  by  a  slight  ridge  below, 
called  the  inferior  curved  line  ;  still  lower,  there  is  a  third  extensive  and  convex 
surface,  serving  for  the  attachment  of  the  gluteus  minimus  muscle.  All  that 
portion  of  the  femoral  face  just  described  forms  a  large  fossa,  alternately  concave 
and  convex,  bearing  the  name  of  the  external  iliac  fossa. 

Towards  the  front,  the  external  face  presents  the  cotyloid  cavity  or  the  aceta- 
bulum, at  its  superior  part;  and  a  little  more  in  advance  and  below,  the  sub- 
pubic, or  obturator  foramen.  This  opening  is  triangular,  with  rounded  angles ; 
its  long  diameter  is  inclined  downwards  and  outwards,  and  its  circumference  is 
sharp  and  irregular,  presenting  above  a  groove,  directed  obliquely  from  behind 


OF     THR     PEL  VIP. 


2t 


forwards  and  from  without  inwards,  through  which  the  obturator  vessels  and 
nerves  pass  out.  A  fibrous  membrane  that  subtends  the  foramen  is  attached  to 
its  periphery,  except  in  the  immediate  vicinity  of  the  groove. 

Upon  the  inner  side  of  the  obturator  foramen,  between  it  and  the  median  line, 
there  is  a  concave  or  nearly  plane  surface  for  the  origin  of  several  muscles. 

2.  The  abdominal,  or  internal  face,  is  directed  forwards  at  its  upper  part,  and 
backwards  at  the  lower.  It  may  be  divided  into  two  portions ;  the  superior  of 
which  is  characterized  by  a  large  excavation,  called  the  infernal  iliac  fossa,  by  a 
semilunar  articular  surface  found  just  behind  this  fossa,  and  called  the  auricular 
facet,  and  still  more  posteriorly,  by  some  rugosities,  analogous  to  those  found  on 
the  articular  faces  of  tho  sacrum. 

The  superior  portion  is  terminated  below  by  a  large,  rounded,  and  concave 
line,  which  separates  it  from  the  other  moiety.  The  latter,  or  inferior  portion, 
presents  behind  a  nearly  triangular  plane  surface,  which  corresponds  to  the  coty- 
loid cavity  and  to  the  body  of  the  ischium ;  near  its  middle,  we  find  the  obtu- 
rator foramen,  and  in  front,  the  internal  face  of  the  pubis  and  of  the  ischio-pubic 
ramus. 

3.  Borders.  These  are  four  in  number.  The  posterior  one  has  a  very  irregular 
shape,  being  oblique  from  above  downwards,  and  from  without  inwards.  The 
posterior  superior  sjyinous  process  is  found  at  its  junction  with  the  superior  border. 
This  prominent,  well-marked  eminence  is  separated  by  a  rough  margin  from 
another  though  less  voluminous  one,  called  the  posterior  inferior  spinous  process. 

Below  this  last  apophysis,  the  student  will  observe  a  very  deep  notch,  which 
contributes  to  the  formation  of  the  great  sciatic  foramen,  and  is  terminated  below 
by  a  triangular,  pointed  projection,  bearing  the  title  of  the  spine  of  the  ifcJiium. 
This  process  is  more  or  less  prominent  in  difi"erent  individuals,  and  is  sometimes 
directed  inwards.  A  groove  is  seen  just  beneath  it,  in  which  the  tendon  of  the 
obturator  internus  muscle  plays;  this  groove  is  a  part  of  the  lesser  sciatic  notch; 
and  lastly,  this  border  terminates  at  the  tuberosity  of  the  ischium. 

The  anterior  border  is  concave,  oblique  above,  and  nearly  horizontal  in  front. 
The  anterior  superior  spinous  proctss  is  formed  by  its  union  with  the  superior 
border.  A  considerable  depression  exists  under  this  apophysis,  which  separates 
it  from  another  one,  called  the  anterior  inferior  spinous  process.  Then  we  find 
a  groove  just  under  this  elevation,  for  the  gliding  of  the  conjoint  tendon  of  the 
psoas  magnus  and  the  iliacus  internus  muscles ;  which  groove  is  bounded,  in 
front  and  below,  by  the  ilio-jyectineal  eminence.  And  lastly,  the  border  is  termi- 
nated by  a  triangular  horizontal  surface,  which  is  directed  downwards  and  for- 
wards, and  is  broader  externally  than  internally,  and  by  the  spine  and  angle  of 
the  pubis. 

The  superior  border  or  crest  of  the  ilium  is  thick,  convex,  and  inclined  out- 
wards, excepting  at  its  posterior  part,  where  it  looks  slightly  inwards — being 
twisted,  in  its  course,  somewhat  like  an  italic  /.  Anatomists  have  subdivided  it 
into  the  external  and  internal  lips,  and  the  intervening  space.  The  anterior 
superior  spinous  process  bounds  it  in  front,  and  the  posterior  superior  one  behind. 
The  inferior  border  is  shorter  than  either  of  the  others ;  it  presents,  however. 


22  F  K  M  A  L  K     0  K  G  A  N  S     OF     GENERATION. 

three  parts  for  study.  There  is  an  oval  surface  above,  for  articulating  with  its 
fellow  of  the  opposite  side,  forming  the  symphysis;  below,  it  is  terminated  by 
the  tuberosity  of  the  ischium,  and  in  the  middle,  we  find  the  ischio-puhic  ramus; 
this  is  a  sharp  ridge,  formed  superiorly  by  the  descending  branch  of  the  pubis, 
and  inferiorly  by  the  ascending  portion  of  the  ischium. 

The  coxal  bone  is  developed  from  three  principal  centres  of  ossification,  which 
appear  at  the  same  time  in  the  iliac  fossa,  the  tuberosity  of  the  ischium,  and  in 
the  pubis.  Owing  to  this  mode  of  growth,  it  has  been  customary  to  divide  the 
OS  innominatum  into  three  portions  :  the  superior  one,  styled  the  ilium,  forms,  in 
a  freat  measure,  the  contour  and  prominence  of  the  hip;  the  pubis,  being  ante- 
rior, supports  the  genital  organs;  and  the  inferior  one,  which  sustains  the  body 
when  seated,  is  named  the  ischium.  , 

Several  years  after  birth,  an  osseous  lamina  resting  upon  the  superior  border 
of  the  bone,  is  developed  to  form  the  iliac  crest,  whilst  a  similar  layer  embraces 
the  tuberosity  of  the  ischium,  and  extends  to  its  ramus;  at  the  same  time,  a 
third  centre  of  ossification  appears  for  the  anterior  inferior  spinous  process  of  the 
ilium,  and  a  fourth  forms  the  angle  of  the  pubis. 


ARTICLE   II. 

ARTICULATIONS    OF   THE   PELVIS. 

These  are  five  in  number;  namely,  one  in  front  for  the  pubes,  two  behind  for 
the  iliac  bones  and  sacrum,  that  of  the  coccyx  with  the  sacrum,  and  of  the  latter 
with  the  spine. 

Three  of  these  articulations  have  also  received  the  name  of  syviphyses ;  for 
instance,  the  term  symphysis  pubis  has  been  applied  to  the  articulation  between 
the  two  bones  of  the  pubis,  and  that  of  sacro-iliac  symphyses,  to  those  of  the 
sacrum  with  the  ilium. 

They  have  been  classed  with  the  amphiarthroses.  The  researches  of  M.  Le- 
noir, however,  have  proved  the  correctness  of  those  anatomists  who  regarded 
them  as  arthrodia.  He  has  shown,  by  an  examination  of  the  bodies  of  twenty- 
two  females,  between  the  ages  of  eighteen  and  thirty-five  years,  that  the  four 
pelvic  articulations  are  formed  by  the  contact  of  surfaces  covered  in  great  part 
with  cartilage,  and  lined  with  synovial  membranes. 

§  1.    Symphysis  of  the  Pubis. 

This  articulation  is  formed  by  the  approximation  of  the  oval  surfaces  occupy- 
ing the  upper  part  of  the  lower  border  of  the  coxal  bones.  These  surfaces  are 
slightly  convex  and  unequal,  and  are  covered  with  a  cartilaginous  lamina  which 
fills  up  the  inequalities.  The  convex  shape  and  the  direction  of  their  faces  are 
such,  that  they  only  come  into  contact  for  an  inconsiderable  extent  at  their  inter- 
nal or  posterior  part,  and  hence  they  leave  above,  in  front,  and  below,  an  open 
space,  which  is  the  more  considerable,  in  proportion  to  the  distance  from  the 
centre  of  the  joint.     The  articulating  surface  of  the  two  cartilages  is  a  little 


0  F     T  II  E     P  E  L  V  I  S.  23 

facet,  about  six  to  eiuht  lines  in  its  vertical  diameter,  by  two  to  three  in  its 
transverse  ona.  This  facet  is  smooth,  and  furnished  with  a  synovial  membrane, 
which  is  the  more  lubricated  with  sy^novia  as  the  female  approaches  the  period 
of  labor.  A  considerable  thickness  of  the  interpubic  ligament  fills  up  the  interval 
which  exists  between  the  other  points  of  these  articular  surfaces. 

This  interpubic  ligament  is  formed  of  a  very  dense  fibrous  substance.  It  has 
the  form  of  a  wedge,  with  the  point  forced  down  between  the  bones  and  the  sides 
adhering  to  the  rough  surfaces  fronting  the  articulation.  Two  planes  of  fibres 
are  discoverable  in  it ;  the  deeper  ones,  which  pass  from  one  iliac  bone  to  the 
other,  and  are  shorter  in  proportion  to  their  depth,  are  crossed,  and  disposed  in 
several  layers.  They  constitute  the  interpuhic  ligament  properly  so  called.  The 
others,  which  are  more  superficial,  are  parallel,  and  pass  obliquely  from  within 
outwards  and  from  above  downwards.  Beginning  at  the  upper  part  of  the  arti- 
culation they  spread  in  descending,  until  they  are  finally  divided  into  two 
bundles,  which  become  lost  in  front  of  the  branches  of  the  pubic  arch  by  min- 
gling with  the  periosteum  of  the  bones  and  the  tendons  of  the  muscles  inserted  in 
the  vicinity.     These  form  the  anterior  pubic  ligament. 

The  uppermost  portion  of  the  anterior  pubic  ligament  seems  to  take  its  origin 
in  the  fibrous  cord  which  is  inserted  on  the  spine  of  the  fahis,  and  which 
cushions,  so  to  speak,  the  upper  edge  of  that  bone,  in  such  a  way  as  to  efface  its 
inequalities.     It  constitutes  the  superior  pubic  ligament. 

Lastly,  at  its  lowest  part,  the  anterior  pubic  ligament  assumes  the  form  of  a 
thick  triangular  bundle  occupying  the  summit  of  the  pubic  arch,  and  fixed  by  its 
lateral  edges  to  the  upper  and  internal  part  of  the  two  branches  thereof.  This 
ligament,  called  the  triangular,  or  sub-puhic  ligament,  presents  a  rounded  base, 
which  completes  the  arch  of  the  pubes  by  giving  it  a  regular  curve  calculated  to 
facilitate  the  exit  of  the  foetus. 

Thus,  we  have  three  anterior  pubic  ligaments,  a  superior  pubic  and  a  sub- 
pubic ligament,  all  of  them  represe/iting  a  spreading  out  of  the  interosseous  liga- 
ment. Behind  the  symphysis,  the  fibro-cartilaginous  substance  forms  a  sort  of 
projecting  pad,  which  occupies  the  middle  part  only,  and  disappears  from  above 
downwards. 

Finally,  the  ligamentous  arrangement  of  the  articulation  is  completed  by  the 
posterior  pubic  ligament,  composed  of  fibres  extending  transversely  from  one 
pubis  to  the  other,  above  the  projection  just  noticed.  This  ligament,  which  is 
very  thin,  and  of  moderate  strength,  forms  the  posterior  lining  of  the  synovial 
membrane. 

§  2.   Sacro-iliac  Symphysis. 

This  articulation  is  formed  by  the  junction  of  the  semilunar  facets,  which  were 
pointed  out  in  describing  the  border  of  the  sacrum  and  the  internal  face  of  the 
ossa  ilia. 

Both  these  facets  are  covered  with  a  diarthrodial  cartilage,  which  is  closely 
adapted  to  the  inequalities  they  present ;  that,  however,  which  pertains  to  the 
sacrum,  being  always  much  thicker  than  the  layer  which  belongs  to  the  iliac 


24  FEMALE  ORGANS  OF  GENERATION. 

bones.  The  latter  is  so  thin,  that  its  existence  has  been  denied.  These  carti- 
lages are  covered  with  a  synovial  membrane,  which  secretes  quite  •  abundantly  a 
viscid  and  transparent  synovia.  But,  when  the  female  has  passed  the  prime  of 
life,  this  fluid  often  concretes,  and  becomes  disposed  in  isolated  flakes  upon  the 
articular  surfaces, — a  fact  which  has  caused  its  true  nature  to  be  misunderstood. 
A  very  limited  sliding  motion,  is  all  of  which  this  articulation  is  susceptible. 
The  bones  are  held  together  by  the  following  ligaments : 

1.  The  jiosterior,  or  great  sacro-sciatic  ligament,  is  found  at  the  posterior  in- 
ferior part  of  the  pelvis.  It  is  triangular,  thin,  flattened,  and  narrower  in  the 
middle  than  at  the  extremities.  It  arises  by  a  large  base  from  the  posterior  infe- 
rior spinous  process  of  the  ilium,  the  sacro-spinous  ligament,  the  last  of  the  pos- 
terior tubercles  of  the  sacrum,  and  from  the  inferior  part  of  the  margin  of  this 
bone  and  border  of  the  coccyx,  and  running  outwards,  downwards,  and  a  little 
forwards,  is  inserted  into  the  tuberosity  of  the  ischium.  Its  fibres  are  arranged 
in  such  a  way,  that  the  internal  ones  cross  the  external  about  their  middle. 

2.  The  hsser  sacro-sciatic  ligament  is  smaller  than  the  preceding,  though 
nearly  of  the  same  form,  and  situated  more  in  front.  Within,  it  is  broad,  being 
partially  confouaded  with  the  other,  but  arising  a  little  more  anteriorly  upon  the 
sides  of  the  sacrl||^  and  coccyx;  thence,  it  passes  forwards  and  outwards  to  be 
inserted  into'the  spine  o£  the  ischium. 

The  sacro-sciatic  ligaments  convert  the  two  sciatic  notches  into  foramina. 
They  not  only  serve  to  unite  the  sacrum  to  the  ilium,  but  also  contribute  to  the 
formation  of  the  parietes  of  the  pelvis. 

3.  The  posterior  sacro-iliac  ligament  is  a  collection  of  yellow,  elastic,  fibrous 
bundles,  intermixed  with  fatty  pellets,  which  fill  up  the  rough  excavation  ob- 
served behind  the  cartilaginous  surfaces ;  very  short,  numerous,  and  interlacing 
in  every  direction,  they  become  almost  intimately  blended  with  the  sacrum  and 
coxal  bones.  On  account  of  their  strength,  they  greatly  consolidate  this  articu- 
lation. \ 

4.  The  anterior  sacro-iliac  ligament  is  a  simple  fibrous  lamina,  extended  trans- 
versely from  the  sacrum  to  the  os  innominatum.  It  is  rather  an  expansion  of  the 
periosteum  of  the  pelvis  than  a  true  ligament. 

5.  The  superior  sacro-iliac  ligament  is  a  very  thick  fasciculus,  passing  trans- 
versely from  the  base  of  the  sacrum  to  the  coxal  bone. 

6.  The  inferior  sacro-iliac  ligament  (vertical  sacro-iliac  of  M.  Cruveilhier) 
arises  from  the  posterior  superior  spinous  process  of  the  ilium,  and  is  inserted 
just  below  the  third  sacral  foramen  into  the  tubercle  found  at  the  termination  of 
the  border  of  the  sacrum ;  and  behind,  into  the  great  sacro-sciatic  ligament. 

§  3.    Sacro-coccygeal  Symphysis. 

This  articulation,  which  for  a  long  time  was  supposed  to  resemble  those  be- 
tween the  bodies  of  the  vertebraj,  diff'urs  from  them  materially  in  being  a  true 
arthrodia.  It  is  formed  by  the  opposition  of  the  oval  surface  of  the  point  of  the 
sacrum  to  that  of  the  base  of  the  coccyx ;  the  middle  of  the  former  is  projecting, 
and  corresponds  to  a  depression  in  the  centre  of  the  latter.     The  long  diameter 


OF    THE    PELVIS.  25 

of  the  articular  face  of  the  coccyx  is  directed  transversely.  The  cartilages  cover- 
ing these  surfaces  are  rather  thinner  at  the  centre  than  at  the  circumference. 
They  are  provided  in  the  adult  female  with  a  synovial  membrane,  which  is  sup- 
posed by  M.  Lenoir  to  be  only  developed  by  the  movements  of  the  coccyx  upon 
the  sacrum,  since  he  has  failed  to  meet  with  it  in  subjects  under  eighteen  years 
of  age. 

1.  The  anterior  sacro-coccygeal  ligavient  consists  of  a  few  parallel  fibres,  which 
descend  from  the  anterior  part  of  the  sacrum  to  the  corresponding  face  of  the 
coccyx. 

2.  The  posterior  sacro-coccygeal  ligament  is  flat,  triangular,  broader  above  than 
below,  and  of  a  dark  color.  Arising  from  the  margin  of  the  inferior  orifice  of 
the  sacral  canal,  it  descends  to,  and  is  lost  upon,  the  whole  posterior  surface  of 
the  coccyx.     It  also  aids  in  completing  the  canal  behind. 

In  investigating  upon  the  dead  body  the  anatomical  arrangement  to  which  the 
motion  of  the  coccyx  on  the  sacrum  is  due,  it  was  ascertained  by  M.  Lenoir  that 
the  motion  takes  place  almost  as  frequently  in  the  sacro-coccygeal  articulation,  as 
in  that  of  the  second  piece  of  the  coccyx  with  the  third.  Sometimes  it  happens 
simultaneously  in  both,  whilst  in  few  cases  only  does  it  occur  in  the  connection 
of  the  second  piece  with  the  third,  or  of  the  third  with  the  fourth. 

These  inter-coccygeal  articulations  are  similarly  constructed.  In  all  cases,  in 
fact,  in  which  the  points  of  motion  of  the  coccyx  were  changed,  M.  Lenoir  dis- 
covered a  more  or  less  complete  anchylosis  of  the  articulation  between  the  sacrum 
and  coccyx,  and  of  those  between  the  bones  of  the  coccyx  itself,  at  points  above 
and  below  the  one  which  preserved  its  mobility.  Then,  also  wherever  situated, 
the  movable  articulation  was  constructed  as  follows :  1.  Of  articular  surfaces 
irregular  in  form  but  corresponding  exactly,  which  were  incrusted  with  diarthro- 
dial  cartilages  and  provided  with  a  synovial  membrane.  2.  Of  lax  peripheral 
ligaments  formed  at  the  expense  of  the  layers  of  fibrous  substance  covering  the 
bones  of  the  coccyx.     3.   Lastly,  motion  was  possible  in  every  direction. 

It  is  to  be  observed  that  ossification  is  more  frequent  and  rapid  in  the  joint 
between  the  sacrum  and  coccyx  than  in  that  between  the  first  piece  of  the  coccyx 
and  the  second ;  the  third  and  fourth  become  fused  very  early.  It  is  therefore 
easy  to  understand  how  the  great  mobility  of  the  sacro-coccygeal  articulations 
renders  luxation  possible  in  labor,  whilst  in  cases  of  anchylosis,  either  fracture  or 
a  sudden  separation  of  the  united  bones  might  occur. 

During  pregnancy,  the  ligaments  of  the  pelvic  articulations  become  so  softened 
and  swelled  by  imbibition  of  fluid,  as  to  render  the  mobility  of  the  articular  sur- 
faces very  evident.  This  softening  is  very  considerable  in  some  cases,  and  may 
make  walking  or  even  standing,  impossible. 

§  4.    Sacro-vertebral  Articulation. 

This  is  produced  by  the  junction  of  the  sacrum  with  the  fifth  lumbar  vertebra. 
It  is  a  true  amphiarthrosis,  as  are  all  the  vertebral  articulations.  It  takes  place 
at  three  difi'ercnt  points,  viz.,  between  the  oval  facet,  seen  at  the  middle  of  the 


26  FEMALE     ORGANS    OF    CxENERATION. 

base  of  the  sacrum,  and  the  inferior  surface  of  the  body  of  the  hist  vertebra ;  and, 
at  the  two  articuhar  surfaces  found  near  the  entrance  of  the  sacral  canal. 

The  modes  of  connection  are,  a  fibro-cartilage  (which  is  much  thicker  in  front 
than  behind),  the  termination  of  the  two  anterior  and  posterior  vertebral  liga- 
ments, the  interspinous  ligament,  and  lastly,  the  ancro-vertehral  li(jame7it,  a 
short,  very  strong,  fibrous  bundle,  which  descends  obliquely  from  the  anterior 
inferior  part  of  the  transverse  process  of  the  last  vertebra,  downwards  and  out- 
wards, towards  the  base  of  the  sacrum,  where  it  is  inserted. 

Further,  a  synovial  membrane  is  found  in  the  articulation  between  the  oblique 
processes  of  the  sacrum  and  those  of  the  vertebra). 

To  these  must  also  be  added  the  ilio-lunibar  ligament,  which  passes  from  the 
apex  of  the  transverse  process  of  the  fifth  lumbar  vertebra  to  the  thickest  portion 
of  the  iliac  crest ;  and  the  ilio-vertebral  ligament,  formed  of  two  fibrous  bands, 
the  superior  of  which  arises  from  the  middle  and  lateral  part  of  the  body  of  the 
last  lumbar  vertebra,  and  the  inferior,  from  the  inter-sacro-vertebral  space ;  both 
are  then  spread  out  on  the  coxal  bone. 

The  obturator  membrane  still  claims  a  description,  in  order  to  finish  the  his- 
tory of  the  ligamentous  apparatus  of  the  pelvis.  This,  as  has  been  remarked  by 
M.  Cruveilhier,  like  the  sacro-sciatic  ligaments  already  spoken  of,  is  rather  an 
aponeurosis  serving  to  complete  the  pelvic  walls,  than  a  true  ligament. 

These  resisting  membranes  are  probably  intended  to  diminish,  in  the  hour  of 
labor,  the  compression  of  the  mother's  soft  parts,  included  between  the  infant's 
head  and  the  osseous  parietes  of  the  pelvis,  as  also  to  favor,  by  their  elasticity, 
the  passage  of  the  head  through  the  pelvic  excavation. 

Ohturator  membrane. — This  membrane  subtends  the  foramen  thyroideum,  ex- 
cepting at  its  superior  part,  where  an  opening  exists,  which  converts  the  groove, 
intended  for  the  passage  of  the  obturator  vessels  and  nerves,  into  a  complete 
canal.  Being  inserted  by  its  external  semi-circumference  into  the  corresponding 
part  of  the  periphery  of  the  obturator  foramen,  it  is  attached  by  its  internal  half 
to  the  posterior  face  of  the  ascending  ramus  of  the  ischium.  Its  surfaces  afford 
origins  for  the  two  obturator  muscles.  This  membrane  is  composed  of  aponeu- 
rotic fasciculi,  which  cross  each  other  in  every  direction.     (^Cruveilhier.') 


ARTICLE  III. 

OF   THE    PELVIS    IN    GENERAL. 

Studied  in  its  general  aspect,  the  pelvis  represents  a  cone,  slightly  flattened 
from  before  backwards;  the  base  of  which,  being  above,  is  at  the  same  time  in- 
clined forwards,  whilst  the  apex  is  directed  downwards  and  a  little  backwards. 

§  1.  External  Surface  of  the  Pelvis. 

Anatomists  have  divided  this  surface  into  four  regions  :  the  anterior  of  which 
exhibits,  on  the  median  line,  the  front  part  of  the  symphysis  pubis,  which  is 
directed  from  above  downwards  and  from  before  backwards,  at  an  angle  with  the 


OF     THE     PELVIS.  27 

perpendicular  of  some  15°  to  20° ;  next  (passing  outwards)  is  a  smooth  surface, 
from  whicli  several  muscles  of  the  thigh  arise,  then  the  external  obturator  fossa, 
occupied  in  the  recent  subject  by  the  muscle  of  the  same  name,  and  finally  by 
the  anterior  half  of  the  edge  of  the  cotyloid  cavity. 

The  posterior,  bounded  by  the  hinder  part  of  the  iliac  crest,  presents,  on  the 
median  line,  the  ridge  of  the  sacral  spinous  processes,  the  inferior  opening  of  the 
vertebral  canal,  the  union  of  the  sacrum  with  the  coccyx,  and  the  posterior  face 
of  this  latter  bone. 

The  ten  posterior  sacral  foramina,  transmitting  the  nerves  of  the  same  name, 
are  found  in  two  deep  gutters,  on  the  sides.  These  grooves  prolong  the  spinal 
gutters,  and  are  occupied  in  the  recent  state  by  the  commencement  of  the  sacro- 
spinal muscles.  The  lateral  regions  may  each  be  divided  into  two  parts  :  one, 
the  superior,  is  the  external  iliac  fossa ;  the  other,  or  inferior,  offers,  behind,  the 
posterior  aspect  of  the  sacro-sciatic  ligaments,  and  the  plane  of  the  notches  or 
foramina  bearing  the  same  name ;  and  in  front,  the  cotyloid  cavity  and  the  ex- 
ternal face  of  the  tuberosity  of  the  ischium. 

§  2.   Internal  Surface. 

The  internal  surface  or  cavity  of  the  pelvis  has  been  aptly  compared  to  the 
basin  of  the  ancient  barbers.  (  Vesalius.)  In  fact,  like  those  vessels,  it  has  a 
.superior  part,  which  spreads  out  freely,  and  is  called  the  great,  the  superior,  or 
the  abdominal  pelvis;  and  an  inferior  one,  more  contracted,  bearing  the  title  of 
the  little  jjelvis,  or  j)ehic  excavation. 

1.  The  great  pelvis  has  a  very  irregular  figure,  and  forms  a  species  of  pavilion 
to  the  entrance  of  the  pelvis.  Its  walls  are  three  in  number :  the  anterior  one  is 
deficient  in  the  dried  skeleton,  but  in  the  living  state  it  is  supplied  by  the  ante- 
rior abdominal  muscles ;  its  posterior  parietes  exhibit  a  notch  in  its  middle,  that 
is  ordinarily  filled  up  by  the  projection  of  the  last  lumbar  vertebrae,  which  are 
usually  left  in  connection  with  the  pelvis,  although  in  reality  not  forming  any 
part  of  it.  Two  gutters  are  found  on  the  sides  of  this  eminence,  occupied  by  the 
psoae  muscles ;  further  outwards,  the  anterior  part  of  the  sacro-iliac  symphyses 
appear,  which  constitute  the  boundaries  between  the  posterior  and  lateral  regions  : 
these  latter  are  constituted  by  the  internal  iliac  fossae,  covered  by  the  iliacus  in- 
ternus  muscles. 

2.  The  lesser  pelvis,  or  hasin.  This  forms  a  curved  canal,  larger  in  the  middle 
than  at  its  extremities,  and  slightly  bent  forward.  If  all  the  parts  described  as 
appertaining  to  the  great  pelvis  be  removed  by  the  saw,  as  recommended  by 
Chaussier,  a  species  of  ring  will  remain,  whose  circumference,  being  narrow  in 
front  and  much  broader  behind,  will  furnish  a  correct  idea  of  the  shape  of  the 
pelvis.     Four  regions  are  found  in  this  cavity  also  : 

The  anterior  one,  is  concave  transversely,  and  is  inclined  upwards,  having  the 
posterior  part  of  the  pubic  articulation  near  its  middle  :  this  is  generally  promi- 
nent, assuming  the  form  of  a  longitudinal  pad,  which  may  in  some  cases  project 
to  the  extent  of  from  two  to  three-eighths  of  an  inch.  Towards  the  sides,  a 
smooth  surface  appears,  and  then  the  internal  obturator,  or  sub-pubic  fossa,  hav- 


1 


i 


28  FEMALE  ORGANS  OF  GENERATION. 

ing,  at  its  upper  external  part  the  inner  orifice  of  the  sub-pubic  canal,  through 
which  the  external  obturator  vessels  and  nerves  pass  out  from  the  pelvis. 

It  is  not  at  all  uncommon  for  females  to  complain  during  labor  of  severe 
cramps  in  the  muscles  of  the  upper  internal  part  of  one  thigh.  These  pains  re- 
sult from  the  pressure  made  by  the  child's  head  upon  those  nerves,  as  it  glides 
over  this  portion  of  the  excavation. 

The  posterior  region — constituted  by  the  front  face  of  the  sacrum  and  coccyx — 
is  directed  downwards,  and  is  concave  from  above,  downwards.  It  consequently 
exhibits  those  peculiarities  already  noticed  when  describing  the  sacrum. 

The  lateral  regions  present  two  quite  distinct  portions :  the  anterior  one  is 
wholly  osseous,  corresponding  to  the  back  part  of  the  cotyloid  cavity,  and  to  the 
body  and  tuberosity  of  the  ischium.  It  is  directed  from  above  downwards,  from 
behind  forwards,  and  from  without  inwards. 

The  posterior  one  is  formed  by  the  internal  face  of  the  greater  and  lesser  sacro- 
sciatic  ligaments,  and  by  the  internal  aspect  of  the  great  and  small  sciatic  notches, 
converted  by  them  into  foramina ;  it  has  an  opposite  direction  to  the  former.  One 
of  these  foramina  is  larger  and  situated  higher  up  than  the  other,  and  is  of  an 
oval  form.  The  other  is  triangular,  smaller,  and  more  inferior.  The  pyramidal 
muscle,  the  great  sciatic  nerve,  gluteal  artery,  and  the  internal  pudic  vessels  and 
nerves,  escape  from  the  pelvis  through  the  great  sciatic  foramen.  The  small 
sciatic  hole  is  filled  up  by  the  obturator  internus  muscle,  and  the  internal  pudic 
vessels  and  nerves,  which  re-enter  the  pelvis  in  order  to  supply  the  perineum. 

If  two  vertical  sections  be  made,  the  one  extending  on  the  median  line  through 
the  sacrum  and  the  pubis,  dividing  the  pelvis  into  two  lateral  halves,  and  the 
other  at  right  angles  to  the  first,  dividing  it  into  anterior  and  posterior  halves, 
four  equal  parts  or  quarters  of  the  pelvis  will  be  thereby  produced,  which  ac- 
coucheurs have  designated  as  the  anterior  and  posterior  inclined  planes.  Desor- 
meaux  included  only  the  lateral  regions  of  the  excavation,  which  he  divided  into 
two  equal  parts,  in  the  composition  of  these  planes :  according  to  him,  the  ante- 
rior inclined  planes  are  continuous  with  the  anterior  region ;  the  posterior,  with 
the  front  face  of  the  sacrum ;  and  the  spine  of  the  ischium  is  found  at  the  point 
of  union  of  these  two.  The  direction  of  the  inclined  planes  is  always  the  same, 
whatever  may  be  the  manner  in  which  they  are  formed.  That  is,  the  anterior 
are  directed  from  without  inwards,  from  above  downwards,  and  from  behind  for- 
wards; the  posterior,  from  without  inwards,  from  above  downwards,  and  from 
before  backwards — in  a  word,  in  such  a  way  as  to  resemble  somewhat  the  four 
sides  of  a  lozenge  which  is  slightly  curved  in  its  length.  By  most  authors,  these 
inclined  planes  are  supposed  to  play  an  important  part  in  the  mechanism  of  labor; 
for  they  imagine  that  their  direction  has  an  immediate  influence  upon  the  move- 
ments which  the  head  of  the  foetus  performs  in  the  excavation. 

In  anticipating  that  the  description  of  the  mechanism  of  labor  hereafter  given 
will  invalidate  this  assertion,  we  shall  simply  observe  that  the  movements  of  rota- 
tion executed  by  the  head,  take  place  more  frequently  whilst  the  latter  is  strongly 
bulging  out  the  perineum,  and  is  so  far  below  the  inclined  planes  as  scarcely  to 


0  F     T  H  E     P  E  L  V  I  S.  29 

feel  the  influence  of  their  direction,  and  further,  that  these  motions  often  occur 
in  an  opposite  direction. 

The  great  and  the  lesser  pelvis  are  separated  from  each  other  by  a  kind  of 
horizontal  circle,  which  has  been  designated  by  accoucheurs  as  the  abdominal,  or 
superior  strait,  the  isthmus,  or  margin  of  the  pelvis.  Finally,  the  apex  of  the 
pelvis  presents  an  opening  that  is  limited  by  a  circle,  partly  osseous,  partly  liga- 
mentous, to  which  the  name  of  the  inferior  strait  has  been  applied.  Conse- 
quently, these  two  straits  are  the  extreme  limits  of  the  pelvic  excavation. 

§  3.    Of  the  Superior  Strait. 

The  superior  strait  is  formed,  behind,  by  the  sacro-vertebral  angle,  and  the 
anterior  border  of  the  wings  of  the  sacrum  :  outwardly,  by  the  rounded  margin 
that  bounds  the  internal  iliac  fossa  below;  and  in  front,  by  the  ilio-pectineal 
eminence  and  the  horizontal  ramus  of  the  pubis,  terminating  at  the  symphysis  of 
this  bone.  The  abdominal  strait  has  been  variously  compared  to  an  ellipse,  an 
oval,  and  to  the  heart  of  a  playing  card.  We  may  assert,  however,  with  Chaus- 
sier,  that  its  shape  is  that  of  a  curvilinear  triangle,  the  angles  of  which  have 
been  rounded  oflF,  and  having  its  base  behind  and  the  apex  in  front. 

It  constitutes  the  entrance  to  the  lesser  pelvis,  and  is  therefore  the  first  part  of 
the  narrow  canal  which  the  foetus  has  to  traverse.  Hence,  the  pains  taken  by 
accoucheurs  to  study  this  osseous  opening  can  readily  be  conceived. 

All  the  modern  authors  since  the  days  of  Deventer,  have  endeavored  to  fix 
precisely  the  degree  of  inclination  of  its  plane  and  axis,  to  ascertain  the  direction 
the  foetus  should  follow  in  engaging  in  the  pelvic  canal,  and  to  determine  care- 
fully the  dimensions  of  the  latter,  and  their  accordance  with  those  of  the  body, 
which  is  to  pass  through  it. 

The  plane  of  the  superior  strait  is  inclined  obliquely  from  above  downwards, 
and  from  behind  forwards ;  but  writers  are  far  from  being  unanimous  in  regard 
to  the  degree  of  its  inclination ;  that  is,  in  determining  the  angle  formed  by  the 
sacro-pubic  line,  at  the  point  where  it  meets  a  horizontal  one,  drawn  from  the 
superior  part  of  the  symphysis  pubis  towards  one  of  the  points  on  the  anterior 
face  of  the  sacrum.  Although  originally  placed  at  45°  by  J.  J.  Muller  (1745), 
this  angle  has  successively  been  fixed  at  35°  by  Levret;  at  75°  by  Camper,  and 
at  55°  by  Saxtorph ;  and  still  more  recently,  Professor  Na^gele,  after  a  great 
number  of  researches,  has  concluded  to  consider  it  as  an  angle  of  60°  (1819). 
It  is  now  generally  admitted  that  the  degree  of  inclination  in  the  plane  of  the 
superior  strait  is  from  55°  to  60°  in  the  erect  position  of  the  female. 

The  direction  of  the  plane  being  once  understood,  it  is  an  easy  matter  to  as- 
certain that  of  its  axis ;  for  the  latter  being  a  line  which  falls  perpendicularly 
upon  the  centre  of  this  plane,  it  must  evidently  form  with  the  vertical  the  same 
angle  that  the  plane  itself  does  with  the  horizontal  line,  and  consequently  must 
have  just  the  same  degree  of  inclination.  Being  thus  understood,  the  axis  of 
the  superior  strait  is  a  line  (a  b,  Fig.  1)  which,  commencing  near  the  umbilicus 
of  the  female,  would  pass  directly  through  the  centre  of  this  strait,  and  fall  upon 
the  point  of  union  of  the  upper  two-thirds  of  the  coccyx,  with  its  inferior  third. 


30 


FEMALE     ORGANS     OF     GENERATEON. 


Fig.  1. 


Hence,  it  will  be  directed  from  above  downwards,  and  from  before  backwards. 

Further,  the  inclination  of  this  plane 
varies  according  to  the  woman's  posi- 
tion. Thus,  it  is  almost  nothing  when 
recumbent,  and  sometimes  in  this  posi- 
tion the  plane  of  the  superior  strait  in- 
stead of  being  directed  forwards  and 
upwards,  even  looks  upwards  and  back- 
wards (Dubois)  ;  when  the  trunk  is  bent 
strongly  forward  the  inclination  of  the 
plane  is  diminished  and  becomes  more 
nearly  horizontal;  towards  the  end  of 
gestation,  on  the  contrary,  the  inclina- 
tion increases,  especially  when,  in  order 
to  restore  equilibrium,  the  upper  part  of 
the  body  is  carried  much  backward. 

As  the  figure   which   represents  the 
circumference   of  the  superior  strait  is 
not  a  perfect  circle,  its  dimensions,  taken 
at  different  points,  are,  of  course,  un- 
equal, and,  accordingly,  writers  have  admitted  several  diameters  for  it,  thus : 
There  are  three  principal  ones  (Fig.  2),  namely,  an  antero-posterior,  or  sacro- 

pubic  diameter  a  a,  which  extends 
from  the  sacro-vertebral  angle  to 
the  upper  part  of  the  symphysis 
pubis  ;  it  is  from  four  and  a  quar- 
ter to  four  and  a  half  inches  in 
length.  2.  A  transverse  one,  h  h, 
passing  from  the  middle  of  the 
rounded  border  that  terminates 
the  iliac  fossa  of  one  side,  to  the 
same  point  on  the  opposite  side ; 
this  is  five  and  a  quarter  inches 
long.  3.  An  oblique  diameter, 
c  c,  extending  from  the  anterior 

a  a.  The  antero-posterior,  or  sacro-pubic  diameter.  6  6.  part  of  the  Sacro-iliac  Symphysis 
The  transverse  diameter,  c  c.  The  two  oblique  diameters.  Iq  the  ilio-pCCtinCal  eminence  of 
a  c.  The  sacro-cotyloid  interval.  .         . 

the  opposite  side ;  this  is  found  on 
both  sides,  and  is  four  and  three-quarter  inches  long. 

Lastly,  M.  Velpeau  admits  a  fourth  diameter,  called  by  him  the  sacro-coty- 
loidean ;  before  described,  however,  by  Burns,  under  the  more  exact  name  of  the 
sacro-cotyloid  interval,  a  c,  existing  between  the  promontory  and  the  posterior 
part  of  the  cotyloid  cavity.  This  interval,  according  to  the  examinations  of  the 
French  surgeon,  is  from  four  to  four  and  one-eighth  inches  in  extent;  but  from 
the  results  of  Naegdle  and  Stoltz's  researches  it  is  much  less,  being  scarcely  three 


..cv. 


c  h.  The  plane  of  the  superior  strait  prolonged 
beyond  the  pubis,  c  e.  The  plane  of  the  inferior 
strait  prolonged  beyond  the  pubis,  c  d.  Shows  the 
departure  of  this  plane  from  the  horizontal  line. 
ab.  The  axis  of  the  superior  strait,  g  f.  The  axis 
of  the  inferior  strait. 


Fig.  2. 


OF    THE     PELVIS.  31 

and  a  half  inches  (the  mean  obtained  from  ninety  pelves).  The  circumference 
of  this  strait  varies  from  thirteen  to  seventeen  inches ;  Levret  taught,  that  it 
equalled  one-fourth  of  the  female's  height  j  but  to  establish  such  an  approxima- 
tion, the  development  of  the  pelvis  should  always  be  in  direct  proportion  to  the 
stature  of  the  individual,  which  is  certainly  not  the  fact. 

§  4.    Of  the  Inferior  Strait. 

The  inferior  strait — the  perineal  strait — or  apex  of  the  pelvis  (as  it  is  vari- 
ously called),  is  more  irregular  in  shape  than  the  superior  one.  Its  outline  pre- 
sents, in  fact,  three  tuberosities  or  osseous  projections,  separated  by  as  many  deep 
notches. 

If,  however,  the  advice  of  Chaussier  be  followed,  and  a  sheet  of  paper  be 
placed  over  this  opening,  so  as  to  trace  its  outUne  with  a  crayon,  it  will  be  found 
to  have  an  oval  figure,  the  smaller  extremity  of  which  is  in  front,  and  the  larger 
one,  looking  backwards,  is  broken  in  upon  by  the  prominence  of  the  coccyx. 
This  point,  disappearing  at  the  moment  of  the  head's  passage,  offers  no  obstacle 
to  the  delivery ;  and,  therefore,  the  strait  may  be  considered  as  nearly  an  oval. 

The  periphery  of  the  pelvis  at  its  apes  is  formed  by  the  inferior  part  of  the 
symphysis  pubis,  the  descending  branch  of  this  bone,  the  ascending  branch 
and  tuberosity  of  the  ischium,  the  inferior  margin  of  the  great  sacro-sciatie  liga- 
ment, and  by  the  border  and  point  of  the  coccyx.  Hence,  three  triangular  pro- 
jections are  found  in  it :  the  two  ischia  upon  the  sides,  and  the  coccyx  behind. 
The  first  two  are  immovable,  but  the  last,  on  the  contrary,  is  effaced  at  the  period 
of  delivery,  as  just  mentioned ;  for  the  mobility  of  the  sacro-coccygeal  articulation 
allows  the  coccyx  to  be  pushed  downwards  and  backwards  by  the  foetal  head,  as 
it  traverses  the  inferior  strait.  The  two  lateral  prominences,  made  by  the  tube- 
rosities of  the  ischia,  are  placed  on  a  plane  somewhat  lower  than  the  point  of  the 
coccyx ;  and,  consequently,  in  the  sitting  posture,  the  weight  of  the  body  rests 
solely  on  those  tuberosities,  and  not  at  all  upon  the  coccygeal  extremity.  This 
circumstance  furnishes  us  a  reason  why  transverse  contractions  of  the  pelvis  are 
far  more  frequent  at  the  inferior  strait  than  the  antero-posterior  ones. 

The  three  notches  also  require  a  passing  notice ;  thus,  the  two  postero-lateral 
ones  are  very  deep,  but  when  the  sciatic  ligaments  have  been  preserved,  they  are 
comparatively  superficial ;  the  third  is  found  anteriorly ;  its  apex  corresponds  to 
the  inferior  part  of  the  symphysis  pubis,  its  base  to  a  line  drawn  between  the 
anterior  parts  of  the  tuberosities  of  the  ischia,  and  its  sides  are  formed  by  the 
ischio-pubal  rami.  The  term  arch  of  the  pubis  has  been  applied  to  this  notch. 
The  columns  of  the  arch  are  distorted  outwardly,  as  if  a  rounded  body  had  been 
forcibly  expelled  from  the  pelvis,  whilst  the  bones  were  soft,  and  had  pushed 
them  before  it ;  and  this  arrangement,  which  is  more  marked  in  the  female  than 
the  male,  favors  the  descent  of  the  head.  The  arch  is  three  and  a  half  to  three 
and  three-quarter  inches  broad  at  the  base ;  but  only  one  and  a  quarter  to  one 
and  a  half  inches  at  its  apex ;  in  height,  it  is  about  two,  to  two  and  a  half  inches. 
Hence  the  area  of  the  inferior  strait  will  not  present  a  uniform  plane  (should  it 
be  desirable  to  ascertain  the  irregularities  it  exhibits),  because  all  parts  of  its 


32 


FEMALE  ORGANS  OF  GENERATION. 


margin  are  not  upon  the  same  level.  However,  to  obviate  the  difficulty  met 
with,  in  determining  the  direction  of  this  plane,  Duges  has  divided  the  strait 
into  two  nearly  equal  portions,  the  one  anterior,  and  the  other  posterior,  meeting 
at  the  tuberosities  of  the  ischium,  and  each  presenting  a  distinct  plane  and  axis ; 
but  as  this  method  of  proceeding  uselessly  complicates  the  question,  we  prefer 
considering  the  terminal  plane  of  the  pelvis,  as  represented  by  the  coccy-pubal 
line,  thus  leaving  out  the  lateral  projections  altogether. 

The  question  is  then  reduced  to  these  terms  :  What  is  the  direction  of  the  line 
that  extends  from  the  point  of  the  coccyx  to  the  inferior  part  of  the  symphysis 
pubis  ? 

Writers,  likewise,  variously  describe  this;  for  instance,  according  to  the  majo- 
rity of  the  French  accoucheurs,  the  plane  of  the  inferior  strait  is  slightly  oblique, 
from  below  upwards,  and  from  behind  forwards,  so  that  it  would  unite  with  that 
of  the  superior  strait  (if  prolonged)  in  front  of  the  symphysis  pubis.  On  the 
other  hand,  M.  Naeg^le  concludes,  from  his  numerous  researches,  that  the  incli- 
nation of  the  antero-posterior  diameter  of  this  strait  is  from  10°  to  11°  from  the 
horizon,  and  that  the  point  of  the  coccyx  is  found,  as  a  mean,  from  a  half  to 
three-quarters  of  an  inch  higher  than  the  summit  of  the  pubic  arch ;  and,  there- 
fore, the  cocey-pubal  line  is  a  little  oblique  from  above  downwards,  and  from  be- 
hind forwards.  The  lower  extremity  of  the  axis  of  this  plane  of  the  inferior 
strait  would  cut  the  coccy-pubic  diameter  at  right  angles,  and  terminate  above  at 
the  sacro-vertebral  angle.  As  a  further  result  of  his  labors,  he  has  found  that, 
in  five  hundred  well-formed  persons,  of  different  statures,  four  hundred  and  fifty- 
four  have  the  point  of  the  coccyx  more  elevated  than  the  inferior  portion  of  the 
symphysis ;  in  twenty-six  it  was  lower,  and  in  twenty  individuals  both  points 
were  on  the  same  level.  M.  Velpeau  remarks,  as  we  think  with  some  reason, 
that,  at  the  moment  of  delivery, — the  only  time,  after  all,  when  it  is  requisite  to 
form  an  idea  of  the  direction  of  this  plane — the  point  of  the  coccyx,  being  pushed 

downwards  and  backwards  by  the  pas- 
Fig.  3.  sage  of  the  head,  is  at  least  on  a  level 
with,  if  not  lower  than  the  inferior  part 
of  the  symphysis. 

The  assertion  of  M.  Nseg^le,  there- 
fore, although  true  as  applied  to  the 
female  not  in  labor,  fails  during  partu- 
rition ;  and  it  must  be  admitted  that  the 
plane  of  the  inferior  strait  is  then  ob- 
lique from  below  upwards,  and  from  be- 
hind forwards. 

The  axis  of  this  strait  is  represented 
by  a  line  (a  b,  Fig.  3)  directed  from 
above  downwards,  and  from  behind  for- 
wards, which,  starting  from  the  first 
piece  of  the  sacrum,  falls  at  a  right 
angle  upon  the  middle  of  the  bis-ischi- 
atic  space.     The  remarks  made  upon  the  variations  in  the  direction  of  the  plane. 


c  d.  The  horizontal  line. 
ferior  strait  (during  labor) 
ferior  strait. 


c  €.  The  plane  of  the  in- 
a  b.  The  axis  of  the  in- 


OF     THE     PELVIS. 


33 


apply  with  equal  force  to  its  axis.  The  latter  crosses  the  axis  of  the  superior 
strait  in  the  excavation,  forming  with  it  an  obtuse  angle,  the  sine  of  which  is  in 
front. 

It  is  also  very  important  to  know  the  dimensions  of  the  perineal  strait,  and 
hence  obstetricians  describe  three  principal  diameters  at  that  point,  namely — 

1.  The   antero-posterior  or  coccy-pubal 

diameter  (a  a,  Fig.  4),  running  from  the  ^'S-  ^• 

point  of  the  coccyx  to  the  summit  of  the 

pubic  arch ;    it  is  usually  four  and    a 

quarter  inches  long,  but  may  increase  to 

four   and    three-quarter   inches    during 

labor,  by  the  retrocession  of  the  coccyx. 

2.  The  bis-ischiatic,  or  transverse  dia- 
meter, h  h,  is  four  and  a  quarter  inches 
in  length,  and  goes  from  one  tuberosity 
of  the  ischium  to  the  other.  3.  The 
oblique  diameter,  c  c,  commences  at  the 
middle  of  the  great  sacro-seiatic  liga- 
ment, and  crosses  to  the  point  of  union 
of  the  ascending  branch  of  the  ischium, 
with  the  descending  ramus  of  the  pubis,  and  is  four  and  a  quarter  inches  long, 
but  may  become  one  quarter  of  an  inch  more  during  labor,  from  the  elasticity  of 
these  ligaments. 

All  the  diameters  of  the  inferior  strait  are,  therefore,  in  the  dried  pelvis,  about 
four  and  a  quarter  inches  in  length,  though  their  dimensions  are  susceptible  of 
great  variation  during  labor. 


a  a.  The  antero-posterior  or  coccy-pubal  diame- 
ter. 6  6.  Tlie  transverse  or  bis-ischiatic  diameter, 
c  c.  The  two  oblique  diameters. 


§  5.    Of  the  Excavation. 

The  excavation  is  that  space  comprised  between  the  superior  and  the  inferior 
.straits,  and  it  is  in  this  cavity  that  the  foetal  head  executes  its  principal  move- 
ments; and  it  is  somewhat  surprising  that,  until  quite  recently,  this  canal  was 
scarcely  mentioned  in  the  majority  of  the  classic  works,  notwithstanding  the  im- 
portance of  a  knowledge  of  its  dimensions,  as  also  of  the  direction  of  its  plane 
and  axis. 

Its  dimensions  comprise  both  the  height  and  width  at  the  different  points : 
thus  the  height  in  front,  is  one  and  a  half  inches;  upon  the  sides,  three  and 
three-quarter  inches ;  whilst  it  is  four  and  a  quarter  inches  behind,  if  a  straight 
line  be  drawn  from  the  sacro-vertebral  angle  to  the  point  of  the  coccyx,  and  five 
inches  and  a  quarter,  following  the  curve  of  the  sacrum. 

Three  diameters  are  also  described  for  this  cavity  (like  the  straits),  so  as  to 
appreciate  its  extent  in  the  different  directions.  All  of  them  are  taken  at  the 
centre  of  the  excavation,  and  they  consist  of  an  antero-posterior  one,  of  four  and 
three-quarters  to  five  and  one-eighth  inches  in  length,  a  transverse  diameter  four 
and  three-quarter  inches  long,  and  an  oblique  one,  of  the  same  length ;  conse- 

3 


34 


FEMALE  ORGANS  OF  GENERATION. 


quently,  all  the  diameters  of  this  cavity  are  very  nearly  four  and  three-quarter 
inches  each.  "^ 

If  the  canal  forming  the  excavation  were  a  cylinder,  it  would  only  be  neces- 
sary to  divide  it  by  a  plane,  perpendicular  to  its  walls,  in  order  to  represent  the 
opening  of  this  cavity,  but  a  simple  division,  thus  made,  would  not  give  a  just 
conception  of  the  excavation,  for  two  reasons  :  First,  the  canal  is  not  cylindrical, 
because  its  sides  are  not  parallel,  and  the  anterior  face  of  the  sacrum  presents  a 
well-marked  curvature;  the  pubic  wall  being  nearly  straight,  and  the  lateral 
parietes  very  oblique  from  without  inwards,  and  from  above  downwards.  Con- 
sequently, to  furnish  an  exact  idea  of  the  general  arrangement  of  the  pelvic  ex- 
cavation, it  seems  necessary  to  divide  the  canal  (vide  Fig.  5)  by  a  series  of 
planes,  all  passing  from  the  point  c  (the  point  of  intersection  of  the  planes  of  the 
superior  and  inferior  straits)  to  any  point  whatever,  p  q  r  s  tyOn  the  anterior  face 

of  the  sacrum.  Each  of  these  planes 
Fig.  5.  will  show  the  opening  of  the  pelvic 

cavity  at  the  level  where  it  is  found. 
Now,  to  determine,  with  certainty, 
the  direction  of  the  general  axis  of 
this  excavation,  it  is  requisite  to 
raise  a  perpendicular  line  from  the 
geometrical  centre  of  each  of  these 
sections,  and  to  draw  a  line  <j  k 
through  the  base  of  each. 

This  line  g  k  (which,  as  the  stu- 
dent will  observe,  is  not  straight)  is 
called  the  general  axis  of  the  pelvis. 
It  is  now  readily  understood  that 
this  line  is  nearly  parallel  to  the 
anterior  face  of  the  sacrum,  and  its 
extremities  correspond  with  the  axes 
of   the   superior   and   the    inferior 

The  axis  of  ihe  superior  slrait.    ff  Ar.  The  axis  of  the  exca-    ^^^^j^        j^^  ^^-^    ^^^^^    ^^^^^j 

vation.    pqrst.  Various  points  taken  on  the  sacrum  to  ■'  '  •' 

show  the  plane  ofthe  excavation  at  each  point.  represents    the    wholc    axis     of    the 

pelvis,  or,  in  other  words,  the  line 
which  the  foetus  must  follow  in  traversing  the  pelvic  excavation. 

We  have  considered  the  line,  representing  the  entire  axis  of  the  excavation 
(perhaps  incorrectly),  as  a  simple  curve ;  for  M.  Naeg5le  has  well  observed,  that 
it  cannot  be  composed  of  two  straight  lines,  as  often  taught,  nor  is  it  a  simple  arc 
of  a  circle.  In  fact,  the  anterior  face  of  the  bodies  of  the  first  two  bones  of  the 
sacrum  forms  a  straight  line ;  the  sacral  curve  embracing  only  the  last  three 
bones.  Consequently,  the  central  line,  which  is  evidently  parallel  to  this,  will 
consist  of  a  straight  and  a  curved  portion — straight,  for  that  part  of  the  excava- 
tion corresponding  to  the  two  superior  vertebraj,  and  curved  in  the  space,  which 
is  bounded  behind  by  the  last  three  sacral  vertebrae,  and  in  front  by  the  anterior 
pelvic  walls. 


a  6.  The  plane  ofthe  superior  strait,  j  d.  Tlie  plane  ot 
the  inferior  strait,  c.  The  point  where  lliese  two  pliuies 
would  meet,  if  prolonged,    to  n.  The  horizontal  line.    ef. 


of   the    pelvis.  35 

§  6.    Base  of  the  Pelvis. 

The  base  of  tlie  cone,  represented  by  the  pelvis,  has  its  circumference  directed 
upwards  and  in  front ;  it  exhibits  behind,  a  notch,  into  the  bottom  of  which  the 
base  of  the  sacrum  projects,  and  which  is  further  filled  up  by  the  last  lumbar 
vertebrae  (generally  left  in  situ  to  complete  the  posterior  wall  of  the  greater  pelvis) 
by  the  ilio-lumbar  ligaments,  and  by  the  quadratus  lumborum  muscles ;  2,  out- 
wardly, the  anterior  two-thirds  of  the  iliac  crest  furnishing  attachments  to  the 
external  and  the  internal  oblique  and  transversalis  abdominis  muscles;  and  3,  in 
front,  the  anterior  superior  and  inferior  spinous  processes  of  the  ilium,  the  groove 
for  the  passage  of  the  conjoint  muscles — the  psoas  magnus  and  iliacus  internus, 
the  ilio-pectineal  eminence,  the  superior  border  of  the  horizontal  branch  of  the 
pubis,  the  spine,  and  lastly,  the  upper  margin  of  the  symphysis  of  this  bone. 

§  7.   Differences  of  the  Pelvis. 

1.  According  to  the  sex.  Considered  as  a  whole,  the  pelvis  in  the  male  is 
smaller  but  deeper,  the  bones  are  thicker,  and  the  muscular  impressions  more 
marked,  than  in  the  female.  The  superior  strait  being  more  retracted,  resembles 
the  figure  of  a  heart  on  a  playing  card.  The  excavation  is  not  so  wide,  though 
it  is  deeper,  especially  in  front,  owing  to  the  greater  length  of  the  symphysis 
pubis ;  the  arch  of  the  pubis  is  straight,  nearly  triangular  in  its  shape,  and  is  not 
widened  in  front.  The  coccyx  is  early  joined  to  the  sacrum,  and  the  articula- 
tions of  the  pelvis  are  much  sooner  anchylosed  than  in  the  female.  In  the  latter, 
we  may  add,  that  the  iliac  fossae  are  larger  and  more  warped  outwardly  (whence 
the  prominence  of  the  haunch  bones),  and  the  iliac  crest  less  twisted  in  the  form 
of  an  italic  /;  the  interval  separating  the  angle  of  the  pubis  from  the  cotyloid 
cavity  is  more  considerable,  causing,  in  part,  the  projection  of  the  great  trochan- 
ters, and  a  wider  separation  of  the  femurs ;  the  superior  strait  is  larger  and  more 
elliptical ;  the  curve  of  the  sacrum  deeper  and  more  regular ;  the  tuberosities  of 
the  ischium  are  farther  apart ;  the  pubic  symphysis  shorter ;  the  foramen  thyroi- 
deum  more  triangular ;  the  arch  of  the  pubis  broader,  more  rounded,  and  more 
curved,  and  the  lateral  borders,  formed  by  the  ischio-pubic  ramus,  more  contorted 
outwardly. 

2.  According  to  the  age.  At  birth,  the  pelvis  is  extremely  narrow  and  elon- 
gated, and  of  such  inconsiderable  dimensions,  that  its  cavity  will  not  contain 
several  of  the  organs  afterwards  found  in  it ;  from  which  circumstance,  the  pro- 
tuberance of  the  belly,  observed  in  the  foetus  and  in  children  at  term,  in  great 
measure  results;  the  excavation  has  the  form  of  a  cone,  the  abdominal  strait 
being  strongly  inclined  downwards;  the  sacrum  is  nearly  flat,  and  so  much  ele- 
vated that  a  horizontal  line  drawn  from  the  superior  part  of  the  pubis  would  pass 
beneath  the  coccyx;  the  coxal  bones  are  narrow,  elongated,  and  nearly  straight 
at  their  superior  part,  and  the  cartilaginous  iliac  crests  are  not  twisted. 

From  this  disposition,  it  necessarily  happens  that  the  greatest  diameter  of  the 
pelvis  extends  from  the  sacrum  to  the  pubis.  Burns  declares  that  this  form 
changes  by  degrees  as  the  little  girl  advances  in  age :  thus,  the — 


36 


F  E  51  A  I-  E     ORGANS     OF     G  E  N  E  H  A  T  I  0  X. 


Antero-posterior 

diameter 

At  9  years. 

Al  10  yenrs. 

At  13  years. 

At  14  years. 

At  18  years. 

2-|  inches 
2i      " 

3J  inches 
3  in.  5  lines 

3\  inches 
3|      " 

3f  inches 
4 

3|-  inches 
4^      " 

'  Transverse 

do.     .     . 

§  8.  Uses  of  the  Pelvis. 

The  pelvis  constitutes  the  base  of  the  trunk,  and,  according  to  Desonneaux,  it 
forms  a  complete  ring,  that  may  be  reduced  to  two  arches;  the  posterior  and 
superior  of  which  receives  the  whole  weight  of  the  trunk,  whilst  the  anterior 
and  inferior  one  serves  as  a  buttress  to  it. 

The  two  lower  extremities  are  attached  to  the  lateral  parts  of  this  circle,  and 
support,  in  the  erect  posture,  all  the  weight  of  the  superior  part  of  the  body. 
This  use  of  the  pelvis  satisftictorily  explains  to  the  accoucheur  the  vicious  forms 
the  cavity  often  assumes  when  ossification  is  retarded,  or  whenever  any  disease 
alters  and  softens  the  bones. 

Another  function  of  the  pelvis  is  to  enclose  and  protect  the  bladder,  rectum, 
and  seminal  vesicles  of  the  male;  the  uterus.  Fallopian  tubes,  and  ovaries  in  the 
female.  During  gestation,  it  sustains  and  gives  a  proper  direction  to  the  womb; 
and  in  labor,  it  affords  a  passage  to  the  child. 


ARTICLE   IV. 

OF   THE   PELVIS,  COVERED   BY   THE   SOFT   PARTS. 

It  will  not  suffice  to  study  the  pelvis  as  found  in  the  skeleton  alone,  for  the 

changes  produced  in  its  form  and 
dimensions  in  the  living  female, 
by  the  arrangement  of  the  soft 
parts,  also  require  our  special  at- 
tention. 

Being  continuous  above  with  the 
abdomen,  the  great  pelvis  encloses 
andsuppoi'ts  the  mass  of  the  intes- 
tines, and  affords  points  of  attach- 
ment by  its  walls  to  two  orders  of 
muscles.  The  one  destined  to 
form  the  enclosure  of  the  belly 
fills  the  large  opening  exhibited 
in  front,  and  thus  constitutes  the 
anterior  abdominal  wall ;  the  ex- 
tensibility of  which,  in  compari- 
son with  the  resistance  of  the 
posterior  plane,  accounts  readily 


Pelvis,  with  the  soft  parts  seen  from  above. 
A.  A  section  of  the  aorta,    b.  The  vena  cava  interior,    c. 
The  internal  iliac  artery,  arising  together  with  n.  the  exter- 
nal iliac,  from  the  primitive  iliac  trunk,    e.  External  iliac     „        ,  ,  „     , 
vein.     F,  The  iliacus  internus,  and  a,  the   psoas   magnus     lOf  taC  tendency  of  the  utcrUS  tO 

muscles,    h.  The  rectum,    i.  The  uterus  with  its  appen-   incline  forward  in  the  advanced 

(lages.    K.  The  bladder,  the  fundus  of  which  is  depressed  so 
as  to  bring  the  womb  into  view. 


stage  of  gestation.      The  others, 


OFTHEPELVIS.  37 

two  in  number,  are  placed  in  the  iliac  fossae ;  they  are  the  iliacus  internus,  and 
the  psoas  ruagnus  muscles,  which,  from  being  situated  on  the  lateral  parts  of  the 
abdominal  strait,  change  both  its  form  and  dimensions.  The  first  of  these  has  radi- 
ated fibres,  and  occupies  the  iliac  fossae ;  the  second  descends  from  the  sides  of  the 
lumbar  vertebrae,  and,  after  having  been  joined  to  the  preceding,  is  inserted  into 
the  lesser  trochanter  of  the  thigh  bone.  These  two  muscles,  surrounded  and  confined 
by  an  aponeurosis  (fascia  iliaca),  may  be  regarded  as  a  sort  of  cushion,  forming 
a  convenient  support  to  the  developed  uterus,  and  destined  to  protect  it  by  the 
elasticity  of  the  soft  parts  against  the  shocks  and  concussions  continually  pro- 
duced by  locomotion.  Notwithstanding  the  presence  of  these  muscles,  the  strait 
still  resembles  a  curvilinear  triangle  in  shape^  the  base,  however,  of  the  triangle 
being  in  front  instead  of  behind,  as  it  was  in  the  dried  pelvis ;  the  transverse 
diameter  is  diminished  half  an  inch  by  their  presence ;  the  antero-posterior  one 
is,  perhaps,  a  little  abridged  by  the  thickness  of  the  vesical  walls,  uterus,  and 
soft  parts  that  line  the  posterior  face  of  the  symphysis  and  anterior  surface  of  the 
sacrum,  the  oblique  diameters  alone  remaining  unchanged;  the  location  of  the 
rectum,  however,  on  the  left,  shortens  slightly  the  corresponding  diameter. 

The  modification  of  the  transverse  diameter,  produced  by  the  psoas  muscles, 
is  always  much  less  when  these  are  in  a  state  of  relaxation  from  the  flexure  of 
the  thighs.  Finally,  as  Baudelocque  has  remarked,  the  bis-iliac  diameter  is 
diminished  in  length,  in  proportion  to  the  thickness  of  these  muscles,  and  the 
antero-posterior  one  being  more  contracted,  the  strait  becomes  more  elliptic  or 
rounded.  Two  muscles  are  also  found  on  each  side  of  the  excavation,  coveriuo- 
the  obturator  and  ischiatic  foramina;  namely,  the  obturator  internus,  and  the 
pyramidales.  Flamand  attributes  the  movements  of  rotation,  executed  by  the 
head  in  the  pelvis,  to  the  action  of  these  muscles ;  but  the  same  reasons  that 
caused  us  to  reject  the  influence  of  the  inclined  planes  on  this  process,  equally 
deter  us  from  entertaijiing  the  opinion  of  the  Professor  of  Strasbourg.  The 
pelvic  cavity  is  still  further  diminished  by  the  rectum,  bladder,  and  cellular 
tissue  J  more  especially  when  the  latter  is  loaded  with  fat.  Consequently,  the 
foetal  head  descends  with  more  difficulty  in  very  corpulent  women  than  in 
others. 

The  perineal  strait,  although  open  in  the  dried  skeleton,  is  here  occupied  by 
a  sort  of  contractile  concave  partition,  which  sustains  the  viscera  of  the  pelvic 
and  abdominal  cavities.  This  floor,  so  to  speak,  is  composed  of  two  muscular 
planes;  the  interior  of  which,  formed  by  the  levator  ani  and  coccygeal  muscles, 
is  concave  above ;  and  the  other,  having  its  concavity  below,  is  constituted  by 
the  sphincter  ani,  the  transversus  perinei,  the  ischio-cavernous,  and  the  con- 
strictor vaginae  muscles.  The  internal  pudic  vessels  and  nerves,  a  large  amount 
of  cellular  tissue,  the  skin,  the  pelvic  aponeurosis,  and  an  inter-muscular  apo- 
neurosis complete  this  floor,  which,  in  the  hour  of  labor,  ought  to  become  thin 
and  distended,  but  which  occasionally  ofi'ers  such  an  obstacle  to  the  spontaneous 
delivery  of  the  foetus  as  to  require  the  intervention  of  art. 

The  extent  of  the  perineum,  in  its  ordinary  condition,  is  three  inches,  namely  : 
from  the  point  of  the  coccyx  to  the  anus,  there  are  one  and  three-quarter  inches, 


38 


FEMALE  ORGANS  OF  GENERATION. 


and  from  the  anus  to  the  vulva,  one  and  one-quarter  inches;  but  at  the  instant 
of  the  passage  of  the  head  through  the  genital  fissure  it  becomes  so  distended, 
that  the  interval  separating  the  anterior  commissure  from  the  coccyx,  is  increased 
from  four  to  four  and  three-quarter  inches. 

It  must  now  be  evident  that  the  terminal  outlet  of  the  pelvic  canal,  in  the 
pelvis,  covered  with  its  soft  parts,  is  not  at  the  point  of  the  coccyx,  but  rather  at 
the  anterior  commissure  of  the  perineum ;  in  fact,  the  latter  is  so  greatly  dis- 
tended in  the  last  moments  of  labor,  that  its  anterior  border  goes  beyond  the  in- 
ferior part  of  the  symphysis  pubis,  thereby  prolonging  very  considerably  the 
posterior  wall  of  the  pelvic  excavation,  and,  as  a  consequence,  the  canal  to  be 
traversed  by  the  foetus.  Wherefore,  the  direction  in  which  the  head  is  ulti- 
mately disengaged  is  not  represented  by  the  axis  of  the  infei'ior  strait,  but  by 
that  of  a  plane  which  may  be  drawn  from  the  lower  part  of  the  symphysis  to  the 
anterior  commissure  of  the  distended  perineum. 

Hence,  in  order  to  form  an  exact  idea  of  the  line  traversed  by  the  foetus,  from 
its  entrance  into  the  superior  strait  until  its  final  exit  from  the  vulva,  it  will  be 
necessary  to  continue  the  operation  already  pursued  upon  the  anterior  face  of  the 
sacrum  (see  page  34)  over  the  curve  represented  by  the  anterior  face  of  the  dis- 
tended perineum ;  that  is,  to  make  a  series  of  planes  from  the  point  c  (Fig.  5) 
to  the  divers  parts  of  the  perineal  curve;  and,  from  the  centre  of  each,  raise  a 
perpendicular,  so  as  to  form  by  their  union  a  complete  axis,  the  upper  extremity 
of  which  is  the  axis  of  the  superior  strait;  the  middle  part,  a  curved  line,  having 


Fig.  7. 


\^ 


Position  of  the  pelvis  and  Uie  direcuuu  of  its  axi?  in  the  dorsal  attitude  assumed  by  the  female 

during  lahor. 
a  b.  Total  axis  of  the  excavation,  being  a  continuation  of  d  b,  the  axi»  of  the  superior  strait,    c  v.  Peri- 
neum as  diilended  at  the  moment  of  the  passage  of  tlie  head.    r.  Anal  orifice,    e  v.  Terminal  plane  of  the 
pelvis. 

its  concavity  anterior  and  its  convexity  parallel  to  the  front  face  of  the  sacrum 
and  perineum,  and  the  inferior  extremity  directed  from  before  backwards,  and 
slightly  from  above  downwards. 

It  must  not,  however,  be  forgotten,  that  the  direction  just  described  belongs 
to  the  vertical  posture,  and  that  it  becomes  remarkably  altered  in  the  various  atti- 


OF  THE  ORGANS  OF  GENERATION.  39 

tudes  assumed  bj  the  female.  Thus,  whilst  lying  upon  the  back,  as  is  usual  in 
France  during  labor,  the  plane  of  the  superior  strait  instead  of  looking  upward 
and  forward  will  be  turned  upward  and  backward,  and  its  axis  directed  from 
above  downward  and  from  behind  forward.  At  the  same  time,  the  plane  of  the 
inferior  strait,  which  before  looked  backward  and  downward,  will  be  turned  almost 
directly  forward,  its  axis  also  passing  directly  from  before  backward.  Finally, 
the  terminal  orifice  formed  by  the  contour  of  the  vulva  presents  another  plane, 
which,  at  the  moment  of  delivery  (the  horizontal  position  being  still  maintained), 
is  directed  upward  and  forward.  In  short,  the  central  line  followed  by  tbe  foetus 
during  its  expulsion  is  a  strongly-marked  curve,  whose  concavity  is  turned  almost 
directly  upward  (Fig.  7). 


CHAPTER   II. 

OF  'the  organs  of  generation. 

The  genital  apparatus  of  the  female  is  much  more  complicated  than  that  of 
the  male,  and  is  composed  of  organs  situated  in  the  interior  of  the  pelvis,  and  of 
parts  attached  to  its  exterior.  The  former  are  the  ovaries,  Fallopian  tubes,  uterus, 
and  vagina,  and  the  latter,  the  mons  veneris,  vulva,  and  perineum. 

SECTION   I. 

OF  THE  EXTERNAL  PARTS  OF  GENERATION. 

These  consist  of  the  mons  veneris,  vulva,  and  perineum. 

Art.  I. — Mons  Veneris. 

The  mons  veneris  is  a  rounded  eminence,  a  species  of  relief,  more  or  less  pro- 
minent according  to  the  embonpoint  of  the  individual,  situated  in  front  of  the 
pubis,  and  surmounting  the  vulva ;  this  eminence  is  partly  produced  by  the  bones, 
and  partly  by  the  subcutaneous  adipose  tissue  ;  the  skin  covering  it  is  very  thick 
and  elastic,  but  being  little  extensible,  it  cannot  aid  in  the  enlargement  of  the 
vulva,  as  asserted  by  M.  Moreau,  at  the  period  of  delivery.  In  the  adult  female, 
it  is  covered  with  hair,  and  contains  a  great  number  of  sebaceous  follicles. 

Art.  II. — Vulva, 

The  vulva  is  a  longitudinal  opening  or  fissure,  situated  on  the  median  line  at 
the  base  of  the  trunk  ;  being  bounded  in  front  by  the  mons  veneris,  behind  by  the 
perineum,  and  laterally  by  the  external  labia. 

"We  shall  comprise  in  its  description,  as  properly  appertaining  thereto,  all  the 
parts  included  between  the  labia  majora. 


40 


F  KM  ALE    ORGANS     OF    FENERATION. 


ExleriKil  sienital  psirtg. 
A.  Mons  veneris.  B.  Labia  majora.  C. 
Clitoris.  D.  Labia  miiiorn.  E.  Orifice  ot 
urethra.  F.  Orifice  of  vagina.  H.  Poste- 
rior commissure  of  tlia  vulva.  L  Peri- 
neum.   J.  Anus. 


1.  The  labia  majora,  or  labia  externa,  are 
two  cutaneous  folds,  flattened  transversely,  and 
thicker  in  front  than  behind,  which  bound 
the  opening  of  the  vulva  externally ;  com- 
mencing at  the  mons  veneris,  they  gradually 
recede  from  each  other,  as  they  pass  back- 
wards, nearly  to  their  middle,  where  they  again 
approach,  so  as  to  unite  at  the  posterior  ex- 
tremity, and  form  there  a  bridle  or  commis- 
sure called  the  fourcheUe,  which  is  generally 
lacerated  during  the  first  labor. 

The  labia  externa  present  an  external  or 
cutaneous  surface,  which  is  covered  with  hairs 
after  puberty ;  and  an  internal  one,  moist, 
smooth,  of  a  rose  color,  and  formed  by  a  mu- 
cous membrane  that  is  provided  with  a  consi- 
derable quantity  of  mucous  follicles. 

In  young  girls,  the  external  lips  are  some- 
what thicker  above,  and  approach  each  other 
closely ;  but  in  females  who  have  borne  chil- 
dren they  are  separated,  and  have  lost  their  regularity. 

They  consist  of  a  cutaneous  and  a  mucous  layer,  between  which  is  a  fibrous 
partition,  a  continuation  of  the  superficial  fiiscia  of  the  perineum.  Between  this 
aponeurosis  and  the  internal  surface  of  the  integument,  is  found  a  very  thick 
layer  of  cellulo-adipose  tissue,  filling  up  a  peculiar  pouch  hitherto  unknown  to 
anatomists  until  discovered  by  M.  Broca.  From  a  dissection  of  it  very  obligingly 
executed  before  me  by  the  skilful  prosector  of  the  Faculty,  the  account  of  it  is 
given.  The  interest  which  it  possesses  for  the  surgeon  and  the  physiologist,  in- 
duces me  to  describe  it  in  detail  in  the  note  below.* 

'  Imagine  a  membranous  pouch,  with  a  long  and  narrow  neck,  to  be  inserted  between  the 
skin  and  the  superficial  aponeurosis,  so  that  its  bottom  shall  be  towards  tlie  fourchette,  and 
its  orifice  directed  upward  and  outward,  terminating  at  the  external  inguinal  ring,  and  we 
shall  have  an  exact  idea  of  the  double  layer  which  I  am  about  to  describe. 

This  layer  commences  at  the  bend  of  the  groin,  in  front  of  the  opening  of  the  external 
inguinal  ring,  and  derives  its  fibres  in  great  part  from  the  fascia  superficiaUs  of  the  thigh 
and  abdomen ;  some  of  them,  however,  proceed  directly  from  the  spine  of  the  pubis  and 
from  the  external  pillar  of  the  ring.  These  fibres  then  descend  obliquely  from  above  down- 
ward, and  from  without  inward,  producing  a  conical  cavity,  the  narrowest  part  of  which  is 
uppermost,  and  is  large  enough  to  receive  the  forefinger  with  ease.  Enlarging  in  proportion 
as  it  descends,  this  membranous  pouch  becomes  flattened  from  before  backward,  and  lodged 
in  the  external  labium,  which  it  fills  accurately;  at  the  fourchette,  its  walls  come  in  contact, 
and  are  united  into  a  single  membranous  layer,  which  is  continuous  with  the /ascia  superfi- 
cialis  of  the  parts  by  the  side  of  the  anus. 

The  anterior  surface  of  the  pouch  is  devoid  of  adhesion ;  it  is  removed  from  the  skin  by  a 
little  adipose  tissue,  and  a  moderate  traction  efiects  its  separation.  It  may  also  be  readily 
isolated  with  the  handle  of  the  scalpel. 

The  posterior  surface  of  the  pouch  is  likewise  free  from  attachments  in  its  upi)er  half; 


OF  THE  ORGANS  OF  GENERATION.  41 

The  external  labia  are  provided  with  vessels,  both  arterial  and  venous,  and 
nerves  :  the  lymphatics  proceed  to  the  inguinal  glands. 

2.  The  ni/mphce,  or  labia  interna,  are  brought  into  view,  by  separating  the 
external  lips,  under  the  form  of  two  mucous  folds,  resembling  the  comb  of  a 

but  below  this,  that  is  to  say,  from  the  orifice  of  the  urethra  to  the  foiirchette,  it  adheres  to  the 
superficial  aponeurosis  and  can  only  be  separated  from  it  by  dissection.  At  the  point  of  in- 
sertion of  the  corpus  cavernosum  upon  the  iliac  bone  its  detachment  is  well-nigh  impossible, 
for  there  the  fibres  of  the  pouch  are  inserted  directly  upon  the  bone  and  blended  with  the 
superficial  aponeurosis. 

The  external  border  of  the  pouch  is  free  in  its  upper  half,  but  from  the  place  of  attachment 
of  the  corpus  cavernosum,  it  adheres  to  the  ischio-pubic  ramus.  The  result  is,  that  the  upper 
part  of  this  border  forms  a  species  of  arch,  with  the  concavity  turned  outward,  the  lower  ex- 
tremity being  implanted  upon  the  ischio-pubic  ramus,  and  the  upper  upon  the  external  pillar 
of  the  inguinal  ring. 

The  internal  border  of  the  pouch  is  also  free  in  its  upper  half;  here,  however,  some  of  its 
fibres  are  lost  in  the  suspensory  ligament  of  the  clitoris.  The  lower  half  of  this  border  is 
adherent  to  the  mucous  membrane  of  the  external  labium,  some  of  its  fibres  being  even  in- 
serted directly  upon  the  integument. 

The  cavity  of  the  pouch  is  filled  with  fat,  which  I  have  never  known  to  be  wanting  even 
in  the  most  emaciated  subjects.  What  is  most  important  to  observe  is,  that  the  round  liga- 
ment, after  having  contributed  some  of  its  fibres  to  the  periosteum  of  the  pubis,  enters  the 
neck  of  the  pouch,  traverses  it  throughout  its  length,  dividing  at  the  same  time  into  several 
cords  of  a  pearly  whiteness,  and  descends,  still  remaining  in  the  cavity  of  the  pouch,  to  lose 
itself  in  the  thickness  of  the  external  labium,  where  it  can  be  followed  no  longer. 

Finally,  the  structure  of  the  walls  of  the  pouch  is  evidently  fibrous,  all  the  fibres  being 
parallel  and  inclined  downward  and  inward  ;  they  are  of  a  yellowish-white  color,  and  ma- 
nifestly elastic.  The  elasticity  is  greater  in  recently-delivered  females,  and  the  fibres  are 
then  reddish  and  form  a  thicker  layer. 

The  analogy  between  this  pouch  and  the  dartos  of  the  male  is  complete ;  both  have  the 
form  of  a  sack,  they  are  in  direct  connection  with  the  surrounding /asda  superficialis,  of  which 
they  are  but  a  transformation,  and  both  are  connected  with  the  femoral  arch,  the  pubis,  and 
the  suspensory  ligament.  One  is  situated  in  the  external  labia,  and  the  other  in  the  scro- 
tum, which  is  universally  regarded  as  the  analogue  of  the  external  labia.  One  surrounds 
the  testicle  and  its  dependencies,  whilst  the  other  receives  the  round  ligament  only;  yet  the 
analogy  between  this  ligament  and  the  gubernacxdum  testis  cannot  be  mistaken :  besides,  if 
we  refer  to  the  period  of  intra-uterine  life  in  which  the  testicle  still  remains  in  the  abdomen, 
we  find  the  resemblance  between  the  dartos  of  the  male  and  that  of  the  female  to  be  com- 
plete. The  only  diflerence,  results  from  the  presence  of  the  vulva  in  the  female.  The  juxta- 
position of  tbe  two  pouches  of  the  dartos  in  the  male  produces  a  partition  which  is  often  im- 
perfect; whilst  in  the  female  the  two  sacks  being  separated  by  the  genital  fissure  can  have 
no  immediate  connection  with  each  other. 

The  dartos  of  the  female  plays  an  important  part  in  the  diseases  of  the  external  labia. 
Inguinal  hernia  descends  inevitably  into  its  cavity.  The  tumors  known  as  hydroceles  of  the 
female,  which  are  in  reality  cysts  of  the  external  labia  increasing  from  below  upward  and 
entirely  independent  of  the  canal  of  Nuck,  these  tumors,  I  repeat,  must  be  situated  within 
the  pouch  of  the  dartos,  for  thus  alone  can  the  uniformity  of  their  relations  with  surrounding 
parts,  and  the  identity  of  their  shape,  which  is  ovoid,  with  the  upper  end  directed  outward, 
be  explained. 

Lastly,  the  effusions  of  blood  in  the  external  labia  as  a  result  of  contusions,  and  abscesses 
of  the  vulva,  all  give  rise  to  swellings  which  remain  circumscribed  by  the  exact  limits  of  the 
pouch  of  the  dartos,  and  which  I  am  therefore  convinced  must  be  contained  in  its  cavity. 


42  FEMALE  ORGANS  OF  GENERATION. 

young  cock.  Contracted  behind,  where  they  are  continuous  with  the  internal 
face  of  the  labia  externa,  they  spread  out  in  front  as  they  converge  towards  each 
other.  These  lips  scarcely  descend  to  the  middle  of  the  external  ones,  but  they 
mount  up  in  front  as  high  as  the  clitoris,  where  they  bifurcate ;  the  inferior 
branch  of  this  bifurcation  is  lost  in  the  clitoris;  but  the  other  surmounts  it,  joins 
its  fellow  of  the  opposite  side,  and  forms  above  this  body  a  little  fold  in  the  shape 
of  a  hood,  called  the  prepuce  of  the  clitoris.  At  birth,  the  nymphse  project  be- 
yond the  external  lips,  but  at  puberty,  they  are  concealed  by  the  latter.  Again, 
they  become  visible  in  child-bearing  women  ;  rather,  however,  by  the  separation 
of  the  labia  majora  than  by  their  own  prominence. 

Further,  their  dimensions  are  very  variable  in  diflferent  individuals,  and  in 
various  climates ;  thus,  in  certain  countries  of  Africa,  they  are  very  long,  and 
constitute  the  famous  apron  of  the  Hottentots.  Besides,  as  Velpeau  has  re- 
marked, these  parts  are  so  extensible  that,  under  the  influence  of  continual  trac- 
tions, they  may  become  vei-y  much  elongated.  I  have  met  with  a  young  female, 
in  my  own  practice,  who  was  afflicted  with  an  excessive  itching  at  the  vulva  at 
the  commencement  of  her  pregnancy.  To  relieve  this,  she  was  in  the  habit  of 
scratching  continually,  and  in  her  impatience  dragged  on  the  right  nympha,  so 
that,  in  less  than  a  fortnight,  it  had  become  twice  as  long  as  its  fellow. 

The  internal  lips  are  furnished  with  a  cryptous  apparatus,  visible  to  the  naked 
eye,  which  is  the  seat  of  an  abundant  sebaceous  secretion,  that  occasionally  be- 
comes very  irritating. 

3.  The  Clitoris. — Under  this  name,  a  little  erectile  tubercle,  resembling  the 
corpus  cavernosum  of  the  male  (except  in  volume),  is  described.  Its  free  ex- 
tremity appears  at  the  front  part  of  the  vulva,  about  half  an  inch  behind  the  an- 
terior commissure  of  the  labia  externa,  and  its  body  is  attached  by  two  crura  to 
the  ischio-pubic  rami ;  these  roots  ascend,  converging  and  increasing  in  size,  to 
the  level  of  the  symphysis,  where  they  unite  to  form  a  single  cavernous  body, 
flattened  on  its  sides,  which,  after  a  course  of  two  or  three  lines  in  front  of  the 
symphysis,  becomes  detached  and  curved  forward  so  as  to  present  a  convexity 
above  and  in  front,  at  the  same  time  growing  more  and  more  slender  towards  the 
free  extremity,  which  is  called  the  glans  clitoriclis. 

During  the  first  months  of  intra-uterine  life  it  is  difficult  to  make  out  the  dis- 
tinction of  the  sexes,  because  the  clitoris  is  as  long  as  the  penis;  even  in  the 
earlier  years  of  existence  its  dimensions  are  quite  considerable,  but  after  this 
period  it  ceases  to  grow,  and,  in  some  females,  apparently  diminishes.  Again,  in 
certain  rare  cases,  it  acquires  a  great  length ;  for  instance,  M.  Cruveilhier  has 
seen  one  whose  free  extremity  measured  two  inches,  and  a  case  is  on  record 
where  it  reached  from  four  and  a  quarter  to  five  inches.  Most  of  the  pretended 
hermaphrodites  may  be  referred  to  anomalies  of  this  kind. 

The  clitoris,  like  the  penis,  has  a  suspensory  ligament,  and  an  erector  muscle; 
the  canal  of  the  urethra  in  the  female,  passes  between  the  two  branches  of  the 
cavernous  body,  as  it  does  in  the  male.  ,. 

In  its  intimate  structure,  the  clitoris  consists  of  erectile  tissue;  and  hence,  the 
blood  determined  there  during  coition,  swells  it  up  and  causes  an  erection.     Ac- 


OF  THE  ORGANS  OF  GENERATION.  43 

cording  to  Cobelt,  the  glans-clitoridis  is  much  more  abundantly  supplied  with 
nerves  than  is  the  glans  of  the  penis,  and  is  asserted  by  all  authors  to  be  the 
principal  seat  of  voluptuousness  in  the  female. 

4.  The  vestibule  is  a  small  triangular  space  placed  at  the  upper  part  of  the 
vulva.  It  is  bounded  above  by  the  clitoris,  below  by  the  urethra,  and  laterally 
by  the  nymphas. 

5.  The  Urethra. — The  meatus  urinarius  is  situated  just  below  the  vestibule, 
about  an  inch  from  the  clitoris,  and  immediately  above  the  prominent  enlarge- 
ment of  the  anterior  part  of  the  vagina.  The  orifice  is  usually  more  contracted 
than  the  canal,  but  the  tubercle,  or  enlargement  just  alluded  to,  enables  us  to 
sound  females  without  uncovering  them,  for  it  is  only  necessary  to  recognize  it 
by  the  finger  in  order  to  direct  the  instrument  properly.  In  my  estimation,  the 
following  is  the  most  simple  method  of  introducing  the  catheter  without  uncover- 
ing the  patient :  I  first  introduce  my  finger  into  the  orifice  of  the  vagina,  and 
rest  its  palmar  face  against  the  anterior  vaginal  wall ;  I  then  slide  the  instru- 
ment along  this  palmar  face  until  it  is  arrested  by  the  fold  already  alluded  to, 
then  I  depress  the  extremity  so  as  to  elevate  the  point  of  the  instrument  one 
or  two  lines,  and,  in  the  majority  of  cases,  the  canal  is  easily  entered  in  this 
manner. 

The  difiiculties  experienced  in  sounding  pregnant  women  will  be  treated  of  here- 
after (article  Pregnancy). 

The  urethra,  a  continuation  of  the  meatus  urinarius,  just  described,  varies  in 
the  female  from  one  to  one  and  a  half  inches  in  length. .  It  is  large,  conical,  and 
slightly  curved.  Its  inferior  portion  is  confounded  with,  or  at  least  intimately 
united  to,  the  anterior  vaginal  wall,  and  its  anterior  parietes,  separated  in  front 
from  the  pubis  by  some  cellular  tissue  only,  is  located  on  a  level  with  the  sym- 
physis, under  the  junction  of  the  two  crura  of  the  clitoris. 

The  canal  of  the  urethra  is  muscular  and  erectile,  having  a  thick  lamina  of 
muscular  fibres,  which  seem  to  be  a  continuation  of  those  of  the  bladder ;  a  simi- 
lar one  of  spongy  tissue  lies  subjacent  to  the  mucous  membrane. 

Occasionally,  this  canal  is  enormously  dilated.  Flamand  met  with  a  case  that 
permitted  the  introduction  of  the  finger,  and  Meyer,  with  another,  which  eventu- 
ally admitted  of  coition  ! 

6.  The  Hymen. — ^^The  irregular  opening  of  the  vagina  is  found  beneath  the 
meatus  urinarius  j  it  is  of  variable  dimensions  after  coition,  and  in  females  who 
have  had  children  ;  but  in  virgins,  it  is  provided  with  a  membrane  by  which  the 
orifice  is  diminished.  This  membrane  is  the  hymen,  a  species  of  diaphragm,  in- 
terposed between  the  internal  organs  and  the  external  genital  apparatus  and  the 
urinary  passages.  It  resembles  a  crescent  in  shape,  the  concavity  being  ante- 
rior ;  sometimes,  the  horns  of  the  crescent  are  prolonged  enough  to  join  each 
other,  thus  forming  a  complete  circle,  perforated  in  the  centre  ;  its  free  margin 
is  thin  and  concave  j  the  convex  one  is  continuous  with  the  membrane  of  the 
vagina  or  vulva,  and  as  this  blocks  up  the  posterior  and  lateral  parts  of  the 
vagina,  a  notable  difierence  will  exist  in  the  extent  of  the  orifice,  dependent  upon 
the  greater  or  less  size  of  the  hymen. 


44 


FEMALE  ORGANS  OF  GENERATION. 


Sometimes  the  hymen  forms  a  complete  imperforate  membrane.  Though  often 
thin,  transparent,  and  very  fragile,  it  is  occasionally  found  thick  and  resisting. 

The  hymen  is  composed  of  a  fold  of  mucous  membrane,  containing  between 
its  laminae  a  few  vessels  and  some  areolar  tissue. 


Fig.  9. 


Fig.  10. 


Fi<r.  9.    Hymen  in  the  form  ot  a  crescent 

A.  Clitoris.  B.  Labia  externa,  c.  Labia  interna,  d.  Orifice  of  the  urethra,  e.  Hymen,  f. 
Orifice  of  the  vagina,    g.  Posterior  commissure  of  the  vulva. 

Fig.  10.  This  figure  exhihils  the  hymen  in  the  form  of  a  circle,  e.  The  hymen,  f.  Tlie  ceiural 
opening  somewhat  elongated. 

This  body  is  generally  ruptured  at  the  first  sexual  approaches,  and  of  its  debris 
are  formed  two  or  three  little  tubercles,  bearing  the  name  of  carunculcc  myrii- 
formes.  fiuch,  however,  is  not  uniformly  the  case,  and  the  different  shapes 
which  it  may  then  assume  have  been  reduced  by  M.  Velpeau  to  the  following 
varieties :  1.  In  the  semicircular  species,  the  hymen  may  form  such  a  narrow 
and  solid  fold  as  to  permit  copulation  without  being  ruptured.  2.  In  the  cres- 
centic  variety  (Fig.  9)  the  concave  border  approaches  more  or  less  towards  the 
urethra,  in  such  a  way  as  to  contract  the  vagina  behind,  and  hence  it  almost 
always  gives  way  in  coition.  3.  In  the  circular  variety,  the  free  border  is  much 
thinner  than  the  other  (Fig.  10),  often  being  fringed,  as  it  were,  and  leaving  an 
opening  which  is  sometimes  round,  sometimes  slightly  elongated,  though  in 
general  situated  somewhat  nearer  to  the  anterior  than  the  posterior  wall  of  the 
vagina.  4.  Again,  we  find  a  disk  or  complete  diaphragm,  that  is  ordinarily 
pierced  by  a  number  of  small  holes  like  those  of  a  watering-pot,  and  at  other 
times  is  without  the  least  aperture.  5.  In  some  instances  a  species  of  bridle,  or 
a  small  cord  attached  under  the  urethra,  or  on  the  concave  border  of  the  hymen, 
supplants  both  the  valve  and  the  circle.  6.  Lastly,  a  second  hymen  occasionally 
exists  above  the  first. 

This  membrane  is  regarded  as  the  seal  of  virginity;  and  yet,  as  just  shown, 
it  is  often  found  after  a  fecundation;  and,  on  the  other  hand,  numerous  causes 
besides  coition  may  destroy  it. 


OF  THE  ORGANS  OF  GENERATION.  45 

7.  The  caruncidce  myrtifonncs  are  some  little  tubercles,  two  to  five  in  num- 
ber, found  in  females  only,  which  appear  to  be  the  debris  of  the  ruptured  hymen; 
the  two  most  anterior  ones,  according  to  certain  physiologists,  appertain  to  the 
median  columns  of  the  vagina.^ 

8.  Fossa  Navicularis. — This  is  a  little  depression,  of  half  an  inch  only  in  ex- 
tent, bounded  behind  by  the  fourchette,  and  in  front  by  the  convex  border  of 
the  hymen.  It,  like  the  fourchette,  formed,  as  before  stated,  by  the  junction 
of  the  inferior  extremities  of  the  labia  majora,  mostly  disappears  after  delivery. 

Art.  III. — Of  the  Secretory  Apparatus  of  the  External  Organs 
OF  Generation. 

In  an  excellent  work  read  at  the  Academy  of  Medicine,  the  manuscript  of 
which  has  been  obligingly  delivered  to  me  by  M.  Huguier,  this  learned  surgeon 
divides  the  glandular  organs  of  the  vulva  and  vaginal  orifice  into  two  classes,  viz. : 
1.  Sebaceous  and  piliferous  follicles.     2.   Muciparous  organs. 

Class  first. — The  sebaceous  and  jiiH/erous  follicles  are  exceedingly  numerous, 
and  are  found  only  on  the  penil,  the  labia  majora,  and  the  genito-crural  folds. 
Those  of  the  lesser  labia  are  exclusively  sebaceous.  The  function  of  all  of  them 
consists  in  the  production  of  an  unctuous  matter,  adapted  to  the  maintenance  of 
the  flexibility,  moisture,  and  sensibility  of  the  external  genital  organs,  to  the  pre- 
vention of  adhesions  between  them,  and  especially,  to  protect  them  from  the  irri- 
tating influence  of  the  urine,  of  the  uterine  and  vaginal  secretions,  and  from  the 
perspiration,  which  in  some  persons  is  acid  and  irritating. 

Class  second. — The  muciparous  organs  diff"er  essentially  from  the  follicles,  both 
as  regards  their  situation  and  the  nature  of  the  fluid  which  they  secrete.  Their 
mode  of  arrangement  and  the  manner  in  which  their  secretions  are  discharged 
upon  the  entrance  of  the  vagina,  admit  of  their  being  noticed  as  two  varieties. 
Those  of  the  first  variety  are  disseminated  and  placed  beside  each  other  upon 
certain  points  of  the  vaginal  orifice,  or  else  they  are  grouped  and  collected  in 
patches.  Already  described  by  several  authors,  and  of  late  by  M.  Robert,  they 
are  called  by  M.  Huguier  isolated  or  agminated  mucipai-ous  follicles.  Those  of 
the  second  variety  are  united  and  heaped  upon  each  other  j  they  are  enclosed  in 
the  same  envelope,  and  discharge  through  a  common  excretory  canal.  Thus 
they  form  a  true  gland,  which  was  noticed  by  Bartholin,  but  is  better  described 
by  Huguier,  as  the  follictdar  hody  of  the  vat/inu,  or  the  vidvo-vaginal  gland. 

A.  Isolated  or  agminated  muciparous  follicles.  These  exist  at  three  or  four 
points  of  the  circumference  of  the  vaginal  orifice. 

1.  Some  six  or  eight  which  are  found  in  the  vestibule,  are  all  minute,  shallow, 

In  consequence  of  oft-repeated  friction,  these  caruncles  may  inflame,  degenerate,  and 
even  become  the  source  of  an  abundant  purulent  discharge ;  and  having  been  mistaken  under 
such  circumstances  for  syphilitic  vegetations,  the  patient  had  been  subjected  to  anti-venereal 
treatment,  which,  at  least,  was  useless.  Personal  cleanliness,  and  some  of  the  vegeto- 
mineral  lotions  are  usually  sufficient  to  cause  their  disappearance.  M.  Velpeau  has  resorted, 
however,  in  some  cases,  to  excision. 


46 


FEMALE  ORGANS  OF  GENERATION. 


Fig.  1]. 


iLit? 


simple,  and  variously  disposed.  Their  openings  are  very  small,  rounded,  and 
placed  so  obliquely  in  the  thickness  of  the  mucous  membrane  as  to  appear  covered 
by  a  kind  of  very  thin  valve,  which  may  be  raised  upon  the  end  of  a  stylet. 
These  are  called  by  M.  Ruguier  vestibular  follicles  (Fig.  11,  a). 

2.  Others,  termed  urethral  foil  ides  on  account  of  their  situation,  are  stated  by 
M.  Huguier  to  be  less  readily  discoverable  than  the  preceding,  on  which  account 

they  were  supposed  by  M.  Robert  to  be  less  nume- 
rous. They  are  of  considerable  size,  and  are  situ- 
ated at  a  depth  of  from  three-eighths  to  four-eighths 
of  an  inch  in  the  cellulo-vascular  tissue  of  the  ure- 
thra (Fig.  11,  c).  They  are  placed  beneath  the 
mucous  membrane  in  a  direction  parallel  to  the 
canal,  and  discharge  in  close  proximity  to  the  ori- 
fice of  the  urethra  upon  the  surface  of  the  projection 
which  forms  the  inferior  boundary  of  that  opening, 
in  such  a  way  as  to  form  a  semicircle,  or  sometimes 
even  an  entire  circle,  around  it.  They  are  closer 
together  than  those  which  have  been  just  described, 
and  sometimes  several  of  them  open  into  the  same 
excretory  cavity,  so  as  to  produce  the  ramified  ar- 
rangement which  Graaf  has  figured  and  described. 

3.  Laterally,  and  at  some  distance  from  the  ure- 
thral  orifice,  are   several  small   and  shallow  ones, 
with  a  common  opening  at  the  bottom  of  a  remark- 
M.  Huguier  states  that  these  are  often  absent,  and  he 
proposes  calling  them  the  lateral  urethral  follicles  (Fig.  11,  b). 

4.  Besides  these,  some  two,  three,  or  four  large  follicles  are  found  in  some 
females  upon  the  lateral  parts  of  the  vaginal  orifice,  immediately  below  the 
hymen  or  the  upper  carunculse  myrtiformes  (Fig.  11,  d)  ;  they  are  the  lateral 
Jjfillicles  of  the  orifice  of  the  vagina.  Their  openings  ordinarily  correspond 
neither  in  number,  situation,  nor  arrangement,  with  those  of  the  opposite  side; 
some  are  slightly  projecting  whilst  others  are  not  so,  and  some  are  readily  visible 
whilst  others  are  hidden  beneath  the  myrtiform  caruncles. 

B.  Vulvo-vaginal  gland. — This  gland  had  been  completely  lost  sight  of  by 
modern  anatomists,  although  described  by  Gaspar  Bartholin ;  and  attention  has 
only  recently  been  called  to  it  by  M.  Huguier.  It  belongs  to  the  class  of  conglo- 
merate glands.  There  are  two  vulvo-vaginal  glands,  one  on  each  side,  where 
they  form  peculiar  bodies  whose  position  it  is  important  to  define  with  exactness. 
They  are  situated  at  the  limits  of  the  vulva  and  vagina,  upon  the  lateral  and  pos- 
terior parts  of  the  latter,  about  three-eighths  of  an  inch  above  the  upper  surface 
of  the  hymen  or  of  the  myrtiform  caruncles,  in  the  triangular  space  formed  on 
each  side  by  the  juxtaposition  of  the  rectum  and  vagina,  upon  the  latter  of  which 
they  repose.  They  lie  at  a  distance  of  from  three-eightlis  to  five-eighths  of  an 
inch  from  the  internal  surface  of  the  ascending  rami  of  the  ischia,  and  from  three- 
quarters  of  an  inch,  to  one  and  a  quarter  inches  from  the  external  labia. 


able  conical  depression. 


OF    THE    ORGANS    OF    GENERATION. 


47 


12. 


The  vulvo-vaginal  gland  has  somewhat  the  shape  of  an  apricot  kernel,  resem- 
bling in  this  respect  the  lachrymal  gland;  like  the  latter,  its  two  surfaces  are  flat- 
tened, and  it  is  besides  slightly  lobular  and  mamelonated.  According  to  M. 
Hufuier,  it  is  much  flatter  in  women  who  have  borne  children,  which  he  attvi- 
butes  to  the  species  of  separation  which  its  granular  elements  must  undergo  from 
the  enormous  distension  of  the  vulva  during  labor.  The  gland  of  the  right  side 
does  not  always  resemble  that  of  the  left;  it  is  indeed  not  uncommon  to  find  one 
much  more  developed  than  the  other. 

Its  size  varies  much  according  to  age,  habits,  and,  adds  M.  Huguier,  according 
to  the  development  of  the  ovaries,  which  appear  to  exercise  a  decided  influence 
over  it ;  for  he  has  always  found  the  largest  gland  upon  the  same  side  with  the 
most  voluminous  ovary.  It  also  appears  larger  in  females  who  indulge  immode- 
rately in  sexual  pleasures.  Its  size  is  greatest,  in  general,  between  the  ages  of 
sixteen  and  thirty-five  years.  Its  diameter  at  this  period  of  life  is,  on  an  average, 
from  four-eighths  to  five-eighths  of  an  inch.  It  is  very  small  at  puberty,  and 
becomes  atrophied  in  old  age. 

Excretory  Duct. — Each  of  the  granules  of  which  the  gland  is  composed,  is 
furnished  with  a  minute  duct,  which  by  uniting  with  those  of  the  neighboring 
granules  gives  rise  to  three  separate  ducts.  The  latter  soon  join  to  form  a  single 
canal,  which  proceeds  from  the  internal  surface  and  vulvar  extremity  of  the  gland 
(Fig.  12,  D),  and  opens  in  virgins,  or  in  females  in  whom  the  hymen  has  been 
only  dilated,  in  the  internal  angle  which  the 
great  circumference  of  this  membrane  forms 
by  its  union  with  the  contour  of  the  vulvar 
opening,  and,  when  the  hymen  has  been 
ruptured,  at  the  base  of  the  lateral  and  pos- 
terior myrtiform  caruncles  (Fig.  12,  E). 
The  orifice,  which  is  smaller  than  the  duct 
which  it  terminates,  is  in  most  women  sur- 
rounded by  a  vascular  area,  which  serves, 
by  its  lively  red  color,  to  distinguish  it  from 
the  neighboring  parts.  If  required,  it  will 
only  be  necessary  to  turn  the  caruncle  in- 
ward in  order  to  render  it  conspicuous  :  it 
should  however  be  distinguished  from  three 
or  four  minute  openings  found  in  the  same 
furrow,  and  which  belong  to  the  lateral  fol- 
licles of  the  orifice  of  the  vagina. 

The  direction  of  the  opening  of  the  duct 
is  perpendicular,  but  its  oblique  orifice  is 
directed  upwards  and  inwards.  Its  external 
semi-circumference  is  provided  with  a  small 
falciform,  valvular  fold  of  mucous  mem- 
brane, which  increases  the  difficulty  of  its 
detection.  In  the  normal  condition  the  dia- 
meter of  the  orifice  hardly  exceeds  the  one-one-hundredth  of  an  inch 


Vulvo  vaginal  Gland. 
A  A.  Section  of  the  labia  inajora  and  of  the 
nymphw,  showing  the  excretory  duct  and  its 
ori6ce.  B.  The  arlaiid.  C.  Excretory  duct 
C.  Stylet  eiigascd  in  the  orifice  of  the  excre- 
tory duct.  D.  Its  glaiulular  extremity.  E.  Its 
vulvar  extremity  and  orifice.  F.  Bulb  of  the 
vagina.    G.  Ascending  ramu?  of  the  ischium 


48  FEMALE  ORGANS  OF  GENERATION. 

The  diameter  of  the  duct  varies  from  the  one-twenty-fourth  to  the  one-eighth 
of  an  inch,  and  its  length,  which  lessens  as  the  gland  is  more  voluminous  and 
approaches  nearer  the  myrtiform  caruncles,  is,  on  an  average,  about  five-eighths 
of  an  inch. 

Oryanization. — The  tissue  proper,  or  glandular  tissue,  is  of  a  yellowish- white 
color,  and,  when  examined  by  a  magnifier,  or  even  by  the  naked  eye,  appears 
composed  of  lobules,  themselves  formed  of  granulations  having  a  rounded  and 
hollow  appearance.  The  entire  mass  is  surrounded  by  a  fibro-cellular  envelope, 
the  thickness  and  transparency  of  which  varies  in  different  individuals.  From 
the  internal  surface  of  the  envelope  are  sent  off  a  great  number  of  fibrous  prolon- 
gations, which  serve  both  to  connect  and  separate  the  granules  of  the  organs. 

These  glands  are  provided  with  arteries,  veins,  lymphatic  vessels,  and  nerves. 
The  arteries,  two  in  number,  are  derived  from  the  clitoric  branch  of  the  internal 
pudic;  one  of  them  is  sometimes  given  off  directly  from  the  trunk  of  the  latter. 
The  veins,  which  form  a  sort  of  plexus  upcm  the  surface  of  the  organ,  empty 
partly  into  the  pudic  veins,  and  partly  into  the  venous  plexus  of  the  vagina  and 
the  bulb. 

The  lymphatic  vessels  proceed  to  the  lymphatic  ganglions  found  in  the  cellular 
triangle  included  between  the  lateral  parts  of  the  vagina  and  the  rectum,  and  not 
into  the  inguinal  glands. 

The  nerves  are  derived  from  the  deep  branch  of  the  perineo-vulvar  branch  of 
the  internal  pudic. 

M.  Huguier  is  inclined  to  believe,  from  the  result  of  his  injections,  that  the 
ultimate  ramifications  of  the  excretory  canal  have  a  direct  communication  with 
the  ramuscules  of  the  arteries  and  veins. 

When  the  glands  are  incised,  they  are  found  to  contain  a  glutinous,  thick,  and 
unctuous  fluid,  which  is  generally  colorless,  transparent,  or  slightly  turbid.  In 
some  cases  it  is  brownish  or  of  a  deep  chestnut  color,  which  appearance  is  due  to 
altered  blood  corpuscles. 

Uses  and  Functions. — The  vulvo-vaginal  gland,  like  the  entire  generative 
apparatus  of  which  it  forms  part,  acquires  its  full  development  only  at  puberty. 
This  concordance  alone,  independently  of  observation,  would  lead  to  the  supposition 
that  the  fluid  which  it  secretes  is  destined  to  bear  a  part  in  the  generative  act. 

The  amount  of  its  secretion  is,  in  fact,  variable.  It  is  especially  increased 
during  sexual  intercourse,  illicit  contacts,  and  under  the  influence  of  lascivious 
thoughts,  desires,  and  dreams.  When,  during  coition,  the  muscles  of  the  peri- 
neum and  vulva  are  excited  to  involuntary  and  convulsive  contractions,  it  is  ex- 
pelled in  an  intermittent  manner  or  by  jets,  as  is  the  sperm  in  the  ejaculation  of 
the  male.  According  to  M.  Huguier,  the  use  of  this  abundant  secretion  is  to 
lubricate  the  external  parts,  and  thus  render  the  first  approaches  less  painful,  to 
maintain  the  humidity  of  the  organs  during  the  act,  and  thereby  preserve  their 
extreme  sensibility. 

There  is  besides,  a  synergy  of  action  between  this  gland  and  the  muciparous 
follicles  of  the  vaginal  orifice,  which  is  satisfactorily  explained  by  the  anatomical 
connection  of  the  two  parts,  by  means  of  nerves  and  vessels  which  are  common 


OF     THE     ORGANS     OF    GENERATION. 


49 


to  both.     Therefore,  the  fluid  which  covers  the  entrance  of  the  vulva  and  of  the 
vagina  during  intercourse,  is  the  joint  product  of  the  gland  and  of  the  follicles. 

Art.  TV. — Perineum. 

9.  The  perineum  is  a  sort  of  bridge,  scarcely  an  inch  to  an  inch  and  a  half 
long,  which  separates  the  vulva  from  the  anus ;  its  inferior  plane  is  composed  of 
the  skin.  But,  for  a  more  full  description  of  the  parts  entering  into  its  struc- 
ture, I  must  refer  to  the  treatises  on  anatomy.     (Vide  art.  Pelvis.) 

SECTION   II. 

OF   THE    INTERNAL   PARTS. 

The  internal  parts  of  generation  are  the  vagina,  and  the  uterus,  together  with 
its  appendages,  the  Fallopian  tubeiwuid  ovaries. 

Art.  I. — Op  the  Vagina. 

The  vagina,  or  vulvo-uterine  canal,  is  a  cylindrical  membranous  tube,  extend- 
ing from  the  vulva  to  the  uterus;  it  is  situated  in  the  pelvic  excavation  between 


A  Vertical  Section  of  the  Pelvis,  showing  the  Org-ans  in  situ. 

B.  The  Madder  is  seen  in  front,  with  its  urethra  passing  out  under  the  eymphysie.  Just  behind  it,  ihe 
uterus  u,  and  the  vagina  v,  are  observed  to  occupy  the  middle  of  the  excavation;  the  rectum  h,  is  still 
more  posteriorly,  being  separated  from  the  vagina  by  the  recto-vaginal  septum,     p.  The  perineum. 

By  reference  to  the  upper  part  of  the  figure,  the  peritoneum  can  be  traced  from  the  anterior  abdominal 
walls  to  the  fundus  vesicae,  then  down  between  the  bladder  and  womb,  forming  a  pouch,  next  over  the 
fundus  uteri,  and  then  between  the  womb  and  rectum,  forming  another  pouch,  and  finally  to  the  posterior 
abdominal  wall. 

the  bladder  and  rectum  ;  extending  from  the  vulva  to  the  superior  strait,  it  has 
ofcour.se  the  same  direction  as  the  general  axis  of  the  pelvis;  that  is,  it  forms  a 

4 


50  FEMALE  ORGANS  OF  GENERATION. 

curve,  the  concavity  of  which  is  anterior ;  the  walls  are  soft  and  yielding,  flat- 
tened from  before  backwards,  with  their  surfaces  in  contact.  Its  length  varies 
from  four  and  a  quarter  to  five  and  a  quarter  inches,  though,  according  to  Pro- 
fessor Velpeau  (Lemons  Orales),  it  is  much  less  than  has  been  generally  imagined, 
or  than  he  himself  has  pointed  out  in  his  works,  being  hardly  two  and  a  quarter 
to  two  and  three  quarter  inches  long.  Although  this  remark  may  be  true,  if  the 
length  be  measured  in  the  dead  subject,  where  the  soft  flabby  walls  of  the  vagina 
easily  yield  under  their  own  weight  and  that  of  the  uterus,  and  in  consequence, 
the  vertical  extent  of  this  cavity  does  not  exceed  three  or  three  and  a  half  inches ; 
yet,  the  elasticity  of  these  walls  will  permit  the  introduction  of  a  speculum  five 
or  six  inches  long,  and  \then  the  uterus  is  raised  completely  above  the  superior 
strait,  the  estimate  of  the  Professor  of  La  Charite  is  certainly  below  the  truth. 

The  length  of  the  vagina  varies  in  different  females ;  thus,  for  instance,  the 
negress  has  it  longer  and  more  spacious  than  the  European,  as  a  general  rule. 
Professor  Chomel  informed  me  that  he  had  frequently  remarked  this  fact,  and  I 
have  since  had  occasion  to  verify  its  truth ;  nor  is  the  vagina  uniform  in  its  size, 
in  all  parts  of  its  extent ;  for  the  inferior  orifice  is  the  most  contracted,  the  supe- 
rior extremity  is  the  largest,  whilst  the  middle  part,  especially  in  women  who 
have  had  many  children,  frequently  exhibits  a  considerable  extension.  The 
walls  apparently  retract  in  aged  females,  and  greatly  diminish  the  area  of  its 
cavity,  returning  very  nearly  to  the  same  dimensions  as  are  found  in  young  girls. 

This  canal  is  sometimes  very  short,  reduced  even  to  one  and  a  half  or  two 
inches ;  but  this  congenital  brevity  must  not  be  confounded  with  the  apparent 
shortening  produced  by  the  descent  of  the  uterus.^ 

The  vagina  is  in  relation  by  its  external  face  :  in  front,  with  the  bas-fond  of 
the  bladder,  to  which  it  is  united  by  some  condensed  areolar  tissue,  and  also  with 
the  canal  of  the  urethra,  which  indeed  appears  to  be  channelled  out  in  its  sub- 
stance ;  behind,  it  is  connected  with  the  rectum,  superiorly  by  a  double  fold  of 
peritoneum,  and  inferiorly  by  areolar  tissue,  which  is  less  condensed  than  that 
existing  in  front.  Hence,  the  rectum  is  seldom  drawn  upon  in  the  displace- 
ments of  the  uterus,  whilst  the  bladder  always  participates  more  or  less  in  these 
accidents.  The  lateral  borders  afford  attachment,  above  to  the  broad  ligaments, 
and  below  to  the  pelvic  areolar  tissue  and  to  some  venous  plexuses. 

The  internal  face  of  the  vagina  is  covered  by  a  mucous  membrane,  continuous 

'  M.  Cruveilhier  says  these  cases  are  daily  confounded  in  practice,  though  nothing,  how- 
ever, is  easier  than  to  distinguish  them  from  each  other ;  for,  in  the  former  one,  the  uterus 
cannot  be  raised,  whereas,  in  the  case  of  descent,  it  yields  without  resistance  to  the  pressure 
of  the  finger,  and  resumes  its  natural  position. 

Congenital  shortening  is  a  frequent  cause  of  sterility,  as  well  as  of  sharp  pains  in  coition, 
and  is  a  fruitful  source  of  the  acute  or  chronic  inflammatory  engorgements  of  the  uterus.  I 
have  met  with  a  case  of  considerable  shortening  of  the  vagina,  in  which  the  os  tincre  had 
been  sufficiently  dilated  by  the  memhrum  virile,  to  admit  the  index  finger.  In  some  instances 
the  repeated  coition  produces  a  sort  of  artificial  vagina,  behind  the  os  uteri,  at  the  expense 
of  the  posterior  vaginal  wall,  and  if  the  finger  be  then  carried  under  the  neck  of  the  womb, 
it  will  dip  into  a  pocket,  the  anterior  wall  of  which  is  placed  against  the  posterior  one  of  the 
uterus.  This  artificial  vagina,  produced  by  forcing  up  the  posterior  cul-de-sac,  is  sometimes 
longer  than  the  natural  canal. — Analomie  Descrii  live. 


OF  THE  ORGANS  OF  GENERATION.  51 

witli  that  of  the  uterine  cavity,  excepting  that  its  epithelium  is  not  prolonged 
into  the  orifice  of  the  latter,  but  terminates  by  a  sort  of  denticulated  border, 
similar  to  the  relation  of  the  oesophageal  epidermis  with  the  stomach;  the  inter- 
nal surface  also  exhibits  some  wrinkles  or  rather  some  transverse  elevations  near 
the  vulvar  orifice.  A  raphe,  or  prominent  ridge  found  on  the  median  line,  ex- 
tends the  whole  length  of  the  anterior  wall  of  the  vagina,  affording  origin  to  all 
those  rugae ;  but  the  raphe  is  not  so  well  marked  on  the  posterior  parietes  as  on 
the  anterior;  the  term  columns  of  the  vagina  has  been  applied  to  these  two  ridges. 

The  transverse  rugae  are  much  better  developed  in  young  virgins  and  aged 
females;  but,  on  the  contrary,  during  pregnancy,  and  for  a  short  time  after  deli- 
very, they  are  nearly  effaced.  These  transverse  ruga3  have  by  some  physiologists 
been  regarded  as  organs  of  special  sensation,  and  as  designed  to  increase  friction 
by  the  irregularities  which  they  present. 

The  mucous  membrane  contains  a  large  number  of  muciparous  glands  that 
secrete  abundantly;  these  are  particularly  numerous  at  the  inferior  part  of  the  canal. 

The  superior  extremity  of  the  vagina  embraces  the  neck  of  the  uterus,  but  the 
manner  in  which  the  two  organs  are  connected  has. not  been  properly  studied. 
Thus,  M.  Dubois  fell  into  an  anatomical  error  which  I  think  it  important  to 
rectify,  when  he  stated  that  the  superior  extremity  of  the  vagina  is  attached 
to  the  circumference  of  the  uterine  neck,  precisely  upon  the  limit  indicated  by 
the  connection  itself,  between  the  vaginal  portion  and  the  part  above  the  vagina. 
At  its  upper  extremity,  the  vagina  is  composed  of  little  else  than  the  mucous 
membrane  and  the  fibrous  tunic,  the  dartoid  layer  being  nearly  absent.  The 
fibrous  tunic  extends  to  the  body  of  the  uterus,  when  it  becomes  blended  with 
the  tissue  proper  of  that  organ,  without  any  well-marked  line  of  demarcation. 
The  mucous  coat  alone  is  inflected  upon  the  external  surface  of  the  neck,  a  little 
lower  in  front  than  behind,  and  descends  to  the  external  orifice,  where  it  joins 
the  lining  membrane  of  the  cavity  of  the  neck.  The  adhesion  between  the  ex- 
ternal surface  of  the  mucous  coat  of  the  vagina  and  the  external  surface  of  the 
neck,  is  very  close  toward  the  lower  extremity,  but  at  the  upper  part,  is  very 
loose  and  easily  destroyed,  as  may  be  readily  proved  upon  the  dead  body.  If,  in 
fact,  the  vagina  and  uterus  be  entirely  removed,  it  will  then  be  seen  that  under 
the  influence  of  a  slight  traction,  the  portion  of  the  neck  which  projects  into  the 
vagina,  and  on  that  account  termed  sub-vaginal,  becomes  almost  completely 
effaced.  The  same  efi'ect  is  produced  at  an  advanced  period  of  pregnancy  (see 
Pregnancy),  when  the  uterus,  as  it  rises  in  the  abdominal  cavity,  draws,  neces- 
sarily, upon  the  upper  vaginal  attachments. 

In  thus  folding  upon  itself  in  order  to  embrace  the  neck,  the  mucous  mem- 
brane of  the  vagina  forms  a  circular  groove  or  cul-de-sac,  described  as  the  ante- 
rior and  posterior  cul-de-sac.  The  posterior  one  is,  generally,  deeper  than  the 
anterior,  owing  probably  to  the  insertion  of  the  vagina  behind,  upon  a  more  ele- 
vated point  of  the  neck. 

The  inferior  extremity,  or  vulvar  orifice,  presents,  in  front,  a  transverse  rugous 
prominence,  that  seems  to  diminish  the  entrance. 

Structure  of  the  Vagina. — The  parietes  of  the  vagina  are  formed  of  an  erec- 


52  FEMALE  ORGANS  OF  GENERATION. 

tile,  spongy  tissue,  interposed  between  two  very  strong  fibrous  laminse,  the  exter- 
nal of  which  is  the  thicker ;  around  the  erectile  tissue,  a  condensed  layer  of 
moderate  thickness  is  found,  analogous  to  the  structure  of  the  dartos  membrane ; 
and,  in  addition  to  these,  a  few  muscular  fibres,  that  constitute  what  is  erro- 
neously called  (see  below)  the  constrictor  vagina;  muscle,  are  situated  around  the 
outer  extremity.     lu  some  females,  this  is  quite  strong  and  well  developed. 

Finally,  under  the  name  of  huJh  of  the  vagina,  a  swelling  or  cavernous  body 
is  described,  that  separates  the  orifice  of  this  canal  from  the  roots  of  the  clitoris : 
moderately  thick  in  the  centre,  where  it  is  placed  between  the  meatus  urinarius 
and  the  junction  of  the  cruras  clitoridis,  it  gradually  swells  out,  as  it  recedes 
from  this  point,  and  terminates  below  in  an  enlarged  extremity  on  the  sides  of 
the  vagina,  being  deficient,  however,  on  the  posterior  wall  of  this  canal.  The 
length  of  the  bulb  when  injected,  is  about  one  inch  and  three-eighths  of  an  inch; 
its  greatest  width,  from  one-half  to  three-quarters  of  an  inch,  and  its  thickness 
from  about  three-eighths  of  an  inch  to  one-quarter  of  an  inch.  (Kobelt.)  The 
bulb  of  the  vagina  is  composed  of  an  erectile  tissue  analogous  to  that  of  the  bulb 
of  the  urethra  in  the  male,  and  communicates  freely,  as  shown  by  M.  Deville, 
with  the  cavernous  tissue  of  the  clitoris,  by  means  of  several  veins  of  consi- 
derable size. 

The  bulb  of  the  vagina  is  surrounded,  as  it  were,  by  a  layer  of  muscular  fibres 
(constrictor  cunni'),  in  regard  to  the  arrangement  of  which  authojs  differ.  Ac- 
cording to  Kobelt,  there  are  two  constrictor  muscles.  It  takes  its  origin  by  a 
large  and  flattened  base  from  the  aponeurosis  of  the  perineum,  almost  directly  at 
the  middle  of  the  space  which  separates  the  anus  from  the  tuberosity  of  the 
ischium ;  thence  it  rises,  becoming  at  the  same  time  narrower  towards  the  cli- 
toris, and  covers  or  rather  embraces  in  the  shape  of  a  half  cylinder  the  entire 
length  and  width  of  the  bulb  of  the  vagina. 

A  closer  examination,  says  Kobelt,  shows  that  this  muscle  is  composed  of  two 
flattened  layers,  the  deeper  of  which  glides  in  between  the  upper  border  of  the 
bulb  and  the  root  of  the  clitoris,  and  so  appears  above  the  urethra  to  unite  with 
the  muscle  of  the  opposite  side ;  the  upper  layer,  on  the  contrary,  which  is  also 
flat,  rises  upon  the  back  of  the  clitoris,  and  is  connected  with  its  fellow  by  a  flat 
and  narrow  tendon. 

This  muscle,  which  is,  in  fact,  at  a  considerable  distance  from  the  vaginal 
orifice,  has  been  erroneously  regarded  as  a  sphincter  of  the  vagina.  Now  its 
power  to  diminish  the  orifice  of  the  vagina  is  but  momentary,  and  only  by  com- 
pressing the  bulb  when  greatly  distended  at  the  moment  of  coition.  Its  proper 
office  is,  in  fact,  that  of  a  compressor  of  the  bulb,  whilst  its  upper  extremity 
tends,  at  the  same  time,  to  depress  the  gland  of  the  clitoris  towards  the  vestibule. 

Veaseh. — The  vaginal  arteries  come  from  the  hypogastric ;  the  veins  are  very 
numerous  and  plexiform,  and  discharge  into  the  hypogastrics ;  the  lymphatics 
empty  into  the  ganglions  of  the  pelvis,  and  the  nerves  arise  from  the  hypogastric 
plexus. 

The  vagina  serves  in  the  female  both  as  the  organ  of  copulation  and  as  the 
canal  for  the  passage  of  the  menstrual  fluid,  and  for  that  of  the  product  of  con- 
ception. 


OF     TJIE     ORGANS     OF     GENERATION. 


63 


Fi2.  13. 


Art.  II. — Of  the  Uterus. 

The  uterus  is  the  organ  of  gestation,  in  which  the  ovum  is  destined  to  re- 
main, from  the  period  of  its  escape  from  the  Fallopian  tube,  until  the  moment 
of  final  delivery. 

In  form,  it  resembles  a  small  gourd, 
or  a  pear  flattened  from  before  back- 
wards, having  its  base  turned  up- 
wards and  the  apex  downwards.  The 
axis  runs  from  above  downwards,  and 
from  before  backwards,  corresponding 
nearly  with  that  of  the  superior  strait. 

It  is  situated  in  the  excavation, 
usually  on  the  median  line,  between 
the  bladder  and  rectum,  being  re- 
tained in  position  by  the  round  and 
the  broad  ligaments  on  the  sides,  and 
below  by  the  vagina,  upon  which  it 
rests. 

The  organ  is  divided  into  two  parts, 
the  superior  of  which,  called  the  body, 
is  the  largest,  and  comprises  more 
than  half  the  total  length ;  the  other, 
or  inferior  portion,  styled  the  neck, 
is  smaller;  a  slight  circular  constric- 
tion serves  to  indicate  externally  the 
point  of  union  of  the  body  with  the 
neck. 

As  we  have  said  before,  the  neck  of  the  uterus  is  embraced  about  its  middle 
by  the  mucous  membrane  of  the  vagina,  being  thereby  divided  into  two  portions, 
of  which  the  one  situated  above  the  insertion  of  the  vagina  is  called  the  superior 
vaginal;  and  the  other,  which  projects  into  the  upper  part  of  that  canal,  is 
termed  the  inferior  vaginal  portion  of  the  neck. 

The  connections  of  the  uterus  are  very  loose  and  extensible ;  it  therefore 
exhibits  a  great  degree  of  mobility,  and  may  easily  be  moved  in  every  direction. 

Its  volume  varies  with  age,  being  quite  small  prior  to  the  fifteenth  year,  but 
augmenting  rapidly  at  this  era ;  the  womb  returns  very  slowly  to  its  primitive 
dimensions  in  women  who  have  borne  children,  and  finally,  in  advanced  age,  it 
often  appears  to  waste  away,  and  to  dwindle  down  to  the  size  it  had  prior  to  the 
fifteenth  year.  Its  dimensions  after  puberty  are  as  follows,  viz. :  The  vertical 
diameter  varies  from  two  and  three-fourths  to  three  and  one-eighth  inches  ;  the 
transverse  one,  at  the  fundus,  one  and  three-eighths  to  one  and  a  half  inches, 
and  at  the  neck,  about  half  an  inch  in  every  direction.  Certain  physiological 
conditions  produce  a  great  augmentation  in  its  volume.  For  instance,  I  have 
frequently  observed  at  the  approach  of  the  monthly  courses,  that  it  presented 
twice  the  ordinary  size  at  least,  and  in  some  women  the  increase  in  volume  is  so 


The  Internal  Genital  Organs. 

A.  The  uterus,  seen  on  its  anterior  face.  b.  The  iii- 
tra-vaginal  portion  of  the  neck  of  the  uterus,  c,  c.  The 
Fallopian  tubes.  D.  The  pavilion,  or  fimbriated  ex- 
tremily  of  the  tube,  e,  e.  The  ovaries,  f.  The  liga- 
ment of  the  ovary.  G,  G.  Tne  round  ligaments,  n.  The 
vagina,  laid  open. 

On  the  right,  the  fimbriated  extremity  of  the  tube  is 
seen  applied  to  the  ovary. 


54  FEMALE     ORGANS     OF    G  E  X  E  R  A  T  I  0  X. 

marked  at  this  period,  as  to  be  mistaken  for  the  commencement  of  a  pregnancy. 
(See  Diagnosis  of  Pregnane i/.) 

The  uterus  likewise  varies  in  situation  at  different  epochs;  thus  it  surmounts 
the  superior  strait  in  the  foetus,  and  rests  in  the  abdominal  cavity,  so  that  the 
Fallopian  tubes  and  ovaries  occupy  the  iliac  fossae,  the  fundus  uteri  correspond- 
ing to  the  fifth  lumbar  vertebra.  After  birth,  in  consequence  of  the  develop- 
ment of  the  pelvis,  it  appears  to  sink  gradually  into  the  excavation,  and,  at  ten 
years,  the  fundus  is  on  a  level  with  the  superior  strait,  but  subsequently  gets 
below  this  point.  The  womb  is  generally  inclined  to  the  right  or  left  in  aged 
females,  or  is  turned  backwards  on  the  rectum. 

The  axis  of  the  uterus  approaches  that  of  the  inferior  strait  in  many  women, 
especially  in  those  having  a  short  vagina.  It  must  further  be  observed,  that  the 
direction  described  by  us  as  normal,  is  far  from  being  constant  in  all  women,  as 
a  great  variety  of  circumstances  may  change  it ;  thus,  in  some  cases,  the  fundus 
may  be  thrown  so  far  forwards  as  to  render  the  anterior  wall  the  most  inferior 
part,  thereby  constituting  what  pathologists  have  described  as  an  anteversion  ;  in 
others,  the  superior  border  is  thrown  towards  the  most  inferior  portion  of  the 
sacrum,  the  neck  being  carried  behind  the  posterior  face  of  the  pubis,  thus  pro- 
ducing a  retroversion;  again,  it  is  often  turned  towards  one  side  of  the  excava- 
tion, the  neck  being  directed  to  the  opposite  side  :  this  is  lateral  version. 

Another  singular  anomaly  in  the  relative  direction  of  the  axis  of  the  body  and 
that  of  the  neck  of  the  uterus  remains  to  be  described.  In  the  normal  condition, 
the  axis  of  the  neck  seems  to  be  identical  with  that  of  the  body,  and  to  be 
simply  a  continuation  of  it.  Now,  in  some  subjects,  the  body  of  the  uterus  is 
found  to  form  with  the  neck  an  angle  which  approaches  more  or  less  to  a  right 
ano-le,  as  though  one  of  these  parts  had  been  strongly  bent  upon  the  other,  like 
the  body  of  a  retort  upon  its  beak.  This  inflexion  may  take  place  anteriorly, 
posteriorly,  or  laterally,  and  has  been  sty\e6i  accordingly  anteflexion,  retroflexion , 
and  lateroflexion. 

This  alteration  in  the  relations  of  the  axis  of  the  body  with  that  of  the  neck 
of  the  womb  may  occur  accidentally,  and  we  have  several  times  observed  it  as  a 
consequence  of  anteversion  or  retroversion,  but,  certainly  it  is  often  congenital, 
and  then,  should  it  remain  after  puberty,  and  especially  should  it  increase  in  ex- 
tent, it  might  become  a  cause  of  sterility.* 

The  weio-ht  of  the  womb,  in  girls  at  puberty,  is  from  six  to  ten  drachms ;  but 
in  women  who  have  had  children,  it  ranges  from  an  ounce  and  a  half  to  two 
ounces ;  and  from  one  to  two  drachms  in  very  aged  females. 

The  uterus  exhibits  an  external  and  an  internal  surface. 

•  It  is  the  opinion  of  M.  Follin,  in  which  he  is  fully  sustained  by  the  anatomical  re- 
searches of  MM.  Boulard  and  Verneiiil,  that  confrenital  inflexions  are  not  merely  a  common 
exception,  but  constitute  the  normal  condition  in  the  fcEtus  at  term.  M.  Boulard  has  already 
examined  a  large  number  of  foetuses  with  a  view  to  the  elucidation  of  this  point,  and  in  all, 
without  exception,  the  uterus  was  anteflexed.  The  organ  resembled  a  bishop's  crozier,  or 
the  index  finger  when  bent.  Pursuing  his  researches,  he  found  that  the  uterus  was  more  or 
less  inflexed  in  all  women  who  had  not  conceived.      Of  twelve  women,  one  had  an  ante- 


of  the  okgans  of  generation.         55 

§  1.  External  Surface. 

The  external  surface  presents  for  our  study^two  faces,  two  borders,  a  base,  and 
an  apex. 

The  anterior  face  is  slightly  convex,  is  covered  by  the  peritoneum  on  its  supe- 
rior three-fourths,  and  lies  in  a  mediate  relation  with  the  posterior  face  of  the 
bladder,  from  which  it  is  frequently  separated  by  some  folds  of  the  small  intes- 
tine ;  whilst,  at  the  inferior  fourth,  it  is  in  contact  with  the  bas-fond  of  the 
bladder,  to  which  it  is  united  by  some  loose  cellular  tissue.  This  latter  connec- 
tion explains  the  frequent  participation  of  the  bladder  in  the  uterine  displace- 
ments, however  inconsiderable  they  may  be,  as  also  how  in  certain  cases  vesico- 
uterine fistulas  may  be  produced  after  difficult  labors. 

The  posterior  face  is  much  more  convex  than  the  preceding,  being  covered 
throughout  its  whole  extent  by  the  peritoneum;  it  is  in  a  mediate  relation  with 
the  anterior  surface  of  the  rectum,  the  intestinal  convolutions,  however,  often 
separating  them ;  it  may  be  readily  examined  through  this  gut.  The  lateral 
borders  are  slightly  concave,  aflFording  an  attachment  to  the  broad  and  the  round 
ligaments;  but,  as  M.  Cniveilhier  remarks,  these  ligaments  are  attached  to  the 
anterior  edge  of  the  borders,  and  hence  all  the  thickness  of  these  margins  is 
found  behind  the  broad  ligaments,  and  consequently  the  latter  are  on  the  same 
plane  as  the  anterior  face  of  the  womb. 

The  base,  fundus,  or  superior  border  of  the  womb,  is  convex,  looking  upwards 
and  forwards,  and  covered  by  the  convolutions  of  the  small  intestine.  It  never 
attains  the  level  of  the  superior  strait  in  the  unimpregnated  state,  and  therefore 
it  is  only  possible  to  feel  it  through  the  inferior  abdominal  wall,  by  using  great 
pressure. 

At  the  junction  of  this  base  with  the  lateral  borders  of  the  body  the  two  angles 
are  formed,  from  which  the  Fallopian  tubes  and  ligaments  of  the  ovary  arise. 

The  inferior  extremity,  or  the  uterine  neck,  is  located  in  the  upper  part  of  the 
vagina,  and  merits  the  accoucheur's  most  particular  attention. 

flexion,  and  one  a  retroversion.  In  three  living  females,  not  mothers,  he  professes  to  have 
discovered  anteflexion ;  therefore  he  is  convinced  that  this  deviation  is  normal,  and  simply 
a  persistence  of  the  fffital  condition. 

We  have  examined  for  ourselves  the  pieces  presented  to  the  Biological  Society  by  MM. 
Verneuil  and  Boulard,  and  are  satisfied  that  in  at  least  a  majority  of  cases,  the  womb  of  the 
fostus  is  in  a  more  or  less  decided  state  of  inflexion.  We  are  also  disposed  to  regard  it  as  a 
necessary  consequence  of  the  elevated  position  of  the  body  of  the  womb.  Situated  as  it  is 
above  the  superior  strait,  and  deriving  a  tendency  forward  both  from  the  direction  of  the 
axis  of  this  strait,  and  the  pressure  of  the  mass  of  intestines,  the  body  is  necessarily  urged 
forward,  whilst  the  neck,  which  is  much  elongated  and  placed  wholly  in  the  excavation, 
retains  the  direction  of  the  axis  of  this  canal,  which  presents  an  anterior  concavity. 

But  we  are  far  from  believing  that  these  inflexions  continue  in  the  adult  female,  at  least 
as  a  general  rule.  We  believe  that  in  proportion  as  the  entire  organ  descends  into  the  lesser 
pelvis,  the  above-mentioned  causes  of  the  fostal  inflexion  disappear,  and  that  in  an  immense 
majority  of  cases,  the  uterus  presents  its  habitual  rectitude  at  the  period  of  puberty. 

Whatever  value  this  explanation  may  have,  the  researches  of  MM.  Follin,  Boulard,  and 
Verneuil  are,  nevertheless,  of  great  interest,  and  appear  to  me  of  a  nature  to  modify  greatly 
the  generally  received  idea  relative  to  the  pathological  importance  of  these  uterine  inflexions. 


56  FEMALE  ORGANS  OF  GENERATION. 

Or  THE  Neck  of  the  Uterus. — Very  remarkable  diflFerences  are  found  be- 
tween the  neck  of  the  uterus  in  a  woman  who  has  borne  children,  and  that  in 
one  who  has  never  been  a  mother ;  we  shall,  therefore,  consider  it  successively  in 
each,  because  the  modifications  it  undergoes  during  pregnancy  can  only  be  appre- 
ciated after  a  careful  study  of  the  ordinary  condition. 

1st.  In  the  icoman  who  has  never  been  a  mother,  the  neck  of  the  uterus  is 
from  an  inch  to  an  inch  and  three-eighths  in  length,  and  is  separated  from  the 
body  by  a  narrow,  constricted  portion,  which  can  easily  be  distinguished,  even  on 
the  exterior  of  the  organ.  At  the  central  part,  where  it  is  a  little  enlarged  and 
fusiform,  it  is  about  three-quarters  of  an  inch  in  the  transverse  diameter,  and 
half  an  inch  in  the  antero-posterior  one.  Near  the  junction  of  the  superior  third 
with  the  inferior  two-thirds,  it  is  embraced  by  the  upper  end  of  the  vagina,  which 
descends  a  little  lower  on  the  anterior  than  on  the  posterior  face,  whence  the 
subvaginal  portion  of  the  neck  is  somewhat  longer  behind,  but  the  contrary  is 
true  for  that  part  above  the  vagina. 

The  cervix  is  terminated  by  an  extremity  that  is  less  voluminous  than  the  other 
portions  of  its  extent,  so  as  to  present  a  conical  form  to  the  finger.  This  ex- 
tremity bears  the  name  of  the  os  tincce,  or  tench's  mouth.*  The  os  tincse  pre- 
sents two  lips,  separated  by  a  small  transverse  fissure,  somewhat  swollen  in  the 
middle,  called  the  external  orifice  of  the  neck.  The  orifice,  from  being  com- 
pletely closed  up,  is  sometimes  difficult  to  find  in  a  young  marriageable  girl. 
But,  according  to  Dubois,  if  the  index  encounters  it,  we  may  recognize  the  part 
by  comparing  the  sensation  then  experienced  with  that  produced  by  applying  the 
pulp  of  the  finger  upon  the  extremity  of  the  nose,  and  feeling  the  depression  be- 
tween the  alae  nasi.  The  anterior  lip  is  the  thicker,  though  both  are  very  nearly 
of  the  same  length,  the  anterior  one,  perhaps,  descending  a  little  lower  than  the 
other.''  These  lips  are  smooth  and  polished  throughout,  neither  presenting  any 
inequalities  nor  any  depressions ;  in  fact,  the  whole  external  surfiice  of  the  neck 
is  equally  smooth,  and  without  elevations. 

The  cervix  is  slightly  directed  backwards,  so  that,  if  prolonged,  it  would  ter- 
minate near  the  coccyx,  or  the  most  inferior  part  of  the  sacrum.  It  is  situated 
in  the  upper  half  of  the  excavation,  yet  the  finger  can  easily  reach  and  pass  over 
its  whole  exterior  surface. 

2d.  In  the  female  who  has  had  several  children,  the  neck  has  not  the  same 

'  This  conicity  of  the  neck  has  been  regarded  by  some  authors  as  a  cause  of  sterility,  but 
I  feel  assured  that  the  cause  has  here  been  confounded  with  the  effect.  The  conical  form 
of  the  neck  is,  in  fact,  the  normal  one  in  young  girls,  and  is  generally  destroyed  by  the  first 
labor.  If,  on  the  contrary,  the  female  has  never  had  a  child,  this  form  remains  through  life; 
its  persistence  is  not  therefore  the  cause,  but  the  effect  of  sterility. 

2  Most  authors  teach  that  the  anterior  lip  of  the  neck  descends  lower  than  the  posterior. 
In  detaching  the  uterus  from  a  dead  body  no  great  difference,  however,  is  observed  in  this 
respect;  but,  on  the  contrary,  if  we  touch  a  female,  the  distinction  is  much  better  marked.  I 
believe  this  results  solely  from  the  fact  of  the  neck  being  directed  a  little  posteriorly,  so  that 
the  surface  of  the  os  tincae  is  not  horizontal,  but  inclined  backwards;  and,  therefore,  the  an- 
terior lip  is  necessarily  somewhat  lower  than  the  posterior.  Besides,  the  finger  in  passing 
from  below  upwards,  and  from  before  backwards,  must  first  encounter  the  anterior  lip,  and 
is  then  obliged  to  go  higher  and  further  behind  to  reach  the  posterior  one. 


OF    THE     ORGANS     OF     GENERATION.  57 

aspect,  and  the  length  is  so  variable  that  it  is  not  possible  to  announce  it  in  ad- 
vance ;  though  we  may  say,  in  general  terms,  that  it  is  shorter  in  proportion  to 
the  larger  number  of  children  the  woman  has  borne,  a  portion  of  it  seeming,  as  it 
were,  to  have  been  destroyed  at  every  labor. 

Two  females,  one  of  whom  had  seventeen,  the  other  nineteen  children,  have 
been  under  my  carej  the  neck  in  eaeh  of  them  was  completely  destroyed,  in  its 
intra-vaginal  portion.  No  prominence  was  found  at  the  superior  part  of  this 
canal,  and  the  finger  only-  encountered  two  little  tubercles,  as  large  as  a  lentil, 
separated  by  an  open  orifice,  by  which  latter  alone  the  neck  could  be  recognized. 

This  diminished  length  of  the  infra-vaginal  portion  of  the  neck  in  women  who 
have  borne  many  children,  is  due  to  the  strong  traction  upon  the  upper  extremity 
of  the  vagina  in  the  preceding  pregnancies,  produced  by  the  elevation  of  the 
uterus :  in  consequence  of  this  traction,  and  the  laxity  of  its  adhesions  with  the 
middle"  part  of  the  neck,  the  vagina  becomes  detached  from  it  at  that  point,  and 
adheres  to  it  only  at  its  inferior  extremity.  When  this  has  occurred,  it  is  plain 
that  the  portion  which  projects  into  the  vagina  must  be  much  less  considerable 
than  before.  Although  it  still  preserves  a  certain  length,  the  regular  form  that 
it  previously  had  is  wanting,  for  it  is  no  longer  a  fusiform  body,  with  an  exterior 
surface  polished  and  smooth  everywhere,  but  a  kind  of  irregular  teat,  covered  on 
its  external  face  by  more  or  less  numerous  elevations. 

Sometimes  it  is  more  swollen  at  the  inferior  portion,  whilst  the  upper  part  ap- 
pears to  be  hollowed  out  in  its  whole  circumference  by  a  deep  excavation. 

The  orifice  of  the  os  tinc^  is  sufficiently  patulous  to  admit  the  extremity  of  the 
finger,  or  even  one-half  of  its  ungual  portion  may  occasionally  be  introduced. 
The  lips  are  unequal,  presenting  a  variable  number  of  notches.  Being  rarely 
found  on  the  middle  part  of  the  lips,  these  depressions  are  continually  met  with 
about  the  level  of  the  commissures,  and  more  frequently  on  the  left  side  than  the 
right.'  They  result  from  the  lacerations  that  have  occurred  in  former  labors,  at 
the  moment  when  the  head  cleared  the  os  uteri;  and  the  lochial  discharges  have 
prevented  the  lips  of  these  little  wounds  from  uniting,  and  they  have  cicatrized 
separately.  The  depressions  are  sometimes  so  numerous  as  to  subdivide  the  lips 
into  six  or  eight  small  tubercles,  separated  by  as  many  fissures  of  variable  depth. 

In  case  the  woman  has  not  had  children  for  several  years,  and  more  especially 
if  she  has  had  but  one  or  two  of  them,  these  characters  are  much  less  deter- 
mined, the  orifice  is  nearly  obliterated,  and  the  neck  has  gradually  resumed  its 
primitive  form ;  nevertheless,  the  fissure  of  the  orifice  is  always  sufficiently 
marked,  as  well  as  the  inequalities  on  the  lips,  to  indicate  antecedent  labors. 
These  marks  may  become  more  and  more  faint,  but  they  never  disappear  altogether. 

'  The  frequency  of  these  depressions  on  the  left  side  may  be,  I  think,  readily  explained. 
At  the  period  of  the  head's  passage  through  the  neck,  it  is  evident  that,  if  a  laceration  be 
produced,  it  will  be  at  the  point  which  sustains  the  greatest  effort.  Now,  the  left  occipito- 
iliac  positions  being  much  the  more  frequent,  the  occiput,  which  constitutes  the  largest  ex- 
tremity of  the  head,  will  consequently  correspond  to  the  left  commissure  of  the  neck.  Fur- 
ther, the  uterus  is  habitually  inclined  to  the  right,  so  that  the  line  of  its  contractions  is  directed 
from  right  to  left,  and,  therefore,  acts  more  energetically  on  the  left  side  of  the  cervix.  Hence, 
the  most  violent  efforts  occur  at  this  point. 


58 


FEMALE  ORGANS  OF  GENERATION. 


§  2.    Internal  Surface. 

The  uteras  presents  an  internal  surface  circumscribing  its  cavity.  This  latter 
is  divided  into  the  cavity  of  the  body,  and  that  of  the  neck. 

A.  The  cavity  of  the  body  is  triangular  in  shape,  presenting  an  orifice  at  each 
of  its  three  angles ;  the  inferior  one  of  which  establishes  a  communication  between 
the  cavities  of  the  body  and  neck,  and  hence  is  called  the  internal  or  uterine 
orifice.  The  other  two  are  the  orifices  of  the  Fallopian  tubes ;  they  are  scarcely 
visible,  and  occupy  the  bottom  of  the  funnel-shaped  cavities  found  at  the  superior 

angles  of  the  womb. 

Fig.  14. 
H  .in 


15. 


Cavity  of  the  Ulerus  and  the  Fallopian  Tubes. 

A.  Superior  border  or  fundus  of  the  womb.    b.  Cavity  of  the  womb.    o.  Cavity  of  the  neck  of  the  uterus. 

D.  The  canal  of  the  Fallopian  tube  cut  open.    E.  The  fimbriated  extremity  or  pavilion,  likovvise  laid  open. 

F  F.  The  ovaries,  one-half  of  which  has  been  removed  so  as  to  bring  into  view  several  of  the  Graafian 

vesicles,    a.  The  cavity  of  the  vagina,    h  h.  The  ligaments  of  the  ovaries.     G  g.  The  round  ligaments. 

In  the  state  of  vacuity,  no  cavity,  to  speak  correctly,  exists  in  the  womb,  for 
the  uterine  walls  are  in  contact  throughout  their  extent :  the  cavity,  like  that  of 
the  pleura  for  example,  has  a  real  existence  only  when 
the  walls  become  separated  by  a  liquid  effusion.  Fig.  15 
will  afford  an  idea  of  the  dimensions  of  the  uterine  cavity 
when  empty. 

The  congenital  deficiency  of  a  cavity  in  the  body  is 
very  rare,  but  yet  no  trace  of  it  existed  in  a  uterus  pre- 
sented to  M.  Cruveilhier  by  M.  Rostan,  although  that 
of  the  neck  remained.  In  aged  women,  however,  it  is 
not  very  rare  to  find  the  cavity  partly  efi"aced  by  more  or 
less  extensive  adhesions. 

B.  The  cavity  of  the  ncclc  is  fusiform,  flattened  from 
before  backwards,  and  presents  an  assemblage  of  rugre 
on  its  anterior  and  posterior  walls,  which  constitute  a 
median  vertical  column  upon  each  wall,  occupying  the 
whole  length  of  the  neck,  and  from  which  a  number  of 
smaller  columns  pass  off  at  various  angles,  representing 
a  fern  in  relief.  The  term  arbor  vittn  has  been  applied 
to  these  rugosities.  After  delivery  they  frequently  dis- 
appear, but  sometimes  they  still  persist. 

The  uterine  cavity  likewi.se  exhibits  a  variable  num- 
ber of  transparent  vesicles,  mistaken  by  Naboth  for  eggs, 


This  profilu  view  jjives  an 
exact  idea  of  the  dimensions 
of  the  cavity  of  the  body  and 
of  the  neck  of  the  womb  in  a 
state  of  vacuity. 

A.  Mucous  membrane,  b. 
Tissue  proper,  c.  Caviiy  of 
the  body.  D.  Caviiy  of  the 
neck. 


OF  THE  ORGANS  OF  GENERATION.  59 

hence  they  have  been  called  the  ovula  Nahothi.  These  vesicles  are  nothinfj 
more  than  simple  muciparous  follicles,  and  they  are  particularly  abundant  in 
the  neighborhood  of  the  neck.  They  secrete  a  gelatinous  mucus,  which  may 
accumulate  in  the  cavity  of  the  neck,  and  so  obstruct  it  as  to  render  fecundation 
impossible. 

The  internal  surface  of  the  uterus  is  much  more  vascular  in  the  body  than  in 
the  neck.  This  difference  is  particularly  well  marked  in  women  who  have  died 
during  the  menstrual  period.  The  cavity  of  the  body  is  of  a  rose  color,  and  that 
of  the  neck  of  a  pearly  gray  hue,  which  is  probably  due  to  the  slight  vascularity 
of  this  part  in  comparison  with  that  of  the  lining  membrane  of  the  body. 

§  3.    Structure  of  the  Uterus. 

In  the  ordinary  condition  of  the  womb,  this  structure  is  difficult  to  make  out, 
but  it  becomes  much  more  evident  during  the  period  of  gestation. 

The  constituent  parts  of  the  organ  are :  a  peculiar  tissue,  an  external  perito- 
neal membrane,  and  an  internal  mucous  one,  together  with  numerous  vessels  and 
nerves. 

A.  Peculiar  Tissue. — This  tissue  is  of  a  grayish  color,  and  is  very  dense  in 
structure,  creaking  like  cartilage  under  the  scalpel.  In  general,  the  neck  appears 
less  firm  in  consistence  than  the  body,  resulting,  as  M.  Cruveilhier  supposes, 
from  the  former  being  the  more  frequent  seat  of  sanguineous  fluxions.  (See 
Hen  st  mat  ion.) 

The  uterus  is  more  flexible,  and  of  a  brighter  red  hue,  in  some  particular 
cases ;  such  as  a  suppression  of  the  menses,  and  also  during  the  period  imme- 
diately following  or  preceding  the  courses. 

The  proper  tissue  of  the  womb  is  composed  of  fibres  disposed  lengthwise.  The 
nature  of  these  fibres  has  led  to  numerous  discussions,  but  at  the  present  day  they 
are  generally  considered  to  be  muscular  in  character,  and,  since  this  muscular 
nature  becomes  clearly  evident  towards  the  end  of  gestation  (see  Pregnancy), 
we  must  acknowledge  that,  notwithstanding  the  fibrous  appearance  of  its  tissue 
in  the  unimpregnated  condition,  the  fibres  composing  it  are  not  the  less  muscular 
in  their  structure.  This  organization  is  concealed  by  the  state  of  condensation ; 
of  atrophy,  maintained  either  by  inertia  or  want  of  action ;  but  which  becomes 
distinct,  in  consequence  of  the  very  considerable  determination  to  the  uterus ;  of 
its  distension,  and  of  the  development  of  its  fibres  during  pregnancy. 

According  to  most  anatomists,  the  direction  of  these  fibres  in  the  state  of 
vacuity,  is  very  irregular,  and  their  inter-crossing  is  nearly  inextricable,  as  every 
one  must  confess,  in  this  particular  condition,  says  M.  Cruveilhier.  But  as  the 
structure  of  the  uterus,  except  in  gestation,  is  not  of  any  consequence  (practically 
speaking)  to  the  accoucheur,  we  refer  to  the  article  Pregnancy  for  the  more  par- 
ticular study  thereof. 

B.  The  External,  or  Peritoneal  Membrane. — The  peritoneum  having  covered 
the  posterior  face  of  the  bladder,  is  reflected  upon  the  anterior  one  of  the  uterus, 
covering  only  its  superior  three-fourths ;  and  having  reached  the  fundus  uteri. 


60  FEMALE  ORGANS  OF  GENERATION. 

and  gained  the  posterior  wall,  it  covers  this  entirely,  is  prolonged  on  the  vagina 
for  a  short  distance,  and  is  then  reflected  upon  the  rectum.  The  broad  ligaments 
are  produced  by  the  transverse  elongations  of  this  membrane ;  and  its  falciform 
folds,  seen  in  the  interval  that  separates  the  bladder  from  the  uterus,  are  called 
the  vesico-uteri7ie,  or  the  anterior  ligaments ;  and  those  formed  by  it,  between 
the  rectum  and  uterus,  are  called  the  posterior,  or  the  recto-uterine  ligaments. 
The  adherence  of  the  peritoneum  is  quite  loose  on  the  borders  of  the  uterus,  but 
it  becomes  more  intimate  towards  the  median  line. 

C.  The  Internal  or  3Incons  Memhrane. — The  existence  of  this  membrane  was 
for  a  long  time  contested,  and  there  can  be  no  doubt,  that  if  a  membrane  resem- 
bling' the  majority  of  those  which  line  all  the  mucous  cavities  be  sought  for  in  the 
uterus,  it  will  be  sought  in  vain.  Still  its  existence  is  rendered  very  probable 
by  the  functions  of  the  organ,  for,  as  Cruveilhier  has  remarked  :  1st.  Every  or- 
ganic cavity  communicating  with  the  exterior  is  lined  by  a  mucous  membrane. 
2d.  Anatomy  demonstrates  that  the  vaginal  mucous  membrane  is  continued  into 
the  cavity  of  the  neck,  and  then  into  that  of  the  uterus.  3d.  When  examined 
by  a  lens,  the  internal  surface  of  the  uterus  exhibits  a  papillary  disposition,  but 
the  papillas  are  imperfectly  developed.  4th.  This  internal  surface  has  follicles 
or  crypts  scattered  over  it,  from  which  mucus  can  be  squeezed  out,  and  which,  if 
their  orifices  be  obstructed  or  obliterated,  become  distended  by  the  liquid,  and 
form  little  vesicles.  5th.  It  is  continually  lubricated  by  mucus.  6th,  and 
lastly ;  the  internal  surface  of  the  uterus,  like  all  other  mucous  membranes,  is 
subject  to  spontaneous  hemorrhages,  to  catarrhal  secretions,  and  to  the  mucous, 
fibrous,  and  vesicular  vegetations,  called  poli/pi;  and  it  is  generally  admitted 
that,  wherever  there  is  an  identity  of  action,  there  is  also  an  identity  of  nature. 

These  physiological  probabilities  are  at  present  fully  confirmed  by  anatomical 
research,  the  numerous  preparations  in  the  possession  of  M.  Coste  leaving  no 
doubt  whatever  as  to  the  existence  of  the  mucous  membrane.  I  shall  therefore 
borrow  from  this  able  physiologist  the  principal  facts  which  pertain  to  its  de- 
scription. 

The  thickness  of  the  uterine  mucous  membrane  varies  in  different  parts  of  its 
extent.  Towards  the  middle  of  the  body,  it  forms  one-fourth  of  the  thickness  of 
the  walls  of  the  uterus,  that  is  to  say,  its  usual  depth  at  this  point  is  from  one- 
eighth  to  three-sixteenths  of  an  inch,  amounting  to  about  the  one-fourth  of  the 
thickness  of  the  uterine  parietes.  It  thins  off  rapidly  towards  the  point  of  union 
of  the  body  with  the  neck,  as  also  towards  the  apertures  of  the  Fallopian  tubes. 
Its  greatest  thickness  in  the  neck  does  not  exceed  the  one  twenty-fourth  part  of 
an  inch. 

The  thickness  of  the  mucous  membrane  is  clearly  exhibited  by  the  assistance 
of  a  perpendicular  section  of  the  uterus.  It  is  then  found  to  be  injected,  and 
varying  in  color  from  a  deep  or  bright  red,  to  a  semi-transparent  reddish  or  pearly 
gray :  the  muscular  tissue,  on  the  contrary,  is  almost  always  of  a  reddish-gray 
color,  and  is  besides  easily  distinguished  by  the  numerous  vascular  openings  upon 
the  surface  of  the  section,  and  from  which  blood  may  be  caused  to  exude  by  pres- 
sure.    In  addition,  there  is  always  a  whitish  line  of  demarcation  between  the 


OF    THE     ORGANS     OF     G  E  N  E  E  A  T  I  0  N. 


61 


FiK.  16. 


two  tissues,  which  becomes  most  distinct  when  the  injection  of  the  mucous  mem- 
brane is  greatest. 

Its  consistence  is  less  than  that  of  the  tissue  proper  of  the  uterus,  being  very 
friable,  and  easily  crushed. 

It  adheres  very  strongly  to  the 
substance  of  the  uterus,  and  is  sepa- 
rated from  it  with  great  difficulty : 
it  is  also  incapable  of  any  gliding 
motion  upon  the  parts  which  it 
covers,  on  account  of  the  entire  ab- 
sence of  a  submucous  cellular  tissue. 

Its  internal  surface  presents  a  mul- 
titude of  small  orifices,  rather  regu- 
larly arranged,  which,  though  barely 
perceptible  to  the  naked  eye,  become 
very  evident  with  the  assistance  of 
a  lens.  About  forty-five  of  them 
are  contained  in  a  space  equivalent 
to  the  square  of  one-eighth  of  an 
inch.  They  are  the  orifices  of 
glands. 

M.  Robin  has  given  an  excellent 
description  of  the  elements  which 
enter  into  the  composition  of  the 
mucous  membrane  ;  they  are  : 

1.  Fibro-plastic  elements;  2.  Cel- 
lular  tissue  ;    3.    Some   nucleated 
fibres ;  4.  Amorphous  matter,  form- 
ing a  medium  of  connection ;  5.  Glands ;   6.   Capillary  vessels, 
ourselves  to  a  brief  account  of  the  uterine  glands. 

Two  species  of  glands  exist  in  this  mucous  membrane,  one  being  found  only 
within  the  body  of  the  uterus,  whilst  the  other  is  confined  to  the  neck. 

1.  According  to  M.  Coste,  who  was  the  first  to  describe  them,  the  glands  of 
the  body  are  especially  visible  when  death  has  occurred  during  menstruation ; 
they  then  appear  as  minute  canals  of  about  the  one  two-hundred-and-fiftieth  part 
of  an  inch  in  diameter,  placed  vertically  beside  each  other.  They  are,  however, 
disposed  so  compactly,  that  the  mucous  membrane  as  seen  by  a  lens  appears  to 
be  formed  of  them  almost  exclusively.  Their  adherent  extremities  terminate  in 
culs-de-sac  and  repose  upon  the  muscular  tissue.  The  bodies  of  the  glands  are 
rendered  somewhat  flexuous  by  the  mucous  membrane  being  too  thin,  as  it  were, 
in  the  state  of  vacuity,  for  the  length  of  the  tubes.  They  contain  a  whitish, 
viscid  fluid,  which  may  be  squeezed  from  them,  especially  at  the  menstrual  period. 

2.  The  glands  of  the  neck  (glands,  or  ovula  of  Naboth)  are  found  in  all  the 
interval  between  the  line  separating  the  cavity  of  the  neck  from  that  of  the  body, 
and  the  neighborhood  of  the  borders  of  the  os  tincae.  Their  orifices  are  readily 
seen  upon,  and  especially  between,  the  folds  of  the  arbor  vitaj. 


This  figure  represents  the  arrangement  of  the  mucous 
membrane  and  of  the  tissue  propsr  of  the  uterus,  as  also 
their  relative  dimensions. 

A.  Cavity  of  the  neck  and  arbor  vitae.  b.  Cavity  of 
the  body.  c.  Mucous  membrane,  d.  Intervening  mem- 
brane. E.  Represents  the  marked  thinning  off  of  the 
mucous  membrane  towards  the  neck. 


We  shall  limit 


62  FEMALE    ORGANS     OF     GENERATION. 

These  glands  have  the  form  of  a  minute  cylinder,  terminating  in  a  rounded 
cul-de-sac,  which  is  inflated  into  the  form  of  a  lentil  or  vial,  and  enclosed  in  the 
tissue  of  the  mucous  membrane,  even  descending  a  little  between  the  fibres  of 
the  muscular  structure. 

The  excretory  orifice  is  always  smaller  than  the  glandular  tube.  Pressure 
causes  the  escape  from  it  of  a  transparent,  viscid,  tenacious,  and  completely  homo- 
geneous fluid. 

We  shall  treat  hereafter  of  the  modifications  which  these  glands  undergo 
during  gestation. 

D.  Vessels. — The  arteries  of  the  uterus  come  from  the  hypogastric  and  ovarian 
arteries.  Both  series  describe  a  number  of  flexuosities  in  the  tissue  of  the  organ. 
The  veins  empty  into  the  corresponding  trunks.  The  lymphatic  vessels  are  very 
numerous,  and  run  to  the  pelvic  and  lumbar  ganglia.  The  nerves  are  derived 
from  the  great  sympathetic,  some  of  them  proceeding  from  the  renal  and  others 
from  the  hypogastric  plexuses ;  to  the  latter  are  united  some  fibres  from  the 
sacral  plexus. 

It  is  an  important  practical  remark  of  M.  Jobert,  that  the  entire  intra-vaginal 
portion  of  the  neck  is  destitute  of  a  supply  of  nervous  fibres,  whilst  the  portion 
above  the  insertion  of  the  vagina  receives  a  great  number  of  them,  which  form 
species  of  plexuses,  furnishing  ascending  or  uterine  branches  and  descending  or 
vaginal  ones.  The  latter  are  extremely  numerous,  and  ramify  to  infinity  in  the 
substance  of  the  vagina. 

This  distribution,  which  would  explain  a  number  of  physiological  and  patho- 
logical facts,  needs  confirmation  from  new  researches,  for  recent  preparations 
deposited  by  M.  Boulard  in  the  Museum  of  the  School  of  Medicine,  give  it  a 
formal  denial. 

Development. — According  to  some  authors,  the  uterus  is  bifid  in  the  embryo 
as  late  as  the  end  of  the  third  month,  but  M.  Cruveilhier  says  he  has  never  ob- 
served this  bifurcation.  During  the  intra-utcrine  life,  the  volume  of  the  neck 
surpasses  that  of  the  body,  and,  at  this  period,  its  largest  portion  corresponds  to 
the  vaginal  extremity.  After  birth,  it  remains  nearly  stationary,  until  puberty, 
and  then  it  acquires,  in  a  very  short  time,  the  dimensions  observed  in  the  adult 
woman.    The  organ  often  becomes  atrophied  in  old  age. 

§  4.    Ligaments  op  the  Uterus. 

We  have  already  spoken  of  the  anterior  and  posterior  ligaments.  The  broad 
and  round  ones  still  remain  to  be  described. 

The  Broad  Licjaments. — As  elsewhere  stated,  the  double  lamina  of  the  peri- 
toneum, which  covers  the  anterior  and  posterior  faces  of  the  uterus,  is  prolonged 
transversely,  the  two  folds  resting  against  each  other,  and  forming  by  their  union 
a  transverse  partition,  extending  from  each  side  of  the  uterus,  which  divides  the 
pelvis  into  two  cavities;  the  anterior  of  which  lodges  the  bladder,  and  the  poste- 
rior the  rectum.  Outwardly,  and  below,  these  ligaments  are  continuous  with  the 
peritoneum  that  lines  the  excavation ;  their  superior  border  is  free,  and  is  ex- 
tended from  the  angles  of  the  uterus  to  the  iliac  fo^ste — presenting  three  folds, 


OF  THE  ORGANS  OF  QENERATIO^^  63 

called  the  wings.  The  anterior  wing  is  not  admitted  by  some  anatomists ;  it  is 
but  slightly  developed,  and  is  occupied  by  the  round  ligament.  The  middle  one 
encloses  the  Fallopian  tube,  and  the  posterior  contains  the  ovary  and  its  ligament. 

The  two  serous  folds  that  constitute  the  broad  ligament,  are  separated  by  a 
loose  and  very  extensible  lamellated  cellular  tissue,  continuous  with  the  fascia 
propria  of  the  pelvis.  The  broad  ligaments  disappear  during  gestation,  their 
two  laminae  assisting  to  cover  the  anterior  and  posterior  faces  of  the  developed 
womb. 

Bodies  of  Rosenmuller. — By  the  inspection  of  pieces  prepared  by  JM.  Follin, 
we  have  become  assured  of  the  existence  of  an  organ  between  the  two  laminae  of 
the  broad  ligament,  which  has  not  been  even  noticed  by  French  anatomists,  but 
which  certain  German  anatomists  figure  under  the  name  of  the  organ  of  Rosen- 
muller, who  was  the  first  to  discover  it.  Its  general  arrangement  is  not  yet  well 
understood,  its  development  is  involved  in  obscurity,  and  the  details  of  its  histo- 
logy had  not  hitherto  been  described.  The  researches  undertaken  by  M.  Follin 
in  reference  to  this  subject  show,  that  the  organ  is  composed  of  seven  or  eight 
tubes  folded  upon  themselves,  terminating  in  blind  extremities,  and  all  converg- 
ing towards  the  tube  which  serves  as  a  point  of  entrance  for  the  vessels  of  the 
ovary.  The  tubes  are  generally  closely  approximated  to  each  other,  so  that  their 
inflexions  frequently  correspond.  When  examined  by  transmitted  light,  the  as- 
semblage of  canals  is  distinctly  seen  in  the  broad  ligament  near  the  fimbriated 
extremity  of  the  Fallopian  tube.  Sometimes  these  tubes  are  not  very  apparent, 
and  their  number  is  much  less,  yet  some  are  always  to  be  found.  They  exist  at 
all  ages,  but  are  much  more  readily  distinguished  in  the  broad  ligaments  of  the 
foetus,  or  of  children,  for  then  the  slight  development  of  the  bloodvessels  does 
not  obscure  them,  nor  are  they  hidden  from  observation  by  the  fat,  which  infil- 
trates the  lamiufe  of  the  broad  ligaments  in  adults. 

The  size  of  the  tubes  is  variable  :  and  they  often  present  dilatations,  and  some- 
times true  cysts  filled  with  a  citrine  fluid. 

M.  Follin  has  not  been  able  to  discover  an  excretory  orifice  to  these  tubes, 
either  in  young  girls  or  adult  women. 

Their  structure  resembles  that  of  the  glandular  tubes  of  many  simple  glands. 
They  are  provided  with  a  central  cavity,  which  presents  the  dilatations  so  often 
observed  in  tubes  of  this  class.  Externally,  the  tube  is  formed  of  cellular-tissue- 
membrane  with  longitudinal  fibres.  The  internal  surface  of  the  tube  is  covered 
with  pavement  epithelium. 

Some  observations  are  calculated  to  produce  the  impression,  without  however 
confirming  it,  that  this  assemblage  of  tubes  has,  in  its  origin,  some  relation  with 
the  corpora  Wolfliana. 

Attached  to  the  free  edge  of  the  broad  ligaments,  it  is  not  uncommon  to  find 
five,  six,  or  even  more  small  cysts  which  have  escaped  the  notice  of  authors. 
They  are  generally  connected  with  the  ligament  by  a  very  slender  pedicle,  of 
variable  length,  but  which  is  sometimes  so  short,  that  the  cyst  appears  to  be  ses- 
sile, and  directly  adherent  to  the  ligament.    (See  Fig.  17.) 

It  is  difiicult  to  understand  the  mode  of  development  of  these  cysts.     They 


64  FEMALE  ORGANS  OF  GENERATION. 

may,  perhaps,  liave  some  relation  with  the  tubes  of  which  the  bodies  of  Rosen- 

luuller  are  composed.     It  has  however  seemed  to  us  worth  while  to  call  attention 

to  them,  particularly  as  they  are  stated  by  M.  Broca  to  be  present  in  the  great 

majority  of  cases. 

Fig  17. 


The  figure  exhibits  the  small  cysts  appended  to  tlie  ree  edge  of  the  broad  lisrnments.  One  of  the  Fallo- 
pian tubes  is  represented  with  a  double  fimbriated  extremity,  as  in  the  case  described  by  G.  Richard. 

A.  Uterus.  B.  Fallopian  tubes,  c.  The  additional  fimbriated  extremity.  D,  £.  The  normal  fimbriated 
extremities,    f,  o,  h.  The  cysts  described  above. 

The  round  ligaments,  or  supra-pubic  cords,  are  evidently  continuous  with  the 
tissue  of  the  uterus,  to  which  their  proper  substance  is  precisely  similar ;  arising 
from  the  lateral  border  of  this  organ,  below  and  a  little  in  advance  of  the  Fallo- 
pian tube,  it  runs  upwards  and  outwards  by  raising  up  the  small  ligament.  Ac- 
cording to  M.  Deville,  this  fringe,  or  ligament,  is  bent  downward  in  the  anterior 
fold  of  the  broad  ligament,  and  reaches  the  internal  orifice  of  the  inguinal  canal, 
into  which  it  entei-s,  accompanied  by  a  prolongation  of  the  peritoneum,  bearing 
the  name  of  the  Canal  of  Nuck.'  It  then  divides  into  a  number  of  fibrous  fasci- 
culi, which  are  lost  in  the  cellular  tissue  of  the  mons  veneris  and  that  which  fills 
the  dartoid  sack,  described  (page  40)  as  existing  in  the  labia  externa.  According 
to  Madame  Boivin,  the  round  ligament  on  the  right  side  is  the  shorter  and  larger 
of  the  two.  They  contain  a  great  number  of  veins,  which  are  liable  to  become 
varicose. 

These  ligaments  serve  to  retain  the  uterus  in  position,  and  to  prevent  its  dis- 
placements ;  and  it  is  probably  to  them  that  the  pains  in  the  groins,  experienced 
by  some  women,  during  chronic  aflfections  or  displacements  of  the  womb,  may  be 
referred.  They  are,  in  a  great  measure,  composed  of  cellular  tissue  and  vessels, 
but  containing  also  some  muscular  fasciculi,  the  superior  of  which  are  prolonged 
from  the  uterus,  and  the  inferior  come  from  the  internal  oblique  muscle.  The 
superior  muscular  fibres  are  much  more  evident  during  pregnancy. 

Finally,  the  vesico-iiterine  and  utero-saci-al  litjaraents,  formed,  as  we  have 
stated,  of  folds  of  the  peritoneum,  which,  after  having  covered  the  uterus,  are 
reflected  upon  the  posterior  surface  of  the  bladder  and  the  anterior  surface  of  the 
rectum ;  these  ligaments  are,  so  to  speak,  reinforced  by  collections  of  fibres  which 
appear  to  be  prolongations  from  the  tissue  proper  of  the  womb,  and  which  are 
attached  anteriorly  to  the  posterior  surface  of  the  bladdej,  and  posteriorly  to  the 
anterior  surface  of  the  rectum. 


OF  THE  ORGANS  OF  GENERATION.  65 

Art.  III. — Of  the  Fallopian  Tubes. 

The  xiterine  or  Fallopian  tiihes  are  two  canals,  varying  from  four  and  a  quarter 
to  five  inches  in  length,  and  placed  in  the  thickness  of  the  superior  border  of  the 
broad  ligament.  They  extend  transversely  from  the  lateral  angles  of  the  womb 
nearly  to  the  iliac  fossa  on  the  corresponding  side.  Their  volume  is  made  more 
evident  by  inflating  them.  (G.  Eichard.)  It  may  then  be  ascertained  that  be- 
yond the  uterine  parietes,  the  tube  has  a  diameter  of  about  three-sixteenths  of 
an  inch  j  towards  the  middle  of  its  course  it  increases  to  about  one  quarter  of  an 
inch,  and  just  before  the  ostium  abdominalc,  to  five-sixteenths  of  an  inch.  Their 
calibre  is  very  variable  at  different  points.  The  elasticity  of  the  walls  is  how- 
ever so  great  as  to  allow  of  their  increase  to  an  enormous  extent,  as  is  proved  by 
the  cysts  which  are  frequently  found  in  them. 

The  internal  orifice  of  the  tube  (^ostium  uterinum'),  is  stated  by  M.  Richard  to 
be  the  one-sixteenth  of  an  inch  in  diameter,  from  thence,  the  calibre  of  the  canal 
increases  gradually  to  its  external  orifice.  Near  the  free  extremity  it  spreads  out 
and  becomes  fringed.  This  termination  constitutes  the  pavilion,  or  fimbriated 
extremity  (the  morsus  diaboli). 

It  is  generally  taught  that  one  of  these  fringes,  which  is  longer  than  the 
others,  attaches  itself  to  the  extremity  of  the  ovary.  On  the  contrary,  M.  Cru- 
veilhier  believes  that  this  adherence  takes  place  through  the  intervention  of  a 
groove,  the  concavity  of  which  looks  downwards  and  backwards,  and  facilitates 
the  communication  between  the  ovary  and  the  cavity  of  the  tube.  All  the  fringed 
folds  are  attached  to  a  small  circle  which  is  more  contracted  than  the  part  of  the 
tube  which  it  terminates.  This  small  circle  is  called  the  external  orifice  of  the 
tube.  The  internal,  or  uterine  orifice  is  the  name  given  to  the  one  by  which  it 
opens  into  the  uterine  cavity. 

The  peritoneum  forms  the  external  tunic  of  the  tube ;  a  mucous  membrane 
and  an  intervening  coat  complete  its  structure.  Most  authors  describe  the 
raucous  membrane  as  continuous  with  the  uterine  mucous  membrane  on  the  one 
hand,  and  with  the  peritoneum  on  the  other,  thus  presenting  the  only  example 
of  continuity  between  a  mucous  and  a  serous  membrane.  Now,  according  to 
MM.  Robin  and  Richard,  both  these  opinions  are  equally  fallacious. 

M.  Richard  states,  that  the  mucous  membrane  of  the  womb  and  that  of  the 
oviduct,  have  an  entirely  difierent  physiological  office  to  perform,  and  that  they 
present  an  appearance  and  organization  which  indicate  at  once  their  line  of  de- 
marcation. The  first  is  of  a  rose  color,  is  smooth,  polished,  and  exhibits  to  the 
naked  eye  a  multitude  of  minute  dark  points,  which  are  the  orifices  of  its  innu- 
merable glands;  the  second  is  of  a  paler  hue,  and  is  roughened,  even  in  this 
region,  with  short  and  rigid  folds,  having  a  longitudinal  arrangement.  Accord- 
ing to  the  same  author,  the  pretended  continuity  of  the  mucous  with  the  serous 
membrane  is  only  apparent,  and  that  there  exists  on  the  contrary  a  well-defined 
limit  between  the  two  membranes.  When  the  serous  membrane  which  accom- 
panies the  body  of  the  tube  has  reached  the  external  surface  of  the  fimbriated 
extremity,  it  terminates  suddenly,  at  a  distance  of  from  one-sixteenth  to  three- 
sixteenths  of  an  inch  from  the  edge  of  the  fringe,  by  a  slightly  sinuous  and  often 


66  FEMALE  ORGANS  OF  GENERATION. 

leflexed  border.  This  line,  which  is  the  limit  of  the  peritoneum,  describes  a 
circle  around  the  fimbriated  extremity,  but  is  prolonged  upon  the  external  surface 
of  the  tubo-ovarian  fringes,  and  thus  reaches  the  obtuse  extremity  of  the  ovary. 

Until  of  latter  time,  the  middle  coat  of  the  tubes  had  been  regarded  as  a  pro- 
longation of  the  tissue  of  the  uterus.  M.  Robin  states  that  this  is  incorrect,  and 
that  the  tube  is  simply  attached  to  the  uterus  so  as  to  complete  the  conducting 
canal.  If  the  womb  of  a  pregnant  female  be  dissected,  the  oviduct  may  be 
traced  with  ease  through  the  thick  walls  of  the  organ.  In  its  course  through  the 
uterus,  the  tube  preserves  the  volume  which  it  had  upon  entering  it.  It  remains 
of  a  whitish  color,  whilst  the  uterine  tissue  is  of  a  reddish  gray.  A  thin  cellular 
layer  is  interposed  between  the  two  structures,  and  allows  them  to  be  separated 
with  ease.  Muscular  fibres  are  discoverable  in  the  uterus,  whilst  in  the  oviduct 
nothing  but  cellular  tissue  and  fibro-plastic  elements  are  to  be  met  with.  The 
uterine  extremity  of  the  tube  terminates  at  the  internal  surface  of  the  muscular 
structure  of  the  womb,  by  a  slight  thinning  off  of  its  walls. 

A  special  artery,  derived  from  the  numerous  branches  with  which  the  uterus  is 
supplied,  and  two  veins,  which  join  the  ovarian  veins,  constitute  the  vascular 
apparatus  of  the  tube.  It  is  provided  with  nerves  from  the  spermatic  and  hypo- 
gastric plexuses. 

The  Fallopian  tube  serves  the  double  purpose  of  a  canal  for  transmitting  the 
fecundating  principle-  of  the  male,  and  for  carrying  the  germ  furnished  by  the 
female  from  the  ovary  to  the  uterus. 

The  use  of  the  fimbriated  extremity  is  to  embrace  the  ovary  at  the  moment  of 
fecundation,  and  probably  also  at  each  menstrual  period,  and  to  apply  itself  over 
the  point  from  whence  the  germ  is  detached.  At  this  time,  the  vessels  of  the 
Fallopian  tubes  are  engorged — the  mucous  membrane  assumes  a  well-marked  red 
qqIox — the  walls  are  thickened,  and  the  canal  is  enlarged.  The  tubes  are  at  the 
same  time  affected  with  peristaltic  contractions,  which  are  probably  intended  to 
propel  the  ovule  into  the  uterine  cavity. 

The  anomaly  presented  by  the  existence  of  supernumerary  pavilions,  or  fim- 
briated extremities,  upon  the  same  tube,  as  described  by  M.  Gustavo  Richard,  is 
here  deserving  of  notice.  In  the  bodies  of  twenty  women,  selected  at  random, 
he  observed  it  five  times.  One  or  several  of  them  were  found  attached  to  the 
tube  either  immediately  behind  the  normal  fimbriated  extremity,  or  at  distances 
varying  from  three-quarters  of  an  inch  to  an  inch  and  a  quarter  beyond  it;  all 
of  them  were  formed  like  the  one  which  terminated  the  oviduct  by  the  fringe- 
like division  of  the  mucous  membrane.  By  floating  the  fringes  under  water,  an 
opening  was  discovered  conducting  into  the  tube,  through  which  a  stylet  might 
be  introduced  and  brought  out  through  either  the  internal  or  external  orifice  of 
the  tube. 

According  to  Dr.  Hamilton,  of  Edinburgh,  the  Fallopian  tube  undergoes  some 
modification  during  gestation,  to  which  he  attaches  great  importance,  as  a  charac- 
teristic sign  of  pregnancy.  This  change  consists  in  the  formation  of  a  little 
pocket,  or  sac,  about  an  inch  from  the  fringed  extremity.  This  partial  dilatation 
of  the  tube,  previously  described  by  Roederer  under  the  name  of  antrum  tubce, 


OP  THE  ORGANS  OF  GENERATION.  67 

is  certainly  an  exceptional  fact.  I  have  never  observed  it;  and  M.  Montgo- 
mery has  encountered  it  but  once  in  fourteen  uteri,  examined  in  the  state  of 
gestation ;  so  that  it  cannot  have  all  the  importance  that  certain  authors  wish  to 
ascribe  to  it. 

Art.  IV. — Of  the  Ovaries. 

The  ovaries  (^testes  muliehres)  are  the  analogues,  in  the  female,  to  the  testicles 
of  the  male ;  that  is,  both  of  them  secrete  a  product  indispensable  to  reproduc- 
tion. Two  in  number,  they  are  situated  on  the  sides  of  the  uterus,  in  that  por- 
tion of  the  broad  ligament  called  the  posterior  wing,  just  behind  the  Fallopian 
tube.  They  are  maintained  in  position  by  those  ligaments,  as  also  by  a  special 
one,  denominated  the  ligament  of  the  ovary. 

The  ovaries  vary  in  situation,  according  to  the  age  of  the  individual,  and  the 
state  of  the  uterus.  In  the  foetus,  they  are  placed,  like  the  fundus  uteri,  in  the 
lumbar  region ;  but,  during  gestation,  they  rise  into  the  abdomen  along  with  the 
body  of  the  uterus,  upon  the  sides  of  which  they  lie. 

Immediately  after  delivery  the  ovaries  occupy  the  iliac  fossae,  where  they  some- 
times continue  throughout  life ;  again,  it  is  not  at  all  uncommon  to  find  them 
turned  backwards,  and  adherent  to  the  posterior  face  of  the  womb. 

The  ovaries  vary  in  size,  both  from  age,  from  the  plenitude  or  vacuity  of  the 
uterus,  and  from  health  or  disease.  Being  proportionably  larger  in  the  foetus 
than  in  adult  age,  they  diminish  after  birth,  augment  in  volume  at  puberty,  es- 
pecially at  the  monthly  periods,  and  dwindle  away  in  old  age.  During  preg- 
nancy and  after  delivery,  they  acquire  in  some  cases  quite  a  considerable  volume. 

Fig.  18. 


Ovary  of  ihe  Young  Female  after  Puberty. 

A.  Body  of  the  ovary,    b.  Utero-ovarian  ligament,    c.  Tubo-ovarian  ligament.    D.  Fallopian  lube. 

E.  Fimbriated  extremity  of  the  tube. 

Before  the  age  of  puberty,  the  external  surface  of  the  ovaries  is  of  a  light  rose 
color,  and  is  smooth  and  free  from  inequalities.  In  women  who  have  men- 
struated for  several  years  the  surface  is  rough,  fissured,  covered  with  small 
blackish  cicatrices,  and  sometimes  with  ecchymotic  spots.  Some  of  these  cica- 
trices are  linear,  others  are  triangular  or  radiated ;  they  are  of  a  red  color  when 
recent,  but  become  brown  in  the  course  of  a  few  months.     Sometimes  a  complete 


68  FEMALE  ORGANS  OF  GENERATION. 

union  fails  to  take  place  between  their  edges,  leaving  a  small  opening,  which  com- 
municates with  the  ruptured  cavity.  After  the  period  of  life  at  which  the  menses 
disappear,  the  external  surface  presents  numerous  wrinkles,  which  are  not,  as  has 
been  supposed,  the  result  of  old  cicatrices,  but  are  due  simply  to  the  atrophy  of 
the  ovaries,  and  the  plication  of  the  external  envelope  which  is  the  consequence. 

The  ovaries  are  ovoidal  in  shape,  a  little  flattened  from  before  backward,  and 
of  a  whitish  color. 

The  external  extremity  of  the  ovary  is  adherent,  as  we  have  said,  to  one  of  the 
fringes  of  the  fimbriated  extremity  of  the  Fallopian  tube ;  the  internal  extremity 
is  attached  to  the  uterus  by  the  ligament  of  the  ovary,  which  is  inserted  at  the 
corresponding  angle  of  that  organ. 

The  ligament  of  the  ovary,  which  we  have  already  considered,  was  for  a  long 
time  regarded  as  a  canal,  designed  like  the  Fallopian  tube  to  convey  the  fecun- 
dated ovule  into  the  cavity  of  the  uterus ;  modern  anatomists,  however,  believe 
it  to  be  solid. 

From  the  researches  of  Gartner,  of  Copenhagen,  and  of  M.  de  Blainville,  it 
appears  that  in  some  quadrupeds,  and  especially  the  sow,  a  canal  is  almost  always 
to  be  found  extending  from  its  external  orifice  by  the  side  of  the  meatus  urina- 
rius  (corresponding  with  a  similar  orifice  on  the  other  side  of  the  meatus), 
through  the  substance  of  the  muscular  fibres  of  the  vagina  to  the  neck  of  the 
uterus;  here  the  canal  becomes  narrower,  but  continues  on,  following  the  body 
of  the  uterus  and  imbedded  in  its  fibrous  structure,  and  finally  leaves  it  to  pass 
in  a  direction  parallel  to  the  corresponding  angle  into  the  substance  of  the  broad 
ligament. 

M.  Follin  found,  whilst  injecting  the  duct  of  Gartner  in  the  sow,  that  he  in- 
jected at  the  same  time  a  long  tortuous  tube,  situated  in  the  substance  of  the 
ligament,  at  the  point  occupied  in  the  human  female,  by  the  collection  of  glan- 
dular tubes  which  I  have  described.  I  have  been  able  to  determine  the  fact 
that  in  the  sow  this  duct  does  not  open  by  a  large  orifice  at  the  lower  part  of  the 
vagina,  as  has  been  represented,  but  in  reality  by  a  very  narrow  one.  It  is  not  ter- 
minated at  its  entrance  into  the  broad  ligament  by  a  few  brush-like  divisions,  as 
stated  by  M.  de  Blainville,  but  is  continuous  with  a  very  fine  tortuous  tube 
which  extends  to  the  external  extremity  of  that  ligament.  The  duct  of  Gartner 
is  furnished  internally  with  a  pavement  epithelium,  and  communicates  through- 
out its  course  with  many  glandular  tubes  finer  than  itself.    (Follin.) 

We  have  sought  for  this  duct  of  Gartner  in  the  human  female,  but  found 
nothing  which  could  be  reconciled  with  the  description  given  by  him  of  it ;  how- 
ever, we  cannot  avoid  remarking  that  since  these  researches  N.  C.  Baudelocque 
has  observed  in  a  woman  a  canal  which  seemed  to  be  produced  by  a  bifurcation 
of  the  Fallopian  tube,  and  which,  after  passing  through  the  entire  uterine  walls, 
opened  into  the  upper  part  of  the  vagina  near  the  neck  of  the  womb.  Madame 
Boivin  and  some  others  have  met  with  a  similar  canal,  and  Mauriceau  and 
Dulaurens  considered  it  of  quite  frequent  occurrence. 

The  arteries  which  supply  the  ovary  are  the  spermatics,  and  proceed  directly 
from  the  aorta. 


OF  THE  ORGANS  OF  GENERATION.  69 

The  numerous  small  venous  branches  originating  in  the  ovary,  are  collected 
into  a  common  trunk,  called  the  spermatic  vein,  which  empties  into  the  inferior 
vena  cava,  though  sometimes  into  the  renal  vein. 

The  numerous  lymphatic  vessels  with  which  it  is  provided  contribute  to  the 
formation  of  the  spermatic  plexus,  which  itself  empties  into  the  lumbar  plexus, 
and  thence  passes  to  the  thoracic  duct. 

The  nerves  are  derived  from  the  great  sympathetic. 

§  1.  Structure  of  the  Ovaries. 

The  ovary  consists,  1st,  of  a  dense  fibrous  envelope,  covered  by,  and  intimately 
united  to,  the  peritoneum  ;  2d,  of  a  spongy,  vascular  tissue,  the  meshes  of  which 
seem  to  be  formed  of  very  delicate  prolongations  of  the  exterior  envelope,  analo- 
gous to  glandular  tissue. 

Baer  has  given  to  the  sub-peritoneal  fibrous  envelope  the  name  of  the  stratum 
superficiale,  and  that  of  the  stratum  intimum  seu  proprium  to  the  proper  ovarian 
tissue.  He  designates  both  of  these  lamince  (which  he  considers  of  the  same 
nature)  under  the  title  of  stroma.  The  glandular  substance  exhibits  a  number 
of  small  cavities,  in  which  some  little  follicles,  described  by  Graaf,  and  bearing 
his  name,  are  found  enclosed. 

Some  of  these  follicles  or  vesicles  are 
plunged  into  the  very  interior  of  the  Fig.  19. 

organ ;  others,  that  are  larger  and  better 
developed,  occupy  the  surface,  where 
they  are  more  or  less  imbedded  in  the 
stroma,  producing  sometimes  little  round- 
ed elevations  on  the  latter,  which  give  a 
tuberculous  aspect  to  the  whole  ovary. 

In  such  cases,  they  are  only  covered 
on  the  free  surface  by  the  proper  tunic 

f  ,,  1  •    1  •         n     1  This  figure  represeiils  a  lonaritudiiial  secliou  of  the 

01  the  ovary,  which  occasionally  becomes  u     ■      .i  ,     a  ^  a-      .  ^ 

J '  J  ovary,  showing;  the  arrangement  and  different  de- 

SO    thin    there,  as  to    exhibit   the    serous  grees  of  development  of  the  Graafian  vesicles. 

lamina   alone.      The    number  of  well- 
marked  vesicles  varies  from  fifteen  to  twenty  in  the  adult  female,  but  with  the 
aid  of  a  microscope  a  much  larger  number  can  be  brought  into  view,  which, 
although  still  very  small,  will  be  gradually  developed  as  the  others  shall  have 
accomplished  their  mission. 

§  2.  Op  the  Ovarian  Vesicles. 

These  vesicles  are  composed  of  two  portions :  1st,  of  a  containing  part,  the 
envelope;  2d,  of  a  contained  one,  the  nucleus.  The  former  consists,  1st,  of  some 
foreign  parts,  those  not  proper  to  the  vesicle  itself,  but  appertaining  to  the  ovary, 
and  which  are  subtended  and  transformed  by  it  into  teguments ;  and  2d,  of  a 
proper  capsule  for  the  vesicle. 

A.   The  tegument  (^indnsium,  Baer)  only  invests  the  prominent  part  of  the 


70 


FEMALE  ORGANS  OF  GENERATION. 


Fig.  20. 


vesicle,  being  formed  of  a  peritoneal  lamina  and  of  a  thin  layer  of  the  stroma  or 
proper  ovarian  tissue. 

B.  The  capsule  (theca,  Baer)  is  composed  of  two  lamince,  the  external  and  the 
internal.  The  former  is  thin  but  tenacious,  very  retractile,  semi-transparent, 
and  formed,  like  all  thin  membranes,  of  a  dense  cellular  tissue ;  some  vessels 
ramify  in  its  substance,  and  their  extremities  go  to  the  internal  layer.  This 
latter  is  softer,  thicker,  more  opaque,  and  slightly  or  not  at  all  retractile.  Its 
internal  sui'face  is  lubricated,  exhibiting  granulations,  and  some  extremely  deli- 
cate villosities,  whilst  the  outer  surface  is  intimately  united  to  the  external 
layer ;  the  little  vessels  that  penetrate  it,  immediately  subdivide  into  very  deli- 
cate ramuscules,  assuming  a  pencillous  arrangement,  so  as  almost  to  constitute  a 
third  layer,  which  is  essentially  vascular. 

C.  The  Nucleus. — The  parts  entering  into  the  composition  of  the  nucleus  are, 
1st,  a  granular  membrane  which  encloses  the  humor  of  the  Graafian  vesicle;  and 
2d,  a  liquid  produced  by  the  aggregation  of  three  humors  of  a  difi'erent  aspect, 

viz.,  a  limpid  mucosity,  clear,  though  a  little 
oily,  a  number  of  small  rounded  granulations, 
transparent  in  their  central  cavity,  and  slightly 
opaque  at  their  periphery,  and  some  oil  glo- 
bules. 3d,  and  lastly,  an  ovule  floating  in 
the  midst  of  this  liquid. 

1.  The  (jranidar  membrane  (see  Fig.  20, 
g').  a  delicate  membrane  is  found  applied 
on  the  internal  face  of  the  Graafian  vesicle, 
formed  of  granules,  or  rather  of  cellules,  and 
bearing  the  name  of  the  yrunular  viembrane. 
It  tears  with  great  facility,  from  its  extreme 
tenuity,  and  hence  many  authors  have  denied 
A.  The  ovule.  G.  The  granular  cumulus,  its  existence.  Upon  one  part  of  the  mem- 
g'.  The  granular  membrane,  k.  The  cavity    brano  (that  corresponding  to  the  free  side  of 

of  the   Graafian   vesicle,     m.  The   mucous      ,,  -in,!  i    ,•  ^^ 

surface,    v.   The  vascularlayer.    f.    The     the    VeSlclc)    the    granulations.    Or    CClls     pro- 

fibrous  layer,   p.  The  peritoneal  coat.  ducing  it,  are  more  numcrous  or  more  com- 

pact, and  in  the  centre  of  this  compact  mass, 
which  has  been  called  the  proligerous  disk,  the  ovule  is  found. 

The  granulations,  constituting  the  proligerous  disk  (see  G,  Fig.  20),  are  so 
closely  united,  both  with  each  other  and  with  the  latter,  that  upon  opening  the 
Graafian  vesicle,  even  where  the  granular  membrane  is  destroyed,  this  portion 
remains  adherent  to  the  ovule,  forming  round  it,  as  it  were,  a  granular  bed. 

This  membrane  is  entirely  destitute  of  vessels.  '<  It  is  extremely  probable," 
says  M.  Coste,  "that  M.  Pouchet  was  deceived  by  appearances,  which  led  him 
to  regard  the  vessels  distributed  upon  the  innermost  layer  of  the  Graafian  vesicle, 
as  belonging  to  the  granular  membrane." 


The  Ovule  in  the  Graafian  Vesicle. 


§  3 .  The  Ovule. 

Since  the  labors  of  Graaf,  the  majority  of  authors  agree  with  him,  that  the 
ovule  is  constituted  by  the  vesicle  just  described;  but  the  honor  of  having  first 


OF    TUB     ORGANS     OF     G  E  N  E  R  A  T  I  0  X. 


71 


21. 


discovered  the  ovule,  as  a  distinct  organ  in  this  vesicle,  belongs  to  Charles 
Ernest  Baer.  The  ovule  is  completely  formed  in  the  ovary  during  the  earlier 
years  of  life.  It  is  imbedded  from  the  period  of  its  maturity,  as  stated  above,  in 
the  midst  of  a  mass  of  granulations,  which  are  more  compact  than  those  which 
fill  the  remainder  of  the  vesicle. 

It  therefore  occupies  a  fixed  position  in  the  vesicle,  and  is  almost  constantly 
met  with  at  a  point  opposite  to  that  whence  the  large  vascular  trunks  spread  out 
upon  the  ovarian  capsule,  that  is  to  say,  at  the  point  which  projects  from  the 
surface  of  the  ovary.  When  examined  with  a  lens,  it  appears  as  an  opaque 
rounded  body,  at  least  more  opaque  than  the  liquid  enclosed  in  the  same  vesicle; 
it  is  extremely  minute,  although  the  diameter  of  the  little  sphere  it  represents  is 
subject  to  variations. 

"  The  largest  human  ovules  I  have  seen  and  manipulated,"  says  Bischoflf", 
"did  not  exceed  the  tenth  of  a  line,  being  barely  perceptible  to  the  naked  eye." 
When  placed  under  a  microscope,  it  is  seen  to  con- 
sist of  an  exterior  envelope,  called  the  vitelline 
membrane  (Coste),  transparent  zone,  cortical  mem- 
brane, or  chorion  (Baer),  of  a  substance  aptly  com- 
pared to  the  yolk  of  an  egg,  and  designated  as  the 
vitellus,  and  of  another  vesicle  (placed  within'  the 
latter)  called  the  germinal  vesicle. 

A.  Vitelline  31emhrane. — If  the  ovule  be  exa- 
mined by  a  magnifying  glass  of  sufficient  power, 
an  obscure  sphere  will  be  brought  into  view,  sur- 
rounded by  a  large  clear  ring,  the  nature  of  which 
it  is  difficult  to  make  out.  M.  Coste  has  given  the 
name  of  the  vitelline  membrane  to  this  ring.  It  is 
evidently  a  thick  membrane,  the  external  and  in- 
ternal outlines  of  which  assume  the  appearance  of 
two  circular  lines  enclosing  a  transparent  ring. 
Many  persons  have  merely  considered  it  as  a  layer  of  albumen  surrounding  the 
yolk,  but  any  one  may  easily  convince  himself  that  it  is  at  least  a  resisting  mem- 
brane, by  cutting  the  ovule,  or  by  compressing  it  by  means  of  an  instrument  called 
the  compressor;  "  for  after  proceeding  in  this  manner,"  says  Bischoff,  "there 
cannot  be  a  doubt  that  the  transparent  zone  is  an  elastic,  thick,  hyaline,  and  trans- 
parent membrane,  without  a  determinate  texture." 

Though  entirely  destitute  of  cells  and  vessels,  it  is  nevertheless  a  living  enve- 
lope, because,  as  soon  as  the  ovum  in  the  mammalia  arrives  in  the  cavity  of  the 
uterus,  it  becomes  the  seat  of  an  active  vegetation,  and  produces  villosities  which 
are  more  or  less  ramified.  The  latter,  as  they  become  developed,  insinuate  them- 
selves into  the  tissue  of  the  uterine  mucous  membrane,  and  thus  attach  the  ovura 
to  the  place  which  it  is  to  occupy  for  the  future. 

The  vitelline  membrane  is  entirely  closed,  and  presents,  contrary  to  the  opinion 
of  Barry,  neither  slit  nor  circular  opening,  whereby  the  spermatic  animalculce 
might  find  entrance  into  its  cavity.     (Coste.) 


A  Non-fecundaled  Huinaii  Ovule. 

A. The  vitelline  membrane,  or  irans- 
pareiit  zone.  B.  The  vilellus,  or  yolk, 
c.  The  vesicle  of  Purkiiije,  or  the 
germinal  vesicle,    d.  The  germinal 

spot. 


72  FEMALE    ORGANS     OF    GENERATION. 

B.  Yolk,  or  Vitellus. — The  cavity  of  the  vitellioe  membrane  is  occupied,  in 
great  measure,  by  a  granular  liquid,  that  does  not  adhere  to  the  exterior  envelope, 
and  even  escapes  from  it  readily  when  the  latter  is  broken. 

According  to  Bischoff,  the  yolk  of  the  human  ovum  is  formed  of  a  coherent, 
indistinctly  granular,  transparent,  and  viscous  mass,  which  does  not  run  out  when 
the  egg  is  cut  or  crushed ;  each  portion  of  the  zone  reserving  its  particular  seg- 
ment of  yolk,  or  the  latter  escaping  altogether. 

"In  certain  cases,"  says  he,  ''the  vitelline  granulations  are  not  united  in  a 
single  mass.  I  have  seen  the  yolk  divided  in  two,  and,  on  one  occasion,  into  five 
parts  of  different  volume." 

The  vitellus  usually  fills  the  interior  of  the  zone  completely,  and  has  the  same 
form,  but  sometimes  the  vitelline  sphere  is  smaller  than  that  destined  to  receive 
it.  Some  authors  likewise  believe  that  a  very  delicate  membrane  exists,  which 
encloses  and  unites  the  yolk  in  a  single  mass;  but  Messrs.  Coste  and  Bischofi' 
ao-ree  in  rejecting  the  existence  of  this,  and  contend  that  the  granulations  of  the 
vitellus  are  placed  in  juxtaposition  with  the  transparent  zone,  which  forms  its  sole 
and  only  envelope. 

c.  Germinal  Vesicle. — In  the  midst  of  this  yellow  body,  in  very  young  girls, 
or  on  one  of  the  neighboring  points  of  the  peripheral  envelope  in  the  matured 
ovules,  a  small,  perfectly  transparent,  and  colorless  vesicle  is  seen  like  a  clear 
spot,  surrounded  by  a  mass  of  a  deeper  yellow.  Purkinje  had  described  it  in 
the  eo-gs  of  birds,  and  gave  his  own  name  to  it,  but  M.  Coste  is  entitled  to  the 
honor  of  having  first  demonstrated  its  existence  in  the  ovum  of  mammiferje,  and 
of  thus  having  established  the  perfect  identity  between  the  latter  and  the  egg  of 
birds.  This  is  the  vesicle  of  Purkinje,  or  the  germinal  vesicle.  It  is  slightly 
oval,  and  consists  of  a  very  delicate,  transparent,  and  colorless  membrane,  which 
encloses  a  liquid  that  is  frequently  as  limpid  and  transparent  as  itself,  though  it 
sometimes  contains  a  few  granules.  Notwithstanding  its  extreme  tenuity,  this 
vesicle  still  offers  a  certain  consistence,  since  it  has  been  seen  intact,  after  leaving 
the  ovule,  and  being  completely  separated  from  the  granular  liquid  in  which  it 
was  placed. 

It  is  always  very  small,  and  scarcely  measures  the  sixtieth  of  a  line  in  diameter. 

D.  The  Germinal  Spot. — If  the  germinal  vesicle  be  attentively  observed,  an 
obscure  rounded  spot  will  be  seen  on  some  part  of  its  periphery ;  this  was  first 
discovered  by  Wagner,  who  gave  it  the  name  of  the  germinal  spot.  It  seems  to 
be  formed  by  the  aggregation  of  fine  small  granules,  or  little  globules,  the  obscure 
hue  of  which  is  brought  out  by  the  clear  contents  of  the  vesicle.  Wagner  has 
sometimes  met  with  two,  or  even  more,  germinal  spots  in  the  mammiferae. 

Before  fecundation,  therefore,  the  ovule  is  composed  :  1st,  of  an  exterior  en- 
velope, the  vitelline  membrane,  or  tran.sparent  zone ;  2d,  of  a  vitellus,  or  yolk, 
contained  in  this  vesicle ;  3d,  of  a  little  vesicle  enclosed  in  the  first  and  swim- 
ming in  the  vitelline  fluid — the  germinal  vesicle  ;  4th,  and  lastly,  of  the  germinal 
spot. 

We  shall  now  proceed  to  examine  more  fully  the  modifications  it  undergoes 
after  conception. 


OF  THE  OKGANS  OF  GENERATION.  73 

CHAPTER   III. 

OF    THE    ORGANS    OP    GENERATION. 

ARTICLE  I. 

OF   THE    MODIFICATIONS    UNDERGONE   BY   THE   OVARIAN    VESICLES. 

The  Glraafian  vesicles,  which  were  barely  visible  in  the  young  girl,  although 
they  may  be  shown  to  exist  immediately  after  birth,  ar^  destined  to  undergo  in 
the  adult  female  a  considerable  development.  Until  the  age  of  puberty  they  are 
of  small  size,  and  concealed  in  the  centre  of  the  stroma ;  but  at  this  epoch,  some 
fifteen  to  twenty  of  them,  which  appear  more  advanced  than  the  others,  increase 
in  size,  and  approach  the  external  surface  of  the  ovary.  At  the  time  when  the 
young  girl  becomes  nubile,  one  of  the  latter  vesicles  seems  to  have  received  a 
great  increase  of  vitality;  it  undergoes  a  remarkable  hypertrophy,  and  forms  a 
projection  upon  the  surface  of  the  ovary ;  this  projection  becomes  greater  and 
greater  until  after  some  days  it  forms  a  tumor  of  the  size  of  a  cherry,  or  even  of 
a  small  nut,  upon  the  ovarian  surface. 

This  considerable  augmentation  of  size  is  due  to  the  distension  of  the  walls  of 
the  vesicle  by  an  increased  secretion  of  the  fluid  which  it  contains.  In  propor- 
tion as  the  development  proceeds,  the  walls  of  the  vesicle  become  thin  and  trans- 
parent ;  the  vessels  which  supply  them  being  compressed  by  the  dilatation,  lose 
their  volume  and  become  obliterated  and  atrophied,  especially  upon  the  point  of 
culmination,  where  the  resistance  is  least.  When  at  last  it  has  arrived  at  its  full 
development,  the  ovarian  capsule  appears  to  remain  stationary,  until  an  over- 
excitement,  produced  either  by  the  maturity  of  the  ovule,  or  by  sexual  inter- 
course, occasions  its  rupture.  (Coste.)  Then,  the  walls  of  the  vesicle,  although 
more  and  more  distended,  begin  to  lose  their  transparency,  on  account  of  the 
hemorrhage  which  ensues.  This  is  sometimes  limited  to  the  production  of  small 
extravasations  upon  the,  as  yet,  entire  walls  of  the  vesicle,  though  most  frequently 
a  true  eifusion  takes  place  within  the  cavity.  The  effused  blood  and  the  super- 
abundant secretion  increase  still  more  the  distension  of  the  walls,  which  is  finally 
carried  so  far  that  rupture  becomes  imminent,  and  it  is  possible  to  distinguish  at 
the  most  projecting  part  of  the  tumor,  the  point  where  it  is  about  to  ensue.  This 
point  is  generally  indicated  by  a  small  reddish  spot,  of  about  a  line  in  extent, 
produced  by  a  strong  injection,  or  even  by  a  slight  effusion  of  blood  in  the  tex- 
ture of  the  walls  of  the  vesicle.  (Raciborsky.)  The  thinned  walls  finally  give 
way  and  tear  gradually ;  the  membranes  of  the  vesicle  itself  being  the  first  to 
yield,  and  after  them  the  peritoneal  layer.  As  a  consequence  of  this  rupture, 
the  ovule  is  expelled,  and  carries  along  with  it  a  part  of  the  granular  contents  of 
the  vesicle ;  it  enters  the  Fallopian  tube,  the  fimbriated  extremity  of  which  is 
prepared  to  receive  it,  and  after  traversing  its  canal  arrives  at  a  later  period  in 
the  cavity  of  the  uterus. 

The  walls  of  the  follicle  collapse  after  the  rupture,  and  its  cavity  becomes  filled 


'4 


FEMALE  ORGANS  OF  GENERATION. 


with  a  small  quantity  of  blood,  which  i»  found  fluid  or  coagulated  according  to 
the  time  at  which  the  examination  is  made. 

The  walls  of  the  torn  vesicle  contract  gradually,  and  the  clot,  which  sometimes 
at  first  is  of  the  size  of  a  small  cherry,  is  slowly  absorbed ;  the  originally  spacious 


Fi2.  22. 


Fi2.23. 


Fig.  22.  Showing  the  ovary,  and  a  Graafian  vesicle  at  its  highest  degree  of  development,  and  just  be- 
fore its  rupture.' 

A.  The  hypertrophied  vesicle  (drawn  from  nature,  and  of  its  real  size),  b,  C;C.  Radiated  cicatrices,  left 
by  previously  ruptured  vesicles. 

Fig.  23.  The  ovary,  with  the  ruptured  vesicle  and  the  large  clot  that  fills  its  cavity.  (Drawn  from 
nature.) 

cavity  diminishes,  the  margins  of  the  rupture  approximate,  so  as  even  to  become 
united  occasionally  by  cicatrization,  and  order  is  finally  restored. 

The  evolution  just  described,  which  is  terminated  by  the  rupture  of  a  vesicle 
and  the  spontaneous  expulsion  of  an  ovule,  is  not  an  isolated  fact ;  on  the  con- 
trary, it  excites  numerous  sympathies  in  the  remainder  of  the  generative  appa- 
ratus and  throughout  the  organism  of  the  female.  We  shall  first  study  the  gene- 
rative organs  and  the  modifications  which  they  undergo  before,  during,  and  after 
this  evolution. 

The  ovary,  which  produces  the  hypertrophied  vesicle,  is  notably  enlarged.  It 
is  of  a  deep  red  color,  and  its  vascular  apparatus  is  remarkably  congested. 

The  Fallopian  tuhe  itself  shares  in  the  congestion,  being  often  of  a  violet-red 
color,  especially  at  its  fimbriated  extremity,  which  has  a  sort  of  velvety  appear- 
ance. It  is  also  endowed  at  this  epoch  with  a  special  erethism,  in  virtue  of 
which  it  applies  its  floating  extremity  upon  the  ovary,  in  such  a  manner  as  to 
receive  the  ovule  and  conduct  it  into  its  cavity. 

The  utn-us  undergoes  such  important  changes  that,  before  the  discovery  of 
spontaneous  ovulation,  it  was  erroneously  supposed  to  play  the  principal  part  in 
the  phenomena  which  we  are  about  to  study.  I  shall  continue  to  draw  from  the 
beautiful  works  of  M.  Coste,  from  which  I  have  already  borrowed  so  freely  in 
the  preparation  of  this  chapter,  the  principal  features  of  the  ensuing  description. 

'  This  figure,  borrowed  from  M.  Raciborsky,  is  the  exact  copy  of  a  preparation  which  he 
had  the  kindness  to  show  me.  But  since  that  time  (1843)  I  have  never  met  with  so  enor- 
mously developed  a  vesicle,  and  I  am  iHsposed  to  believe  that  this  great  size  is  rather  patho- 
logical than  normal. 


OF  THE  ORGANS  OF  GENERATION.  75 

Whilst  the  ovarian  vesicle  is  undergoing  the  rapid  evolution  which  we  have 
just  described,  the  vascular  apparatus  of  the  womb  becomes  developed  and  in- 
jected in  an  unusual  manner ;  immediately  beneath  the  delicate  layer  of  epithe- 
lium which  covers  the  surface  of  the  mucous  membrane,  it  forms  in  particular 
elegant  reticulations,  with  irregular,  lozenge-shaped  intervals,  surrounding  the 
orifice  of  each  of  the  numerous  glandular  tubes  of  which  this  membrane  is  almost 
entirely  composed.  This  network  is  so  fine  as  to  give  a  violet  hue  of  greater  or 
less  intensity  to  the  internal  surface  of  the  womb,  and  is  formed  of  very  delicate 
venous  ramuscules.  The  utricular  glands  increase  perceptibly  in  size,  and  the 
muscular  structure  of  the  uterus,  in  consequence  of  the  congestion  which  it 
undergoes,  acquires  greater  extension,  is  of  a  more  lively  red  color,  and  becomes 
more  spongy  and  supple.  The  entire  volume  of  the  organ  is  increased,  the  neck 
is  tumefied,  and  its  orifice  narrower;  the  lips  of  the  os  tincce  are  warmer  and 
their  color  deeper. 

The  mucous  membrane,  in  consequence  of  this  development  of  its  vessels,  and 
especially  of  the  glandules  of  which  it  is  composed,  has  its  thickness  so  much  in- 
creased in  proportion  to  the  size  of  the  uterine  cavity,  as  to  be  thrown,  in  a  great 
many  subjects,  into  soft,  projecting  folds  or  circumvolutions,  which  are  so  pressed 
together  as  to  leave  no  vacant  space  in  the  cavity  of  the  organ.  M.  Coste  has 
several  wombs  in  his  possession,  whose  mucous  membranes  measure  at  certain 
points,  from  two  to  three-eighths  of  an  inch  in  thickness ;  still,  to  whatever  de- 
gree the  hypertrophy  may  be  carried,  it  never  presents  the  floating  villi  which 
Baer  and  Weber  thought  they  had  observed ;  neither,  except  in  some  patholo- 
gical cases,  does  it  ever  exhibit  the  pseudo-membranous  exudation  which  is  ac- 
knowledged by  almost  all  physiologists.    (See  Deciduous  Membrane.) 

This  great  vascularity  of  the  mucous  membrane,  and  the  high  vascular  con- 
gestion which  the  entire  organ  undergoes,  is  at  first  accompanied  with  the  exuda- 
tion of  a  few  drops  of  blood,  which  by  admixture  below  with  the  vaginal  mucus, 
which  is  itself  at  this  period  increased  both  in  quantity  and  fluidity,  communi- 
cates to  it  at  first  a  rosy,  and  then  a  light  reddish  hue.  After  two  or  three  days, 
a  flow  of  blood,  derived  principally  from  the  superficial  network  of  the  mucous 
membrane,  escapes  through  the  neck  and  mingles  with  the  vaginal  secretions. 
Henceforth,  the  efi'usion  presents  all  the  characters  of  a  true  hemorrhage. 

There  can  be  no  doubt  that  the  chief  source  of  this  hemorrhage  is  the  super- 
ficial vascular  network  of  the  mucous  membrane ',  and  in  women  who  have  died 
at  this  period  the  blood  may  be  seen  to  transude  through  microscopic  fissures.  It 
is,  therefore,  a  true  exhalation  of  blood  like  that  of  epistaxis. 

The  flow  preserves  the  same  characters  during  the  two  or  three,  be  they  more 
or  less,  days  of  its  duration ;  then,  as  the  quantity  of  blood  diminishes,  it  re- 
sumes gradually  the  mucous  and  serous  characters  peculiar  to  the  vaginal  secre- 
tion. 

It  is  impossible,  in  the  present  state  of  our  knowledge  of  the  subject,  to  deter- 
mine precisely  at  what  moment  during  the  flow  of  blood  the  rupture  of  the 
Graafian  vesicle  takes  place.  The  result  of  numerous  autopsies  admits  of  the 
supposition  that  this  moment  is  variable,  and  the   curious  experiments  of  M. 


76 


FEMALE  ORGANS  OF  GENERATION. 


Coste  leave  no  doubt  whatever  as  to  the  influence  which  venereal  excitement  is 
capable  of  exerting  upon  it;  this  influence  is  so  great,  that  it  may  determine  the 
rupture  of  an  hypertrophied  vesicle,  which,  without  sexual  intercourse,  would 
have  remained  intact  for  several  days  longer.  However,  it  may  be  admitted,  as 
a  general  rule,  that  the  rupture  occurs  during  the  last  days  of  the  flow. 

The  series  of  phenomena  of  which  the  ovary  is  the  seat,  is  not  terminated  by 
the  rupture  of  the  vesicle,  and  it  remains  for  us  to  state  what  becomes  of  its 
walls  after  the  expulsion  of  the  ovule. 

Of  the  Corpora  Lutea. 

Immediately  after  the  rupture  of 
the  Graafian  vesicle  and  the  conse- 
quent expulsion  of  the  ovule,  an  ef- 
fusion of  blood,  according  to  some, 
and  of  plastic  lymph,  according  to 
others,  takes  place  into  the  emptied 
cavity ;  moreover,  the  walls,  which 
were  greatly  distended,  retract 
strongly  upon  the  eff"used  matter, 
and  form  with  it  a  more  or  less 
compact  mass,  which  after  a  time 
assumes  an  orange-yellow  color. 
From  this  latter  circumstance,  the 
tumor  has  acquired  the  name  of  the 
yellow  hody,  or  corpus  luteuin. 

Although  for  a  long  time  consi- 
dered by  nearly  every  author  as  an 
irrefragable  proof  of  a  previous  con- 
ception, it  is  at  present  well  known 
that  this  body  may  exist  in  a  virgin 
girl,  provided  she  has  previously 
menstruated. 

Very  difi"erent  opinions  have  been  promulgated  as  to  the  mode  of  formation  of 
the  yellow  body,  as  also  in  regard  to  the  precise  period  at  which  it  commences. 
According  to  Robert  Lee,  the  mass  of  this  body  is  formed  exteriorly,  around  the 
empty  capsule  of  the  vesicle,  and  consequently  it  has  intimate  connections  with 
the  ovarian  stroma ;  but  this  opinion  is  inadmissible ;  Montgomery  and  Patterson 
teach  that  an  efi"usion  of  blood,  or  of  a  yellowish  albuminous  matter,  which  con- 
stitutes the  corpus  luteum,  takes  place  between  the  internal  and  the  external 
membranes  of  the  Graafian  vesicle ;  whence  the  yellow  body  will  have  its  inner 
face  lined  by  the  internal  membrane  of  the  vesicle. 

From  the  observations  of  Baer  and  Valentin,  the  yellow  body  results  from  the 
hypertrophy,  or  a  kind  of  puffing  up,  of  the  internal  membrane  of  the  vesicle, 
which  throws  out  a  species  of  vascular  processes  that  serve  to  fill  up  the  whole 
cavity  of  the  follicle,  excepting  at  the  part  occupied  by  the  ovule.  In  the  latter 
view,  as  well  as  in  that  entertained  by  Montgomery,  the  development  of  the 


Ulerus  laid  open,  so  as  to  exhibit  the  Hypertrophy  of  tlie 
Mucous  Membrane  at  the  Menstrual  Period. 
A.  Mucous  membrane  of  the  neck.  b.  Mucous  mem- 
brane of  the  body,  much  swollen,  c.  Thickness  of  the 
section  of  the  mucous  membrane.  D.  Tissue  proper  of 
the  uterus,  e,  f.  Diminution  in  the  thickness  of  the  mu- 
cous membrane  at  the  neck  and  at  the  orifices  of  the  Fal- 
lopian tubes. 


OF     THE     ORGANS     OF     GENEEATION. 


77 


corpus  luteum  will  aid  in  rupturing  the  vesicle,  by  the  distension  it  produces, 
and  will  soon  after  determine  the  expulsion  of  the  ovule,  by  pressing  it  gradually 
towards  the  thinnest  part. 

Both  suppose  that  the  corpus  luteum  is  completely  developed  when  the  vesi- 
cular rupture  and  the  discharge  of  the  ovule  take  place,  which,  however,  appears 
altogether  inadmissible  to  me.  I  am  convinced  to  the  contrary,  from  the  speci- 
mens which  M.  Kaciborsky  has  had  the  kindness  to  show  me.  In  a  female,  who 
died  during  menstruation,  I  was  enabled  to  prove  the  recent  rupture  of  a  vesicle 
that  was  very  much  hypertrophied  ;  its  cavity,  however,  did  not  contain  a  yellow 
body.  This  does  not,  therefore,  precede  the  rupture  of  the  vesicle.  In  my 
opinion,  M.  Raciborsky  has  perfectly  described  the  phenomena,  consecutive  to 
this  rupture,  in  the  interesting  treatise  published  by  him  (Z)e  la  Ponfe  pcriodique 
chez  les  Femmes  et  les  Mammiferes,  1844) ;  and  as  his  opinions  are  not  as  yet 
very  widely  disseminated,  it  may  prove  useful  to  publish  them  in  this  work, 

"  If  the  ovai'ies  be  examined  eight,  ten,  or  twelve  days  after  the  cessation  of 
the  menstrual  discharge,  a  small,  rounded  tumefaction,  surmounted  by  a  red  spot 
like  an  ecchymosis,  and  presenting  in  its  centre  a  slight  linear  fissure,  will  be 
found  on  the  surface  of  one  of  these  organs.  The  margins  of  the  fissure  are 
agglutinated,  even  this  early,  in  the  majority  of  cases;  but  it  is  still  easy  to  sepa- 
rate them  by  using  lateral  tractions.  If  the  ovary  be  then  opened  at  the  ecchy- 
mosed  spot,  the  interior  will  exhibit  a  pouch,  already  smaller  than  the  cavity  of 
the  vesicle  before  the  rupture,  but  entirely  filled  by  a  clot  of  blood,  which,  when 
placed  in  alcohol,  has  the  consistence  of  a  solid  body,  though  somewhat  spongy 
in  its  nature.  The  clot  is  usually  about  the  size  of  a  medium  cherry  (see  Fig. 
23),  and  may  be  raised  from  its  cavity  without  difiiculty.  The  parietes  of  the 
vesicle  exhibit,  at  this  period,  a  yellowish  hue,  that  disappears  in  spirits  of  wine. 
The  surface  of  the  internal  membrane  is  at  once  slightly  plaited  and  downy;  the 
plaiting  being  produced  after  the  rupture  of  the  vesicle,  by  the  rapid  contraction 
of  the  highly  elastic  external  membrane,  thus  throwing  the  internal  one,  which 
is  devoid  of  such  elasticity,  into  folds.  The  re- 
traction is  arrested  by  the  resistance  of  the  clot, 
then  the  folds,  that  existed  on  the  internal  mem- 
brane, disappear  in  consequence  of  the  reciprocal 
adherence,  and  the  cavity  diminishes.  In  the 
meanwhile,  the  most  soluble  molecules  of  the  clot 
are  absorbed,  and  then  a  further  retraction  of  the 
external  tunic  takes  place.  The  internal  one,  con- 
tinually forced  to  follow  the  diminution  of  the  clot, 
and  to  become  moulded  upon  it,  forms  anew  a  cer- 
tain number  of  folds,  which  are  lost  in  a  similar 
manner  by  adhering  to  each  other,  and  thus  dimi- 
nishing the  surface  of  the  internal  membrane. 
Afterwards,  a  new  absorption  of  soluble  parts,  a 
further  retraction  of  the  tunics,  a  fresh  diminution 
of  the  cavity,  &c.  &c.     "Whence,  at  the  end  of  a  month,  the  only  remnant  of  the 


25. 


The  ovary  laid  open  longitudinally, 
and  showing  the  corpus  luteum  at  a 
certain  stage  of  its  development. 


78  FEMALE    ORGANS    OF    GENERATION. 

pouch,  that  could  once  have  contained  a  small  cherry,  is  but  a  little  spot,  that 
would  hardly  enclose  its  stone."    (See  Fig.  25.) 

The  internal  tunic  of  the  vesicle  becomes  hypertrophied  whilst  undergoing  the 
forced  plaiting,  caused  by  the  incessant  retraction  of  the  external  one,  thus  con- 
stituting a  radiated  mass,  which,  from  the  imbibition  of  the  coloring  principles 
of  the  blood,  assumes  a  very  characteristic  orange-yellow  color. 

This  coloration  is  not  produced,  as  M.  Montgomery  and  several  others  sup- 
posed, from  the  deposit  of  a  substance  of  new  formation,  either  externally  to,  or 
within  the  vesicle,  or  between  the  two  tunics  that  constitute  its  walls,  but  is 
simply  the  result  of  imbibition.  Finally,  the  absorption  of  the  clot  being  com- 
plete, the  two  opposed  walls  of  the  pouch,  jn  time,  approach  each  other,  and 
thenceforth  form  merely  a  single  slate-colored  line.  The  vesicular  cavities  are 
reduced  to  this  condition  in  from  four  to  six  months. 

Both  M.  Coste  and  M.  Raciborsky  acknowledge  the  folding  of  the  internal 
membrane  of  the  vesicle,  but  the  theory  of  the  former  in  relation  to  it  differs  so 
much  from  that  of  the  latter  as  to  make  it  our  duty  to  explain  it  briefly. 

Immediately  after  its  rupture,  the  ovarian  follicle  becomes  filled  with  a  gela- 
tiniform  matter,  which  often  receives  a  red  color  from  the  blood  which  escapes 
from  a  few  opened  vessels ;  the  matter  itself  assumes  at  a  later  period  a  greater 
consistency.  By  the  spontaneous  retraction  of  the  walls,  as  we  have  already  ex- 
plained, the  internal  layer  is  promptly  thrown  into  folds,  and  the  rugae  which 
result  from  this  rapid  retraction  of  the  external  layer  are  so  numerous,  so  promi- 
nent, and  so  compact,  as  to  bear  some  resemblance  to  the  circumvolutions  of  the 
brain.  (See  Fig.  26.)  Contemporaneously  with  this  folding,  the  internal  layer 
becomes  hypertrophied  and  inflamed ;  it  assumes  a  red  color,  and  encroaches 
more  and  more  upon  the  cavity  which  it  finally  fills,  just  as  though  it  had  given 
rise  to  granulations.  Ere  long,  however,  the  plastic  matter  which  at  first  filled 
the  follicle,  having  been  gradually  absorbed,  the  juxtaposed  circumvolutions  con- 
tract intimate  adhesions  with  each  other,  and  the  replete  follicle  forms  a  large 
tumor  upon  the  surface  of  the  ovary. 

Long  before  the  folds  or  circumvolutions  which  tend  to  fill  up  the  cavity  of 
the  ruptured  follicle  are  so  tumefied  as  to  come  into  contact,  their  tissue  loses 
the  inflammatory  redness  which  it  at  first  possessed.  But  as  M.  Coste  does  not 
recognize  the  formation  of  a  clot  of  blood  in  the  vesicular  cavity,  he  cannot  admit 
with  M.  Raciborsky  that  the  yellow  hue  of  the  mass  just  described  is  due  to  the 
imbibition  of  its  coloring  matter.  On  the  contrary,  he  considers  the  color  to  be 
due  simply  to  the  nature  of  the  molecular  granules  which  enter  into  the  struc- 
ture of  the  internal  layer.  These  granules,  he  says,  are  remarkable  not  only 
from  their  number,  but  on  account  of  their  light  yellow  hue.  Therefore,  as  after 
the  folding  of  the  internal  tunic,  they  are  both  very  numerous  and  very  com- 
pactly bestowed,  the  yellow  tinge,  which  is  very  light  for  each  taken  separately, 
becomes  deep  for  the  entire  mass. 

The  two  opinions  may  therefore  be  recapitulated  thus  :  1.  Effusion  of  a  coagu- 
lable  fluid,  which  is  blood,  according  to  M.  Raciborsky,  and  plastic  lymph,  ac- 
cording to  M.  Coste.     2.  Folding,  and  progressive  hypertrophy  of  the  internal 


OF    THE    ORGANS     OF     GENERATION.  79 

tunic.  3.  Yellow  coloration  of  the  latter,  either  by  the  coloring  matter  of  the 
blood  (Raciborsky),  or  by  the  condensation  of  the  molecular  granules  of  the  in- 
ternal layer  (Coste).  These  two  theories,  which  include  nearly  all  the  others, 
yet  differ  upon  an  important  point.  According  to  MM.  Raciborsky,  Pouchet, 
Dalton,  &c.,  there  is  at  first  an  efiusion  of  fluid  blood,  which  soon  forms  a  clot  of 
greater  or  less  density;  M.  Coste,  on  the  contrary,  regards  this  effusion  of  blood 
as  pathological,  or,  at  most,  as  an  exceptional  occurrence.  It  is  truly  difficult  to 
comprehend  why  there  should  be  this  divergence  of  opinion  in  regard  to  a  fact 
which  ought  to  be  so  easily  determined ;  therefore,  without  wishing  to  decide  the 
question,  we  shall  content  ourselves  with  saying,  that  in  the  numerous  cases 
which  we  have  had  occasion  to  examine,  we  have  always  found  either  fluid  blood, 
or  a  clot,  within  the  ruptured  vesicle.  We  may  also  add,  that  the  fluid  or  coagu- 
lated condition  of  the  blood,  did  not  appear  to  us  to  be  always  in  relation  with 
the  age  of  the  corpus  luteum. 

Whatever  be  the  fate  of  the  ovule  after  its  expulsion,  whether  it  receive,  or 
not,  the  vivifying  influence  of  the  seminal  fluid,  the  remains  of  the  torn  capsule 
always  undergo  the  primary  changes  described  above. 

As  the  formation  of  corpora  lutea  always  follow  the  rupture  of  a  Graafian 
vesicle,  and  as  this  rupture  is  most  frequently  spontaneous,  it  is  evident  that 
medical  jurists  have  committed  an  error  in  regarding  their  existence  in  the  ovary 
as  a  certain  indication  of  an  anterior  fecundation ;  but  some  modern  physiolo- 
gists have  also  been  wrong  in  supposing  that  the  study  of  the  corpora  lutea  could 
have  no  medico-legal  importance  whatever;  for,  although  the  supervention  of 
pregnancy  modifies  the  corpora  lutea  in  no  respect  at  the  commencement  of  their 
formation,  it  exercises  an  incontestable  influence  upon  their  ulterior  development. 
M.  Coste,  who  has  followed  their  evolution  step  by  step  in  the  two  cases,  has  de- 
rived from  his  attentive  observation  sufficient  means  of  distinguishing  a  corpus 
luteum  succeeding  to  a  pregnancy,  from  one  pertaining  to  a  female  who  has  not 
conceived. 

Not  less  than  a  month,  says  he,  is  required  in  a  pregnant  woman  for  the  filling 
up  of  the  follicle,  and  the  commencement  of  adhesion  between  the  folds ;  and 
forty  days,  nearly,  will  have  elapsed,  before  the  connections  are  firmly  esta- 
blished. At  this  time,  their  assemblage  forms  a  compact  and  resisting  tumor, 
of  nearly  an  inch  in  its  longest  diameter,  and  five-eighths  of  an  inch  in  its 
shortest  (Fig.  26).  Having  thus  arrived  at  its  maximum,  it  remains  stationary 
for  some  time,  until  toward  the  end  of  the  third  month  its  period  of  diminution 
commences.  The  tumor  is  gradually  absorbed,  loses  its  volume,  and  seems  to 
enter  again  into  the  organ  upon  the  surface  of  which  it  had  been  raised ;  at  the 
same  time  it  becomes  more  compact,  denser,  and  more  shining.  In  the  course 
of  the  fourth  month  it  is  nearly  one-third,  and  towards  the  end  of  the  fifth,  nearly 
one-half  smaller.  From  the  sixth  to  the  ninth  month  it  will  have  lost  nearly 
two-thirds  of  its  volume ;  still,  however,  it  forms  after  labor  a  tubercle  of  not  less 
than  five-sixteenths  of  an  inch  in  diameter.  The  latter  now  diminishes  with 
considerable  rapidity,  but  nearly  a  month  is  required  for  its  reduction  to  a  small 
and  hard  nucleus  of  indefinite  duration.     There  is  nothing  absolute,  however,  in 


80 


FEMALE     ORGANS     OF     GENERATION. 


the  rate  of  retrogression  of  this  phenomenon.  For,  as  in  some  women  who  died 
between  the  sixth  and  eighth  month  of  their  pregnancy,  the  corpora  lutea  were 
found  as  voluminous  as  in  others  at  the  fourth  month,  so  evident  traces  of  it  may 
sometimes  be  discovered  several  months  after  labor. 

When  the  corpus  luteum  is  produced  under  other  influences  than  those  to 
which  impregnation  gives  rise,  its  development,  adds  M.  Coste,  is  by  no  means 
so  great,  and  its  rate  of  diminution  is  more  rapid.  Whilst,  for  example,  from 
five  to  six  months  are  required  for  the  completion  of  the  chief  modifications 
during  pregnancy,  the  capsules  are  almost  entirely  efl'aced  in  from  twenty-five  to 
thirty  days,  in  women  who  have  not  been  impregnated.  The  phenomena  pre- 
sented at  the  commencement,  in  the  last  case,  are  the  same  as  in  the  former,  but 
the  vesicles  suddenly  soften,  and  are  frequently  entirely  absorbed  before  the  cir- 
cumvolutions of  the  internal  layer  have  acquired  suflEicient  development  to  come 
in  contact,  or  to  contract  adhesions.  M.  Coste  has  never  known  the  corpora  lutea 
of  a  non-pregnant  female,  who  had  died  suddenly,  to  resemble  those  observed  in 
the  second  or  third  month  of  pregnancy ;  they  have  neither  the  size  nor  the  den- 
sity of  the  latter  (Fig.  26).  In  a  word,  adds  the  learned  embryologist,  a  corpus 
luteum  which  is  as  large  as  the  ovary  itself,  which  forms  a  solid  and  resisting 
tumor,  exhibiting  upon  section  the  capsule  of  the  ruptured  vesicle  filled  with 
the  strongly-adherent  internal  circumvolutions,  must  belong  to  a  pregnant  female. 
If  the  circumvolutions  are  but  feebly  united,  having  between  them  a  layer  of 
plastic  matter  which  serves  as  a  medium  of  adhesion,  the  corpus  luteum  corre- 
sponds to  the  second  month  of  pregnancy ;  if,  on  the  contrary,  the  circumvolu- 

Fi-  -26. 


Represents  a  corpus  luleum  derived  from  a  female  who  died  in  the  sixth  month  of  pregnancy. 


tions  are  blended  into  a  compact  mass,  preserving  at  the  same  time  a  size  similar 
to  the  preceding,  it  may  be  regarded  as  derived  from  a  woman  who  had  died  to- 
ward the  end  of  the  third  month  of  gestation. 

From  this  time  the  mass  becomes  more  and  more  compact,  remains  stationary 
for  a  while,  and  then  tends  to  decrease  until  the  end  of  gestation. 

We  have  represented  in  the  same  plate,  several  corpora  lutea  resulting  from 


OF  THE  ORGANS  OF  GENERATION.  81 

menstruation,  together  with  others  observed  at  a  more  or  less  advanced  period  of 
pregnancy.  By  comparing  the  physical  differences  presented  in  the  two  cases, 
we  may  readily  appreciate  the  truth  of  the  observations  just  stated.  For  Figures 
3,  4,  5,  and  6,  I  am  indebted  to  the  kindness  of  my  learned  master,  M.  Rayer. 


EXPLANATION  OF  PLATE  I. 

Fig.  1.  a  a.  Corpus  luteum  four  weeks  after  menstruation. 

Fig.  2.  Corpus  luteum  thirty  days  after  menstruation. 

Fig.  3.  Represents  the  ovary  of  a  young  woman,  who,  after  passing  the  night  with 
her  lover,  committed  suicide  by  throwing  herself  from  the  third  story;  death  took  place 
twenty-four  hours  after,     a.  Small  rupture  produced  by  the  bursting  of  the  vesicle. 

Fig.  4.  Longitudinal  section  of  the  same  ovary  showing  the  interior  of  the  vesicle. 

Fig.  5.  Represents  the  ovary  of  a  non-primiparous  woman,  who  died  in  the  fifth 
month  of  pregnancy,  of  pneumonia  complicated  with  abortion. 

Fig.  6.  Ovary  of  a  woman  twenty  years  of  age,  who  died  in  the  ninth  month  of  ges- 
tation. 

In  reviewing  the  facts  whose  history  we  have  just  traced,  we  see  that  towards 
the  age  of  puberty,  the  ovary  becomes  the  seat  of  an  active  congestion,  and,  it 
might  be  said,  of  a  new  vitality ;  all  the  living  powers  of  the  organ  seem  to  be 
concentrated  upon  one  of  the  Graafian  vesicles,  which  suddenly  assumes  a  consi- 
derable development,  and  in  so  doing,  raises  the  envelope  of  the  ovary,  and  forms 
a  tumor,  which  is  superadded  to  the  organ.  The  walls  of  the  vesicle  become 
weaker  and  weaker  as  their  distension  increases,  until  they  finally  give  way;  in 
consequence  of  the  rupture,  the  ovule  is  expelled  and  carries  with  it  a  portion  of 
the  gi'anular  fluid  with  which  it  was  surrounded.  This  expulsion  constitutes  the 
phenomenon  known  of  latter  time  as  spontaneous  ovulation.  The  void  left  in  the 
vesicle  is  soon  filled  with  blood  and  a  gelatinous  matter,  which  is  secreted  by  the 
internal  walls  of  the  follicle;  the  inner  membrane  of  the  latter  becomes  hyper- 
trophied  and  thi'own  into  folds  by  the  retraction  of  the  external  tunic,  and  soon 
constitutes  the  corpus  luteum. 

As  accessory  phenomena,  it  is  known  that  the  uterus  and  its  annexes  partici- 
pate to  a  greater  or  less  degree  in  the  ovarian  activity,  and  we  have  briefly  de- 
scribed the  peculiarities  which  they  present  during  the  accomplishment  of  the 
process;  we  shall  have  occasion  to  return  to  it  in  future.  Our  attention  should, 
however,  be  first  directed  to  the  great  resemblance  between  this  succession  of 
physiological  acts,  and  the  series  of  phenomena  which  comparative  physiology 
and  anatomy  have  shown  to  take  place  in  mammalia  at  the  rutting  season.  In 
them,  likewise,  the  approach  of  the  male  is  not  necessary  to  the  discharge  of 
the  ovule,  and  the  spontaneous  ovulation  is  accompanied  with  almost  identical 
changes  in  the  genital  organs,  and  manifests  its  influence  upon  the  entire  or- 
ganism by  the  same  assemblage  of  phenomena.  In  the  human  female,  as  in 
mammalia  and  birds,  the  spontaneous  ovulation,  accompanied  with  the  same  cor- 
tege of  symptoms,  occurs  at  more  or  less  regular  intervals.     In  the  rabbit,  it  is 

6 


82  FEMALE  OKUANS  OF  GENERATION. 

the  tumefaction  and  almost  varicose  injection  of  the  vessels  of  the  vulva.  To 
this  coloring  and  tumefaction  is  added,  in  the  bitch,  an  odorous  secretion,  which 
allures  the  males,  and  puts  them  upon  the  track  of  t^e  females.  Finally,  in 
monkeys,  a  more  or  less  abundant  hemori-hage  occurs,  which,  in  the  case  of  the 
macaqufB  and  the  cynocephalas,  coincides  with  so  monstrous  a  swelling  of  the 
vulva,  that,  in  certain  cases,  the  surrounding  parts  are  infiltrated  as  though  in- 
flamed in  consequence  of  the  stings  of  bees.  We  shall  study  hereafter  the  pecu- 
liarities of  these  returns  in  the  human  species. 

The  vesicular  evolution,  accompanied  with  the  array  of  phenomena  just  de- 
scribed, is  reproduced  at  intervals  which  vary  for  different  animals,  but  in  the 
human  female  recurs  at  much  shorter  periods.  Every  month,  in  fact,  in  the 
normal  condition,  a  new  Graafian  vesicle  is  found  to  increase  in  size,  to  become 
excessively  distended,  and  finally  bursting  and  discharging  the  ovule,  to  become 
the  seat  of  the  successive  transformations  presented  by  the  corpus  luteum.  Every 
month,  therefore,  this  curious  phenomenon  of  spontaneous  ovulation  is  renewed; 
and  the  dark-colored  cicatricules  of  various  form,  which  are  observed  upon  the 
surface  of  the  ovary  of  nubile  women,  give  rise  to  the  supposition  exclusive  of 
direct  observation,  that  the  operation  of  which  they  are  the  consequence  must 
have  recurred  a  great  number  of  times. 

Of  the  phenomena  which  we  have  just  described,  the  flow  of  blood  had,  until 
of  late  years,  chiefly  claimed  attention.  This  flow,  as  well  as  the  vesicular  evolu- 
tion of  which  it  is  the  consequence,  occurs  for  the  first  time  between  the  ages  of 
twelve  and  fifteen  years,  and  is  afterward  periodically  renewed  every  month  until 
the  time  of  life  at  which  the  female  loses  her  aptitude  for  fecundation,  that  is  to 
say,  until  she  attains  the  age  of  from  forty-five  to  fifty  years.  Known  under  the 
names  of  the  monthly  sickness,  the  monthlies,  courses,  &c.,  this  periodical  excre- 
tion constitutes  menstruation;  a  phenomenon  which,  though  doubtless  of  im- 
portance, is  nevertheless  far  from  being  the  capital  fact  amongst  those  which  we 
have  studied,  for  it  may  be  absent,  without  the  vesicular  changes  being  notably 
afi"ected  thereby,  whilst,  on  the  other  hand,  it  never  appears  without  having  been 
pi'eceded  and  accompanied  by  the  development  of  a  Graafian  vesicle.  It  is  there- 
fore a  secondary  phenomenon,  intimately  connected  with  those  which  are  accom- 
plished in  the  ovary.  The  details  into  which  we  are  about  to  enter,  in  reference 
to  menstruation,  will  complete  the  history  of  the  ovarian  follicles. 


ARTICLE   II. 

OF    MENSTRUATION. 

Menstruation  is,  as  we  have  said,  a  periodical  flow  of  blood  from  the  genital 
parts,  having  its  source  in  the  walls  of  the  uterus.  Its  first  appearance,  which 
is  always  determined  by  the  ovarian  evolution  of  which  it  is  one  of  the  epiphe- 
nomena,  reveals  the  aptitude  of  the  female  for  fecundation,  and  constitutes  one 
of  the  earliest  signs  of  puberty  or  nubility ;  I  say  one  of  the  earliest  signs,  for  it 


OF  THE  ORGANS  OF  GENERATION.  83 

very  rarely  occurs  suddenly,  and  without  having  been  preceded  by  precursory 
phenomena. 

These  phenomena  are  both  local  and  general.  The  first,  which  are  purely 
physical,  occur  more  especially  in  the  generative  organs.  Thus,  the  pubic  region 
becomes  covered  with  hair;  the  pelvis,  which  hitherto  differed  but  slightly  from 
that  of  the  male,  increases  in  size  in  every  direction,  and  gradually  assumes  the 
shape  which  we  have  indicated  as  peculiar  to  the  well-formed  woman ;  the 
breasts  are  rapidly  developed,  and  the  nipple  is  more  projecting,  turgescent,  and 
sensitive ;  the  skin  which  surrounds  the  latter  is  also  of  a  darker  color  than  be- 
fore. The  outlines  of  the  body  at  the  same  time  become  rounded,  in  conse- 
quence of  the  greater  abundance  and  more  harmonious  distribution  of  the  cellular 
tissue. 

These  physical  changes  are  rarely  found  unconnected  with  an  alteration  in  the 
moral  state  of  the  young  girl.  Her  voice  assumes  a  softer  tone,  her  looks  are 
more  timid,  and  often  embarrassed  in  the  presence  of  persons  with  whom  but  a 
few  months  previously,  she  had  sported  as  a  child.  She  experiences  desires, 
which  are  the  vague  expressions  of  the  development  of  the  senses,  which  she 
cannot  yet  understand.  A  melancholy  sadness,  and  a  taste  for  solitary  places 
congenial  to  reverie,  replace  the  boisterous  pleasures  of  childhood. 

The  congestion  which  precedes  the  hemorrhage  is  indicated  by  new  symptoms. 
The  young  girl  complains  of  lassitude,  of  a  sensation  of  swelling  and  tension  in 
the  lower  part  of  the  abdomen,  of  lumbar  and  sacral  pains,  of  weight  in  the 
loins,  of  heat  in  the  hypogastrium  and  peritoneum,  of  a  slight  itching  and  tume- 
faction in  the  genital  parts,  and  a  painful  swelling  of  the  breasts.  In  many 
cases,  the  excitement  of  the  genital  organs  is  so  great  as  to  produce  a  violent 
general  reaction ;  and,  according  to  Boerhaave,  the  first  appearance  of  the  menses 
is  accompanied  with  fever.  Strange  nervous  disturbances  not  uufrequently  occur, 
and  I  have  sometimes  observed  attacks  of  genuine  hysteria.  These  symptoms 
may  last  from  one  to  eight  days,  and  are  followed  by  a  more  or  less  abundant 
flow  of  mucus ;  in  the  course  of  a  few  days,  this  becomes  mixed  with  a  little 
blood,  and  soon  gives  place  to  a  flow  of  almost  pure  blood.  The  hemorrhage 
continues  for  several  days;  then,  as  the  amount  of  blood  mingled  with  the 
vaginal  mucosities  diminishes,  the  flow  becomes  less  colored,  and  after  resuming 
the  characters  of  the  vaginal  secretions,  ceases  entirely. 

Quite  frequently,  the  first  menstruation  takes  place  without  having  been  pre- 
ceded by  any  of  these  discomforts.  Sometimes  the  eruption  of  blood  occurs 
whilst  playing  or  dancing,  and  sometimes  during  sleep. 

In  most  young  girls,  the  eruption  returns  after  the  lapse  of  a  month,  and  fol- 
lows subsequently  its  regular  periodical  course;  frequently,  however,  it  is  not 
until  after  three  or  four  periods,  and  sometimes  even  later,  that  the  courses  be- 
come regular.  At  other  times,  again,  a  long  interval  elapses  between  the  two 
first  menstruations  :  thus,  M.  Raciborsky,  having  noticed  the  period  between  the 
two  first  menstrual  epochs  in  eighty-seven  females,  found  that  in  all  but  fifty- 
eight,  more  than  a  month  elapsed  between  them.  In  two  women,  the  second 
menstruation  occurred  six  weeks  after  the  first  j  in  four,  two  months ;  in  five, 


84  FEMALE  ORGANS  OF  GENERATION. 

three  months  ;  in  four,  four  months  ;  in  one,  five  months  ;  in  one,  eight  months ; 
in  three,  a  year ;  finally,  in  one,  two  years. 

These  irregularities  in  the  return  of  the  second  period  may,  doubtless,  be  due 
to  a  morbid  condition  requiring  treatment,  but  they  may  also  depend  upon  an 
atony  of  the  genital  organs,  which  does  not  allow  the  physiological  development 
of  the  Graafian  vesicles  to  continue.  This  temporary  atony  does  not  interfere 
with  the  general  health  of  the  female,  nor  prevent  the  future  performance  of  the 
function  ;  it  often  disappears  under  the  excitement  produced  by  a  change  of  life, 
or  by  the  first  conjugal  approaches.    (Raciborsky.) 

In  some  young  girls,  the  functional  troubles  and  abdominal  pains,  which  we 
have  regarded  as  so  many  precursory  phenomena  of  the  first  appearance  of  the 
menses,  may  not  be  followed  by  the  flow  of  blood,  and,  after  having  lasted  for 
several  days,  they  diminish  and  cease  entirely ;  they  may  recur  thus  every  month, 
for  a  certain  time,  without  other  result  than  a  momentary  disturbance  of  the 
general  health,  and  it  is  only,  so  to  speak,  after  several  fruitless  attempts,  that 
the  courses  become  established  in  a  complete  and  regular  manner. 

The  symptoms  which  heralded  the  first  menstrual  flow  do  not  usually  recur  at 
the  subsequent  periods,  or,  at  least,  they  continue  to  diminish  with  each  monthly 
return.  In  some  females,  however,  they  always  appear  with  their  original  inten- 
sity, and  I  have  often  remarked,  in  reference  to  these  cases,  that  the  acute  pains 
and  colics  which  prelude  the  flow  of  blood,  disappear,  or  even  cease  entirely,  im- 
mediately after  the  first  conjugal  approaches,  and  especially  after  the  first  labor. 
In  a  still  greater  number,  the  return  of  the  menstrual  period  is  throughout  life 
indicated  by  some  slight  pains,  a  little  uneasiness,  or  merely  by  a  more  or  less 
marked  distui'bance  of  the  general  condition  ;  the  temper  is  less  even,  the  woman 
becomes  more  excitable,  more  irascible,  in  a  word,  less  amiable. 

The  time  at  which  the  first  appearance  of  the  menses  occurs  varies  exceedingly 
from  the  influence  of  climate,  habits  of  life,  and  constitution.  The  following 
table,  extracted  from  the  work  of  M tiller,  with  notes  by  Jourdan,  gives  an  idea 
of  these  variations  in  difl"erent  countries  : — 


OF     THE     ORGANS     OF     GENERATION. 


85 


H 

2 

u* 

«fe 

B 

a 

t^ 

!^ 

„ 

ef 

ASB. 

■eg 

O 

2  z 

J=  o 

■-  a 

■c§ 

^   m 

A  ta 

>." 

a  s 

o  S 

<8  r! 

!S  r; 

O  ? 

»  M 

ft-S 

jg 

S  «! 

s§ 

OS 

^:; 

ca 

CQ 

S 

ci 

o 

b:: 

'CS 

fe 

J 

5  years,     .... 

1 

7       " 

1 

8      " 

2 

9       " 

11 

1 

10      '• 

29 

5 

7 

11       " 

96 

14 

6 

10 

4 

18 

12       " 

129 

26 

10 

19 

3 

10 

34 

4 

13      " 

138 

47 

13 

53 

8 

20 

40 

4 

14      " 

212 

50 

9 

85 

21 

29 

55 

13 

1 

15      " 

204 

76 

16 

97 

32 

38 

77 

14 

15 

16       '• 

140 

79 

8 

76 

24 

41 

81 

20 

27 

17      " 

133 

58 

4 

57 

11 

20 

72 

13 

35 

18       " 

95 

38 

2 

26 

18 

20 

35 

13 

13 

19      '• 

43 

21 

23 

10 

12 

26 

6 

6 

20       " 

33 

9 

4 

8 

24 

8 

2 

21       " 

8 

5 

1 

4 

14 

3 

1 

22      " 

8 

1 

2 

23      " 

4 

1 

24      '• 

5 

2 

1 

25      " 

1 

1 

1              Total,     .     .     . 

1285 

342 

68 

450 

137 

200 

487 

100 

100 

A                        1? 

il     -^ 

i_T-l  _ 

,1 

1- 

n   /• 

According  to  this  table,  the  greater  number  of  first  menstruations  occur,  at 
Paris,  between  the  ages  of  fourteen  and  fifteen  years,  but  it  may  be  remarked, 
that  the  most  common  variations  fall  between  the  ages  of  eleven  or  twelve,  and 
seventeen  or  eighteen  years. 

Warm  climates,  a  residence  in  cities,  and  the  habits  which  are  contracted 
there,  together  with  robust  constitutions,  seem  to  favor  the  precocious  develop- 
ment of  puberty;  a  low  temperature,  residence  in  the  country,  a  feeble  and  deli- 
cate constitution,  appear,  on  the  other  hand,  to  retard  the  appearance  of  the 
menses. 

Numerous  exceptions  to  the  averages  above  indicated  are  mentioned  by  authors. 
Thus,  as  examples  of  tardy  and  precocious  menstruation,  we  see  by  the  table, 
that  five  women  menstruated  for  the  first  time  at  the  age  of  twenty-three  years, 
six  at  twenty-four,  and  two  at  twenty-five.  In  some  very  rare  instances,  the  first 
appearance  has  been  delayed  for  a  much  longer  time ;  thus,  M.  Kleeman  men- 
tions the  case  of  a  woman  who  was  married  at  the  age  of  twenty-seven  years,  and 
who  did  not  menstruate  until  two  months  after  her  eighth  confinement ;  she  then 
continued  regular  until  the  age  of  fifty-four  years.  Pecklin  speaks  of  a  strong 
and  healthy  married  woman,  who  had  never  menstruated,  although  she  was  forty 
years  of  age ;  her  courses  made  their  appearance  upon  one  of  the  first  nights 
succeeding  her  second  marriage,  and  recurred  regularly  for  two  years,  at  the  ex- 
piration of  which  time  she  became  pregnant. 

If  we  compare  these  cases  of  tardy  menstruation  with  the  numerous  instances 
of  women  who  become  mothers  without  ever  having  menstruated,  and  of  nurses 
in  whom  the  suppression  of  the  menses  did  not  prevent  conception,  we  shall  find 


86  FEMALE  ORGANS  OF  GENERATION. 

a  full  confirmation  of  what  was  stated  in  the  preceding  chapter,  in  regard  to  the 
secondary  importance  of  the  menstrual  discharge. 

We  cannot  accept  all  the  observations  of  very  precocious  menstruation ;  but, 
laying  aside  the  numerous  cases  in  which  the  nature  of  the  discharge  has  not 
been  so  well  determined  as  to  allow  of  their  reception  without  questioning,  there 
are  some  whose  genuineness  is  undoubted,  inasmuch  as  the  appearance  of  the 
discharge  was  attended  with  all  the  attributes  of  puberty.  Thus,  Dr.  Susewind 
knew  of  a  child  of  seventeen  months,  which  had  menstruated  since  she  was  a 
year  old ;  the  hemorrhage  returned  regularly  every  month,  and  the  breasts  and 
mons  veneris  were  those  of  a  girl  of  fourteen  or  fifteen  years  of  age.  The  child 
observed  by  Lenhossek  menstruated  when  nine  months  old,  and  at  two  years  she 
presented  all  the  external  signs  of  puberty.  The  girl  mentioned  by  D'Outre- 
pont,  who  had  four  teeth  when  two  weeks  old,  was  regular  from  the  age  of  nine 
months  ',  she  had  at  that  time  long  black  hair  and  prominent  breasts.  A  woman 
obseiTcd  by  Cams,  menstruated  when  two  years  old,  became  pregnant  at  eight, 
and  died  at  an  advanced  age. 

In  a  memoir  by  M.  Dezeimeris,  many  other  similar  facts,  derived  from  Schoefer, 
Louis  Robert,  Le  Beau,  Descuret,  Comarmond,  Clarke,  Lombstein,  &c.  &c.,  are 
recorded. 

These  premature  menstruations  are  certainly  due  to  the  same  cause  which  de- 
termines their  appearance  in  most  women  about  the  age  of  fifteen  years.  Being 
always  accompanied  by  the  development  of  the  breasts  and  the  other  marks  of 
puberty,  they  are  the  evidence,  that  under  the  influence  of  an  anomalous  vitality 
of  the  ovaries,  the  Grraafian  vesicles  have  undergone  a  very  precocious  develop- 
ment. 

When  once  well  established,  the  menses  assume  their  regular  periodicity,  which 
is  generally  preserved  up  to  the  time  of  their  cessation,  without  other  interrup- 
tion than  that  which  is  occasioned  by  nursing  or  pregnancy.  They  return  about 
every  month,  as  their  name  indicates,  yet  the  interval  between  them  is  far  from 
being  the  same  for  every  female.  The  average  of  the  catamenial  period  is  stated 
by  Roser  and  Wunderlich  at  twenty-eight  days ;  in  a  large  number,  according  to 
Brierre  de  Boismont,  it  is  thirty  daysj  and  in  some  instances  the  intermenstrual 
period  is  longer  than  thirty  days,  extending  to  five  or  six  weeks,  and  sometimes 
even  to  two  months.  In  some  women  the  returns  occur  upon  the  same  day  of 
each  month ;  in  a  much  greater  number,  the  end  of  the  solar  month  is  antici- 
pated by  two,  three,  four,  or  five  days.  Sometimes  the  period  is  much  shorter, 
the  returns  occurring  at  an  interval  of  twenty -four,  twenty-two,  twenty,  and  even 
fifteen  days. 

These  frequent  variations  in  the  duration  and  return  of  the  catamenial  period, 
are  a  refutation  in  advance  of  the  opinion  of  those  authors  who  think  that  all 
women  menstruate  generally  at  the  same  epochs,  and  that  there  are  times  in  each 
month  when  no  one  is  unwell;  it  is  evident  that  the  retardations  or  the  anticipa- 
tions of  which  we  have  spoken,  must  have  the  effect  of  bringing  the  return  of 
some  female  upon  every  day  of  the  year.  The  flow  also  commences  almost  in- 
differently, during  the  day  or  night. 

The  periodicity  of  the  catamenia  generally  continues  until  the  age  of  from 


OF  THE  ORGANS  OF  GENERATION.  87 

forty  to  fifty  years,  at  which  time  they  usually  cease.  We  shall  hereafter  treat 
of  the  peculiarities  which  often  attend  their  cessation. 

The  duration  of  the  floio  varies  between  one  and  eight  days;  according  to 
Brierre,  it  most  commonly  lasts  for  eight  days ;  and  next  in  order  of  frequency, 
we  have  three,  four,  two,  five,  one,  six,  ten,  and  seven  days.  Many  observers 
have  noted  three  or  four  days,  as  expressing  the  most  usual  duration.  In  some 
very  exceptional  cases,  it  lasts  for  a  few  hours  only;  in  others  quite  as  rare, 
apart  from  pathological  conditions,  it  is  prolonged  through  twelve  or  fifteen  days. 

The  quantity  of  blood  lost  is  variable  for  the  same  woman,  and  especially  so 
when  observed  in  different  individuals ;  we  may  here  add,  that  it  is  very  difficult 
in  any  case  to  estimate  it  exactly.  If  the  two  cotyles  of  Hippocrates  be  eighteen 
ounces  (550  grammes),  as  translated  by  Galen,  his  estimate  (provided  Galen's 
rendering  is  correct)  is  evidently  exaggerated,  at  least  for  our  time  and  climate. 
If  we  appreciate  the  amount  of  blood  lost  by  the  quantity  of  stained  linen,  I 
think  the  estimate  of  Haen,  who  set  it  down  as  averaging  from  three  to  five 
ounces,  will  be  found  to  come  nearest  the  truth. 

The  quantity  of  the  discharge  appears  to  be  greatly  influenced  by  the  diet, 
habits  of  life,  and  climate ;  it  is  greater  with  rich  and  indolent  females  who  use 
a  succulent  diet,  than  with  those  who  are  placed  in  an  opposite  condition.  Ac- 
cording to  most  authors,  very  warm  climates  exert  a  marked  influence  upon  it, 
and,  for  my  own  part,  I  am  acquainted  with  several  ladies  who  menstruate  much 
more  abundantly  in  summer  than  in  winter. 

It  is  said  that  women  from  the  country,  who  become  domestics  in  Paris,  soon 
find  their  courses  to  diminish,  and  sometimes  even  cease  entirely.  Such  may  be 
the  case  with  many  of  them,  but  it  is  due  chiefly  to  the  influence  upon  their 
constitutions  of  the  want  of  fresh  air,  exposure  to  the  sun,  and  of  the  exercise, 
to  which  they  had  been  accustomed  from  childhood,  rather  than  to  any  change 
in  their  diet ;  for,  in  general,  the  nourishment  which  they  receive  from  their 
employers,  is  much  better  than  that  with  which  they  were  obliged  to  content 
themselves  in  their  own  poor  families. 

The  amount  of  the  discharge  is  not  the  same  throughout  the  duration  of  the 
menstrual  epoch ;  ordinarily,  it  flows  moderately  on  the  first  and  second  days, 
increases  on  the  third  and  fourth,  and  then  gradually  declines.  Neither  is  the 
discharge  always  continuous ;  it  sometimes  diminishes  and  even  stops  entirely  for 
several  hours,  sometimes  for  one  or  two  days,  and  afterwards  reappears  either 
spontaneously  or  under  the  influence  of  a  walk  or  a  ride.  Moral  emotions,  some- 
times the  process  of  digestion,  and,  above  all,  the  action  of  cold,  may  determine 
its  momentary  or  final  diminution  or  suppression. 

The  seat  of  the  hemorrhage,  and  the  nature  and  qualities  of  the  menstrual 
blood,  have  been  the  subject  of  very  different  opinions.  What  we  have  already 
said,  whilst  describing  the  changes  in  the  uterine  mucous  membrane,  during  the 
ovarian  evolution,  leaves  no  doubt  as  to  the  source  of  the  menstrual  fluid.  It 
exudes,  manifestly,  through  microscopic  fissures  on  the  internal  surface  of  the 
mucous  membrane  of  the  uterus.  This  fact,  which  is  placed  beyond  a  doubt  by 
numerous  autopsies  of  women  who  died  during  menstruation,  had  been  already 


85  .  FEMALE  ORGANS  OF  GENERATION. 

proved  by  the  accumulation  of  blood  in  the  cavity  of  the  womb,  where  the  neck 
was  imperforate,  and  by  the  touch,  and  the  speculum,  whereby  it  has  been  both 
felt,  and  seen  to  flow  from  the  orifice  of  the  uterus. 

Certain  facts  have  been  adduced  in  order  to  prove  that,  in  some  cases,  the 
menstrual  blood  proceeds  from  the  vagina.  I  think  that  the  greater  number  of 
these  observations  have  been  either  badly  made,  or  wrongly  interpreted.  I  do 
not  deny  the  possibility  of  exhalations  of  blood  from  the  walls  of  the  vagina; 
but  if  they  present  the  periodicity  of  the  menses,  they  can  be  regarded  in  no 
other  light  than  as  a  misplacement  of  the  latter.  The  fact  related  in  the  note 
below  appears  to  me  to  possess  great  interest  in  reference  to  this  subject.^ 

'  I  have  recently  (November,  1849)  seen,  in  connection  with  my  excellent  confrere,  Dr. 
Thirial,  a  young  girl,  twenty-one  years  of  age,  who  had  menstruated  only  twice  and  for  three 
days  at  a  time;  and  in  whose  case  the  hemorrhage  must  of  necessity  have  had  its  origin  in 
the  mucous  membrane  of  the  vagina. 

This  young  girl,  who  had  been  for  a  long  time  violently  in  love  with  an  officer,  finally 
yielded  herself  completely  to  his  wishes.  After  several  attempts,  renewed  with  much  ardor, 
but  which  each  time  proved  fruitless,  the  young  man  finally  discovered,  and  acquainted  her 
with  the  fact,  that  she  was  not  formed  like  other  women,  and  advised  her  to  consult  a  phy- 
sician. She  applied  first  to  M.  Thirial,  who  solicited  my  opinion.  A  very  careful  exami- 
nation enabled  me  to  ascertain  as  follows  : 

The  countenance,  stature,  and  development  of  the  limbs  and  breasts,  differed  in  no  respect 
from  what  is  usual  in  young  girls  at  her  age.  Her  general  health  had  always  been  good. 
In  the  month  of  May  last,  her  courses  appeared  for  the  first  time,  and  continued  three  days; 
she  had,  however,  for  several  years  before,  experienced  symptoms  of  uterine  congestion.  In 
the  month  of  July,  they  showed  themselves  again  for  the  last  time.  The  attempts  of  her 
lover  were  twice  followed  by  a  considerable  flow  of  blood,  which  lasted  two  days,  but  she 
attributed  it  much  rather  to  the  amorous  violence  to  which  she  had  been  subjected  than  to 
a  periodic  return  of  the  menses. 

The  mons  veneris  is  completely  destitute  of  the  hair  with  which  it  is  usually  covered. 
Upon  the  lateral  and  inferior  regions,  immediately  above  the  external  orifice  of  the  inguinal 
canal,  a  tumor  is  observed  on  each  side  which  elevates  the  integuments.  The  tumor  has 
the  size,  form,  and  consistence  of  an  ovary  or  a  testicle;  it  is  but  slightly  painful;  under  a 
very  moderate  pressure  it  retreats  through  the  inguinal  canal,  and  disappears  in  the  abdo- 
men, but  as  .soon  as  the  pressure  is  removed  from  the  internal  orifice  of  the  canal,  it  reap- 
pears, sometimes  spontaneously,  sometimes  on  the  slightest  movements,  or  the  least  effort  of 
coughing  or  respiration.  On  no  occasion  was  I  able  to  perceive  the  signs  which  ordinarily 
accompany  the  reduction  of  an  intestinal  or  epiploic  hernia. 

The  vulvar  opening  was  bounded  by  the  greater  and  the  lesser  labia,  but  both  were  much 
less  developed  than  usual.  The  finger,  which  could  be  introduced  only  with  difficulty  into 
the  vulvar  orifice,  was  arrested  at  the  depth  of  three-quarters  of  an  inch,  so  that  it  was  only 
by  forcing  up  the  extremity  of  the  vagina,  that  the  first  phalanx  could  be  made  to  enter  that 
canal. 

Upon  introducing  the  extremity  of  a  speculum,  it  was  impossible  to  discover  any  opening, 
or  any  point  which  would  afford  passage  to  the  end  of  a  stylet.  I  was  able  to  ascertain,  at 
the  same  time,  that  the  membrane  pressed  upon  by  the  extremity  of  the  speculum,  possessed 
all  the  rug;e,  and  other  characters  of  the  vaginal  mucous  membrane. 

On  examination  by  the  rectum,  I  found:  1.  That  the  rectal  pouch,  or  dilatation,  was  much 
larger  than  in  the  normal  condition  ;  2.  That  above  the  extremity  of  the  vagina,  when  pressed 
upward  by  my  thumb,  the  index  introduced  at  the  same  time  by  the  anus  and  carried  as 
high  as  possible,  could  discover  neither  fibrous  cord  nor  tumor;  nothing,  in  fact,  which  could 


OF  THE  ORGANS  OF  GENERATION.  89 

As  we  have  already  said,  the  menstrual  blood  which  is  at  first  small  in  quan- 
tity, becomes  mixed  with  the  mucosities  which  are  secreted  abundantly  by  the 
vagina  for  a  day  or  two  preceding  the  appearance  of  the  catamenia.  The  amount 
of  blood  soon  increases,  and  the  flow  becomes  almost  exclusively  sanguineous. 

It  is  very  diflBcult  to  say  whether  the  blood  is  furnished  by  the  arteries  or 
veins,  or  by  both  together.  In  all  probability,  says  M.  Coste,  the  blood  exudes 
through  the  walls  of  the  very  delicate  ramuscules  which  form  the  vascular  net- 
work of  the  innermost  layer  of  the  uterine  mucous  membrane.^ 

Now,  when  gestation  has  progressed  to  some  extent,  these  ramuscules  become 
so  greatly  developed  that  many  of  them  acquire  the  calibre  of  a  quill.  At  this 
time  their  true  nature  may  be  ascertained,  and  the  fact  settled,  that  they  belong 
to  the  venous  system;  so  that  the  menstrual  hemorrhage  which  they  supply  must 
evidently  have  its  source,  in  great  part  at  least,  in  the  reservoir  of  dark  blood. 

The  physical  characters  of  the  menstrual  blood  vary  according  to  the  time  at 
which  it  is  examined,  since  it  is  mixed  at  the  beginning,  at  the  middle,  and  at 
the  end  of  the  flow,  with  difiierent  amounts  of  vaginal  mucus. 

The  portion  which  escapes  during  the  second  period,  not  only  resembles  com- 
pletely in  external  characters  that  which  is  obtained  directly  from  a  vein  or  an 
artery,  but  is  shown  to  be  identical  by  chemical  analysis.  Its  slight  coagulability 
has  been  regarded  as  an  evidence  of  a  want  of  fibrine ;  but,  though  it  coagulates 
rarely,  as  a  general  facf,  yet  there  are  occasions  in  which  clots  exist  in  the  vagina, 
and  in  the  cavity  of  the  uterus  itself.^  The  presence  of  fibrine  has  been  chemi- 
cally demonstrated,  so  that  though  the  coagulation  of  the  menstrual  blood  be  of 
rare  occurrence,  the  fact  is  certainly  due  to  its  being  uniformly  mixed  with  a 
considerable  amount  of  vaginal  mucus. 

The  eruption  of  the  menses  is  generally  attended  with  a  peculiar  odor,  pro- 
lead  to  a  belief  of  the  existence  of  the  upper  part  of  the  vagina  and  of  a  uterus;  3.  Having 
introduced  a  sound  into  the  bladder,  the  finger  in  the  rectum  perceived  with  the  greatest 
ease  that  nothing  intervened  between  its  palmar  surface  and  the  vesical  sound,  except  the 
normal  thickness  of  the  two  walls  of  the  rectum  and  bladder.  The  sensation  was  identical 
with  that  experienced  when  the  index  is  introduced  into  the  vagina  in  order  to  direct  a  sound 
in  the  urethra. 

From  this  examination  I  thought  myself  justified  in  concluding  :  1,  that  the  tumors  found 
in  the  inguinal  regions  were  the  two  ovaries;  2,  that  the  lowest  extremity  only  of  the  vagina 
was  present;  3,  that  the  upper  four-fifths  of  that  canal  were  completely  wanting;  4,  that, 
most  probably,  there  was  no  uterus ;  5,  that  the  hypogastric  and  lumbar  pains  which  were 
experienced  quite  regularly  and  almost  monthly,  were  the  expression  of  periodical  ovarian 
operations;  6,  that  the  blood  of  the  menses  which  had  appeared  twice  in  this  young  woman, 
had  its  origin  in  the  mucous  membrane  of  the  vagina. 

'  It  has  been  erroneously  said  that  the  blood  exudes  from  orifices  found  at  the  extremities 
of  these  minute  vessels;  but  the  diameter  of  their  canal  is  smaller  than  that  of  the  blood 
corpuscles,  and  could  not  afford  them  passage.  The  walls  of  the  capillaries  are  ruptured 
near  their  terminal  extremity,  and  through  this  solution  of  continuity  the  blood  escapes.  It 
is  not,  therefore,  a  true  exhalation. 

^  It  is,  however,  right  to  observe,  that  the  presence  of  clots  in  the  menstrual  discharge  is 
frequently  due  to  an  alteration  of  the  structure  of  the  uterus,  or,  at  the  least,  to  a  functional 
derangement. 


90  FEMALE  ORGANS  OF  GENERATION. 

ceeding  at  that  time  from  the  secretions  of  the  vulva;  it  increases  in  intensity 
during  the  flow,  and  has  been  compared  by  some  persons  to  the  smell  of  the 
marigold.  Can  it  be  that  the  strange  fears  with  which  menstruating  women  are 
regarded  in  some  countries,  are  attributable  to  this  odor,  which  in  uncleanly  in- 
dividuals is  very  strong  ?  Although  this  is  probable,  I  should  think  it  futile  to 
discuss  the  incredible  stories  upon  which  are  based  the  popular  notions  of  the 
noxious  properties  of  the  menstrual  emanations. 

Certain  females  discharge  by  the  vulva,  at  the  menstrual  epoch,  a  kind  of 
membranous  bag,  which  would  seem  by  its  form  to  have  been  moulded  upon  the 
uterine  cavity,  and  which  bears  a  strong  resemblance  to  the  membranous  pouch 
(deeiduous  membrane),  which  is  expelled  with  the  ovum  in  some  cases  of  abor- 
tion. The  nature  of  the  pouch  is,  in  fact,  the  same  in  both  cases,  being  formed 
of  cellular  tissue,  which  is  both  vascular  and  glandular ;  its  internal  surface  is 
always  smooth,  provided  with  epithelium,  and  often  abundantly  perforated  with 
o'landular  orifices.  The  external  surface,  by  which  it  adhered  to  the  organ  from 
which  it  was  separated,  is  shaggy  and  torn.  It  is  evidently  an  exfoliated  portion 
of  the  mucous  membrane. 

This  exfoliation  usually  occurs  in  such  women  only  as  are  afflicted  with  diffi- 
cult or  very  profuse  menstruation,  accompanied  with  violent  pain,  or  in  such  as 
experience  a  delay  in  the  appearance  of  their  courses.  According  to  M.  Coste, 
this  phenomenon  is  the  result  of  an  excessive  congestion,  a  sort  of  apoplexy  of 
the  mucous  membrane ;  for,  says  he,  coagula  are  almost  always  found  infiltrated 
in  the  substance  of  the  expelled  membrane.  I  would  add  as  probable,  that  in 
some  cases,  at  least,  this  exaggerated  congestion  may  have  been  the  consequence 
of  an  abortive  conception,  or  perhaps  of  solitary  venereal  excitements. 

However  this  may  be,  the  facts  would  seem  to  lend  some  support  to  tbe  theory 
of  those  who,  like  M.  Pouchet,  regarding  menstruation  and  the  heat  of  animals 
as  identical,  have  supposed  that  at  each  menstrual  epoch  an  abundant  exhalation 
took  place  on  the  surface  of  the  uterine  cavity,  and  gave  rise  to  the  formation  of 
a  pseudo-membrane. 

Nothing  of  the  kind  has  ever  been  proved  by  anatomical  investigation ;  for  the 
internal  surfiice  of  the  uterus,  at  whatever  moment  examined  during  the  catame- 
nial  period,  always  retains  the  characters  peculiar  to  the  mucous  membrane,  re- 
maining smooth,  and  covered  with  epithelium.  Sometimes,  however,  the  latter 
exfoliates,  and  bears  away  with  it  a  portion  of  the  substance  of  the  mucous  mem- 
brane, in  which  case,  the  torn  glandular  tubes  rendered  free  and  floating  by  the 
separation,  form,  as  it  were,  a  forest  of  white  filaments,  and  give  accidentally  to 
the  internal  surface  of  the  uterus  the  villous  and  shaggy  appearance  which  some 
authors  have  erroneously  considered  as  normal.  This  circumstance  is,  however, 
altogether  exceptional,  and  results  from  the  membranous  exfoliation  of  which  we 
have  just  spoken. 

Cause  of  Menstruation. — Few  questions  have  given  rise  to  more  lively  discus- 
sions than  the  cause  of  menstruation ;  I  think  it  useless,  however,  to  mention 
*here  the  numerous  and  more  or  less  whimsical  hypotheses  which  have  succes- 
sively appeared  in  reference  to  it.     The  fact  is,  that  after  having  read  all  that 


OF  THE  ORGANS  OF  GENERATION.  91 

has  been  written  on  the  subject,  the  mind  rests  entirely  satisfied  in  its  ability  to 
refer  this  singular  phenomenon  to  one  unchangeable  and  easily-verified  fact, 
namel}',  the  successive  evolution  of  the  Graafian  vesicles.  We  owe  this  satisfac- 
tory explanation  to  the  admirable  labors  of  Negrier,  Coste,  Pouchet,  Raciborsky, 
Robert  Lee,  and  Bischoff",  so  that  the  credit  of  so  beautiful  a  discovery  belongs 
almost  exclusively  to  France. 

That  the  cause  of  the  menstrual  discharge  is  the  evolution  of  a  Graafian  vesicle, 
would  be  an  indisputable  proposition,  provided  we  were  able  to  show:  1,  that  the 
examination  of  women  who  died  during  or  shortly  after  the  menstrual  period, 
has  uniformly  revealed  the  above-named  changes  in  the  ovary ;  2,  that  the  ab- 
sence of  ovaries  involved  of  necessity  the  absence  of  menstruation ;  3,  and  lastly, 
that  there  is  a  complete  analogy  between  the  anatomical  and  physiological  phe- 
nomena of  the  heat  of  animals,  and  those  which  accompany  menstruation  in  the 
human  female. 

1.  Since  attention  has  been  directed  to  this  subject,  no  one  has  succeeded  in 
instancing  the  case  of  a  single  woman,  who  died  at  the  menstrual  epoch,  whose 
ovary  did  not  present  a  vesicle  in  a  greater  or  less  degree  of  development,  or  else 
one  which  had  been  already  ruptured.  The  facts  related  by  Coste,  Negrier, 
Pouchet,  Raciborsky,  and  others,  are  now  so  numerous,  that  it  would  be  impos- 
sible to  reproduce  them  in  a  work  like  the  present.  I  might  myself  add,  if  it 
were  necessary,  a  considerable  number  of  cases  to  the  others.  This  universal 
coincidence  afibrds  from  the  outset  a  very  strong  probability  of  the  relation  of 
causality  which  we  wish  to  establish ;  but  it  would  become  an  absolute  certainty 
were  it  possible  to  prove  that  the  absence  of  the  ovaries  involved  of  necessity  the 
absence  of  the  menses. 

2.  In  the  case  of  animals,  on  which  the  experiment  can  be  repeated  at  plea- 
sure, not  a  doubt  is  permitted,  that  the  extirpation  of  the  ovaries  causes  the  dis- 
appearance, forever,  of  all  symptoms  of  heat.  Analogy  alone  would  lead  us,  in 
the  absence  of  positive  facts,  to  suppose  that  menstruation,  also,  would  cease  after 
castration.  But  although  well-observed  instances  of  the  performance  of  this 
operation  on  women  are  happily  very  rare,  there  is  yet  one  which  derives  a  great 
value  in  the  present  discussion  from  the  name  of  the  author.  The  followino-  is 
an  abridgment  of  it.  A  woman,  says  Percival  Pott,  had  two  small  tumors,  one 
in  each  groin,  which  were  so  painful  as  to  render  working  impossible.  It  was 
decided  to  extirpate  them.  After  having  divided  the  skin  and  the  subcutaneous 
tissues,  a  membranous  sac  was  exposed,  which  contained  a  body  resembling  an 
ovary ;  a  ligature  was  thrown  around  it,  and  it  was  removed.  The  same  opera- 
tion was  performed  on  the  opposite  side.  The  woman  recovered ;  hut  the  meii- 
struation,  which  before  had  occurred  with  the  greatest  regidarity,  never  after- 
wards  appeared;  the  breasts,  which  had  been  voluminous,  subsided;  she  also 
became  thinner,  and  assumed  a  more  muscular  appearance. 

From  the  statement  of  M.  Roberts,  it  would  appear  that  in  Central  Asia,  ves- 
tiges are  still  to  be  met  with  of  the  cruelty  of  the  ancient  kings  of  Lydia,  who 
castrated  women,  either  that  they  might  put  them  in  charge  of  their  seraglios,  or 
in  order  to  gratify  their  unbridled  passions.     After  amving  at  Serai,  he  obtained 


92  FEMALE  ORGANS  OF  GENERATION. 

a  nocturnal  rendezvous  with  three  persons  known  as  Padjeras.  The  necks  of 
these  individuals  were  not  developed,  nor  had  they  any  nipple ;  the  orifice  of  the 
vagina,  which  was  entirely  obliterated,  presented  no  trace  of  a  cicatrix ;  their 
hips  were  narrow,  the  pubis  entirely  destitute  of  hair,  the  nates  were  flattened, 
&c. ;  they  had  no  hemorrhoidal  flux,  no  epistaxis  nor  menstrual  discharge,  neither 
had  they  any  sexual  desires.  They  were  very  muscular,  and  there  was  something 
masculine  both  in  their  external  appearance  and  in  the  character  of  the  voice. 

M.  Roberts  was  unable  to  ascertain  precisely  the  nature  of  the  operation  to 
which  they  had  been  subjected  in  their  childhood,  for  they  had  no  remembrance 
of  it;  but  if  we  may  judge  by  the  results,  which  are  altogether  similar  to  those 
produced  by  castration  in  animals,  it  becomes  more  than  probable  that  the  same 
alterations  are  due  to  the  same  cause. 

3.  Admitting,  finally,  the  incontestable  analogy  between  the  symptoms  of  heat 
and  menstruation,  it  will  be  sufiicient  to  prove,  in  order  to  deduce  therefrom  a 
favorable  argument,  that  the  former  is  always  connected  in  animals  with  the 
ovarian  evolution.  Now  certain  experiments  do  not  allow  of  hesitation.  By 
these  it  is  in  fact  proved  (Coste),  that  the  females  never  enter  into  heat  except 
when  the  preparation  for  the  spontaneous  ovulation  is  going  on  in  their  ovaries, 
that  the  venereal  erethism  continues  throughout  the  entire  duration  of  the  process 
of  evolution,  and  that  it  ceases  when  the  rupture  of  the  capsule  has  taken  place. 
Finally,  it  is  universally  known  that  castration  prevents  the  females  from  entering 
into  heat,  whilst  those  which  have  been  deprived  of  the  womb,  but  not  of  the 
ovaries,  lose  nothing  of  the  ardor  with  which  they  receive  the  male. 

Menstruation  is,  therefore,  intimately  connected  with  the  evolution  of  the 
ovarian  vesicles,  and  cannot  occur  without  it ;  and  every  time  that  it  appears,  we 
may  feel  entirely  satisfied  as  to  the  existence  of  the  vesicular  development.  But, 
as  an  additional  phenomenon,  the  uterine  hemorrhage  may  be  wanting  without 
hindering,  in  any  degree,  the  regular  march  of  the  process  going  on  in  the  ovary. 
In  a  word,  the  spontaneous  ovulation  which  ordinarily  gives  rise  to  an  exhalation 
of  blood  from  the  internal  surface  of  the  womb,  may  have  its  influence  restricted 
to  the  ovary  alone ;  and  to  assume  the  non-appearance  of  the  menses  as  a  ground 
for  denying  an  aptitude  for  conception,  would  be  incurring  the  risk  of  frequent 
deceptions.  Thus  it  happened  that  science  possesses  numerous  examples  of 
young  girls  who  became  pregnant  before  they  had  ever  menstruated,  as  also  of 
women  who  conceived,  notwithstanding  a  suppression  which  had  lasted  for  several 
months. 

On  the  other  hand,  the  regularity  of  the  menstrual  function  does  not  neces- 
sarily imply  the  entire  fulfilment  of  the  vesicular  evolution.  In  certain  cases, 
the  latter  process  has  been  seen  to  remain  incomplete,  and  the  vesicle,  after 
having  attained  a  certain  degree  of  hypertrophy,  to  be  suddenly  arrested  in  its 
development,  to  remain  stationary  for  some  time,  and  then  abort  without  rupture. 
I  have  chanced  to  meet,  say?  M.  Coste,  cases  in  which  the  menstrual  flow  had 
passed  over  entirely,  without  the  ovarian  follicle,  whose  evolution  had  commenced 
and  even  progressed  to  its  final  period,  having  ruptured,  or  accomplished  the 
result  toward  which  it  tended. 


OF  THE  ORGANS  OF  GENERATION.  93 

The  cause  of  menstruation  being  ascertained,  how  shall  we  account  for  its 
monthly  periodicity  ?  In  other  words,  why  is  it  that  ovulation  in  the  human 
species  recurs  about  every  month  ?  To  this  question  science  is  unable  to  reply, 
for  it  is  probably  one  of  the  impenetrable  mysteries  of  nature.  But  why  should 
our  ignorance  upon  the  subject  be  a  cause  of  wonder?  Do  we  know  why  certain 
trees  produce  new  flowers  every  month  ?  why  this  animal  is  prepared  for  fecun- 
dation every  two  or  three  months,  whilst  that  one  is  so  but  once  a  year  ?  The 
processes  which  we  have  studied  are  intimately  connected  with  fecundation,  and 
are,  so  to  speak,  its  preludes.  Why,  when  the  whole  book  is  unintelligible  to 
us,  should  we  expect  to  comprehend  the  preface  ? 

Cessation  of  the  Menses. — As  we  have  before  said,  the  menses  continue  in  the 
majority  of  women  until  about  the  age  of  45  years.  According  to  a  table  of 
Brierre  de  Boismont,  40  years  is  the  age  at  which  the  greater  number  of  women 
cease  to  be  regular.  In  60  women  observed  by  M.  Petrequin,  it  was  between  35 
and  40  years  in  i,  between  40  and  45  in  J,  between  45  and  50  in  ^,  and  between 
50  and  55  in  i.  In  110  women  mentioned  by  M.  Raciborsky,  the  average  age 
of  cessation  was  46  years.  The  latter  author  cites  from  Dr.  Lebrun  of  Varsovia, 
and  Faye  of  Skeen,  results  which  go  to  prove  that  in  Poland  the  average  term 
is  47  years,  and  in  the  neighborhood  of  Christiana  48  ;  all  which  tends  to  show 
that  in  cold  climates  menstruation  terminates  late  in  life.  It  may  be  admitted, 
therefore,  that  the  average  duration  of  the  menstrual  function  is  from  25  to  30 
years. 

But  like  their  commencement,  the  period  at  which  the  menses  cease  is  subject 
to  great  variation.  Desormeaux  mentions  a  lady  with  whom  they  stopped  at  23 
years  of  age,  nor  is  it  rare  to  find  them  suppressed  between  35  and  40.  On  the 
other  hand,  they  are  often  prolonged  much  beyond  the  ordinary  period,  and  with 
them,  the  women  retain  the  power  of  conception  up  to  60,  65,  and  even,  as  some 
authors  relate,  to  70  years.  I  leave  to  the  lovers  of  the  marvellous  those  in- 
stances in  which  menstruation  continued  until  80,  90,  and  even  106  years.  It 
is  infinitely  probable  that,  in  the  cases  of  this  nature,  the  pretended  menstrual 
returns  were  really  due,  as  Haller  remarks,  to  uterine  disease.  I  would  add,  that 
we  should  place  in  the  same  category  those  examples  of  women  who,  after  having 
ceased  to  menstruate  about  the  age  of  45  or  50  years,  have  had  their  courses  to 
reappear  several  years  after,  and  continue  with  regularity. 

According  to  most  authors,  those  women  who  menstruate  very  early  also  cease 
to  do  so  sooner  than  others.  This  remark  appears,  both  to  M.  Raciborsky  and 
myself,  to  be  inexact,  when  not  applied  to  individuals  living  under  difi"erent 
climates.  With  the  former  author,  we  think  that  precocious  menstruation  is  due 
to  an  excess  of  vital  power  in  the  individual,  and  that,  exceptional  circumstances 
excluded,  the  influence  of  this  vital  activity  is  felt  later  in  life,  and  prolongs  the 
aptitude  for  procreation  in  the  woman.  So  that,  in  general,  it  ceases  as  much 
later  as  it  begins  at  an  earlier  age. 

The  cessation  of  the  menses,  and  of  the  vesicular  evolution  of  which  they  are 
an  epiphenomenon,  produces  in  the  generative  apparatus  and  entire  organism  of 


94  FEMALE  ORGANS  OF  GENERATION. 

the  woman,  effects  the  opposite  of  those  which  their  first  appearance  had  deter- 
mined. 

The  ovaries  become  atrophied,  and  diminish  in  size  in  every  direction,  and 
their  external  envelope  becomes  folded  and  wrinkled,  so  as  to  present  an  appear- 
ance which,  says  M.  Raciborsky,  we  can  compare  to  nothing  better  than  the  sur- 
face of  a  peachstone. 

The  Graafian  vesicles  appear  as  pouches  of  a  grayish  or  opaque  white  color, 
with  wrinkled  walls  ;  the  fluid  which  they  contained  is  absorbed ;  sometimes  their 
cavities  are  effaced,  their  thickened  walls  are  in  contact,  and  look  like  a  sort  of 
tubercle,  in  the  centre  of  which  barely  a  trace  of  the  former  cavity  is  visible. 
Sometimes  no  part  of  the  vesicles  can  be  discovered,  and  the  ovaiy,  which  has 
become  transformed  into  a  fibro-cellular  substance,  is  so  flattened  as  to  be  hardly 
distinguishable  at  the  extremity  of  its  ligament.  We  have  already  spoken  of  the 
deep  folds  and  wrinkles  of  its  external  membrane. 

Finally,  the  womb  and  the  breasts,  whose  vitality  became  suddenly  so  active 
towards  the  age  of  puberty,  seem  struck  with  the  same  blow  which  destroyed  the 
ovarian  orgasm ;  they  waste  gradually  away,  and  become,  so  to  speak,  foreign  to 
the  general  life  of  the  body. 

This  cessation  of  the  ovarian  functions  rarely  takes  place  suddenly,  but  is 
almost  always  announced  several  years  in  advance  by  more  or  less  marked  irregu- 
larities or  intermissions.  Frequently,  the  returns  of  the  menses  suffer  postpone- 
ments, which  may  be  prolonged  for  several  weeks  or  months,  and  then,  after 
renewal,  be  deferred  for  a  still  longer  period.  Sometimes  the  epochs  are  marked 
by  a  very  small  discharge,  and  last  for  a  very  short  time ;  again,  on  the  contrary, 
the  quantity  of  blood  lost  may  be  so  considerable  as  to  give  rise  to  apprehension. 
With  certain  women  the  flow  is  so  excessively  prolonged  that  the  menstrual 
periods  are  only  indicated  by  its  increase ;  a  mucous  flux  of  a  yellowish-white 
color,  which  is  quite  abundant,  and  either  continuous  or  periodic,  replaces  the 
flow  of  blood  in  the  interval  of  the  epochs,  and  sometimes  remains  for  a  long 
time  after  they  have  ceased.  Finally,  a  general  and  indefinite  feeling  of  uneasi- 
ness, lumbar  and  pelvic  pains,  colics,  itching  at  the  genital  parts,  flashes  of  heat 
in  the  face,  and  sudden  and  spontaneous  alternations  of  chilliness  with  profuse 
perspirations,  are  added  to  the  local  phenomena  above  indicated. 

In  the  majority  of  cases,  all  these  troubles  are  quite  slight  and  disappear 
promptly ;  but,  in  some  instances,  diseases  before  latent  then  declare  themselves. 
It  is  this  fact  which,  though  much  rarer  than  is  commonly  supposed,  has  obtained 
for  this  time  of  life  the  name  of  the  critical  period.  Its  dangers  have  been  won- 
derfully exaggerated,  and  modern  researches  prove,  in  opposition  to  the  opinion 
of  physicians  who  have  preceded  us,  that  the  organic  affections  of  the  breasts,  of 
the  uterus,  and  of  the  ovaries,  begin  much  more  frequently  before  than  after  the 
cessation  of  the  menses.  Finally,  it  is  shown  by  statistics,  that  the  mortality  in 
women,  between  the  ages  of  40  and  50  years,  is  not  greater  than  at  any  other 
period  of  life. 


PART    II. 

OF  GENERATION. 


Generation  is  effected  in  the  human  species  through  the  medium  of  two 
sexes  distinguished  by  the  possession  of  different  organs.  The  sexual  characters 
being  therefore  peculiar  to  distinct  individuals,  the  male  and  the  female,  these 
evidently  must  first  approach  each  other  before  generation  can  take  place.  This 
first  act  constitutes  copulation.  The  consequence  of  the  approach  is  an  applica- 
tion of  the  fecundating  principle  of  the  male  to  the  germ  furnished  by  the  female, 
in  other  words,  conception  or  fecundation.  The  ovum  having  been  fecundated, 
remains,  and  is  developed  in  the  organs  of  the  mother  during  the  whole  term  of 
gestation.  Lastly,  at  the  expiration  of  a  nearly  uniform  period,  the  new  being 
is  expelled,  to  maintain  thenceforth  a  separate  existence ;  this  final  act  is  termed 
the  accouchement  or  labor. 

We  have  already  described  the  genital  organs  of  the  female,  and  it  is  not  our 
province  to  notice  those  of  the  male.  We  shall  be  equally  silent  upon  all  that 
relates  to  sexual  intercourse,  though  it  is  our  pui-pose  to  treat  briefly  of  concep- 
tion, and  in  detail  of  gestation,  and  especially  of  labor. 


BOOK  I. 

OF  CONCEPTION. 

Conception  takes  place  during  sexual  congress;  but  to  understand  how  it 
occurs,  requires  that  we  should  know  first  what  materials  are  furnished  by  each 
individual,  how  and  where  these  are  brought  into  contact,  and  lastly,  what  is 
not  yet,  and  probably  never  will  be  explained,  how  from  this  contact  a  new  indi- 
vidual is  produced. 

1.  The  spermatic  fluid,  a  glutinous,  consistent,  and  whitish  liquid  secreted  by 
the  testicle,  is  the  fecundating  principle  furnished  by  the  male.  It  is  heavier 
than  water,  and,  when  shaken  with  it,  forms  an  emulsion.     Its  odor  is  peculiar. 


96  GENERATION. 

and  has  been  justly  compared  to  that  emitted  by  bone  filings,  or  the  flower  of  the 
chestnut  tree ;  Wagner  states  that  the  odor  is  due  rather  to  the  secretions  with 
which  it  is  mixed  than  to  the  sperm  itself,  the  latter,  when  pure,  not  appearing 
to  possess  any  particular  smell.  By  chemical  analysis  it  is  shown  to  contain 
albumen,  salts  of  phosphoric  and  chlorohydric  acids,  and  a  peculiar  animal  sub- 
stance called  sperniatine. 

When  examined  under  the  microscope,  with  a  magnifying  power  of  three  or 
four  hundred  diameters,  the  spermatic  fluid  exhibits  :  1.  A  great  number  of  little 
bodies,  lying  quite  close  to  each  other,  and  which  are  still  moving  with  more  or 
less  activity  if  the  fluid  has  been  taken  from  a  recently-killed  animal;  these 
minute  bodies  have  been  designated  as  the  spermatic  animalcules,  or  the  sperma- 
tozoa. 2.  Of  certain  little  granular  globules,  which  are  sometimes  very  few  in 
number,  at  others  more  numerous,  but  always  less  so,  however,  than  the  animal- 
cules ;  Wagner  calls  them  the  spermatic  granules.  3.  These  two  principal 
elements  of  the  sperm  swim  in  a  small  quantity  of  a  clear,  transparent,  and  per- 
fectly homogeneous  liquid, — the  spermatic  liquid.  At  the  time  of  the  ejacula- 
tion, this  liquid  is  mixed  with  a  variable  quantity  of  the  fluids  secreted  by  the 
prostate  gland  and  the  glands  of  Cowper,  which  latter  evidently  serve  merely  to 
lubricate  the  parts,  to  render  the  sperm  more  fluid,  and  consequently,  its  expul- 
sion more  easy. 

The  spermatic  animalcules  attract  particular  attention  by  their  varied  form, 
their  vital  properties,  and  their  development.  They  are  met  with  in  all  animals 
capable  of  reproduction. 

In  man  they  are  very  small,  scarcely  surpassing  the  eightieth  or  the  hundredth 
of  a  line  in  diameter.  The  body  is  small,,  oval,  somewhat  flattened  like  an  almond, 
and  transparent,  having  a  diameter  equal  to  the  three  or  four-hundredth  part  of 
a  millimetre  (001  of  an  inch).  The  tail  is  filiform,  thicker  at  its  origin  than  at 
any  other  part,  and  is  large  enough  to  present  clearly  its  double^outline ;  towards 
the  extremity  it  becomes  so  fine  that  it  cannot  be  traced,  even  by  means  of  the 
highest  magnifying  power,  whence  it  may  be  possible  that  its  delicate  extremity 
is  still  further  elongated,  and  that  the  spermatozoa  may  be  much  longer  than 
they  appear. 

It  is  impossible,  says  Wagner  (from  whose  able  works  I  extract  this  paragraph), 
to  decide  whether  the  spermatic  animalcules  have  an  animal  organization,  that  is, 
whether  they  are  true  animals  with  an  independent  life,  or  not;  and  all  that  is 
either  known,  or  plausibly  supposed  on  this  point,  may  be  reduced  to  a  few  ob- 
scure indications,  that  are  wholly  insufficient  to  establish  any  positive  opinion. 

The  movements  which  they  exhibit  prove  nothing,  because  it  is  exceedingly 
difficult  to  ascertain  whether  they  are  voluntary  or  not.  Again,  the  duration  of 
the  movements  also  varies  in  the  different  classes  of  animals ;  in  the  mammiferae, 
they  have  even  been  observed  for  twenty-four  hours  after  death. 

The  spermatozoa  do  not  appear  in  the  human  species  before  puberty ;  at  this 
period,  the  testicles  receive  a  large  supply  of  blood,  and  increase  in  size ;  the 
parietes  of  the  seminiferous  tubes  become  thickened,  their  capacity  increases,  and 
they  are  filled  with  granules;  then  cysts  or  cells  containing  globules  begin  to 


orcoNCEPTiox.  "  97 

form,  and  finally  the  spermatozoa  appear  in  these  cells.  They  are  always  found 
in  the  testicles  of  men  of  sixty  to  seventy  years  of  age,  though  they  are  then  fre- 
quently absent  from  the  vas  deferens ;  the  vesiculae  seminales,  however,  generally 
contain  them  even  at  this  time  of  life. 

The  germ  furnished  by  the  female  is  evidently  existent  in  the  ovary  at  the 
marriageable  period,  and  this  germ  is  the  ovule.   (See  p.  70  for  its  description.) 

2.  It  is  unnecessary  in  our  day  to  prove  that  an  absolute  contact  of  the  semen 
of  the  male  with  the  ovule  of  the  female  is  indispen.sable  to  fecundation,  for  in- 
numerable experiments  upon  living  animals,  and  numerous  facts  observed  in  the 
human  species,  have  long  since  demonstrated  that,  whenever  any  obstacle  pre- 
vents the  approach  of  these  two  elements,  a  conception  cannot  take  place.  But 
at  what  point  does  this  contact  occur?  Already  had  the  pre-existence  of  the 
ovule  in  the  ovary,  the  occasional  occurrence  of  ovarian  and  abdominal  pregnan- 
cies, and  the  experiments  of  Nuck  and  Haighton,  which  had  rendered  fecunda- 
tion impossible  by  ligating  the  Fallopian  tubes,  tended  towards  the  conclusion 
that  it  occurred  in  the  ovary;  still  this  fact  was  not  actually  demonstrated,  and 
it  needed  the  definitive  proof  of  finding  the  spermatozoa  on  the  ovary  itself  At 
present,  there  cannot  be  a  further  doubt  on  this  point,  for  BischoflF  has  been  for- 
tunate enough  to  see  them  there.  "I  had  often  seen,"  says  he,  "living  and 
moving  spermatozoa  in  the  vagina,  the  womb,  and  the  Fallopian  tubes  of  bitches ; 
but,  on  the  22d  of  June,  1838,  I  had  the  good  fortune  to  perceive  one  on  the 
ovary  itself  of  a  young  bitch,  in  heat  for  the  first  time ;  she  was  covered  on  the 
21st,  at  seven  o'clock  in  the  evening,  and  again  the  following  day,  at  two  o'clock, 
p.  M.,  and  at  the  expiration  of  half  an  hour,  that  is,  twenty  hours  after  the  first 
copulation,  I  killed  her,  and  found  some  living  spermatozoa,  endowed  with  very 
active  movements,  not  only  in  the  vagina,  the  entire  womb  and  tubes,  but  even 
between  the  fringes  of  the  latter  in  the  peritoneal  pouch  that  surrounds  the  ovary, 
and  on  the  surface  of  this  organ  itself."  Since  that  period,  Wagner  and  Barry 
have  made  the  same  observations. 

Now  such  results  evidently  prove  that  fecundation  sometimes  takes  place  in 
the  ovary ;  but  are  we  thence  to  conclude,  that  it  is  possible  in  that  organ  alone  ? 
If  spontaneous  ovulation  be  now  an  incontestable  fact,  may  it  not  be  supposed 
that  the  ovule,  after  having  left  the  ovary,  can  encounter  the  spermatic  fluid  and 
become  fecundated,  whether  it  be  in  the  Fallopian  tube,  or  even  in  the  uterine 
cavity  ?  And  unless  we  admit  (what  analogy  renders  improbable)  that  the  ovule, 
once  out  of  the  ovarian  vesicle,  is  not  capable  of  fecundation,  we  are  constrained 
to  believe  that  the  latter  may  be  accomplished  at  whatever  part  of  the  genital 
organs  the  contact  takes  place. 

But  the  question  arises,  how  does  the  fluid  ejaculated  by  the  male  get  as  ftxr 
as  the  ovary  ?  "We  answer  that,  in  the  great  majority  of  cases,  it  is  evident  that 
the  sperm,  having  first  reached  the  uterus,  upon  the  neck  of  which  it  was  thrown 
by  the  membrum  virile,  travels  through  the  tube  until  it  arrives  there.  This 
course  is  certainly  due,  1st,  to  the  movements  proper  of  the  womb  and  the  tubes; 
for  in  the  latter,  a  rapid  contraction  is  observed,  following  the  direction  from  the 
vagina  towards  the  ovary,  which,  of  course,  is  calculated  to  assist  the  progression 

7 


08  '  GENERATION. 

of  the  sperm;  and  2d,  to  the  niovements  proper  of  the  spermatozoa,  which  thus 
of  themselves  facilitate  their  own  advancement. 

We  have  seen,  however,  that  there  is  in  some  cases  another  route  of  commu- 
nication between  the  ovary  and  vagina.  In  such  instances  as  those  cited  by 
Mauriceau,  Dulaurens,  De  Graaf,  Baudelocque,  and  others,  where  the  Fallopian 
tube  divided  near  the  angle  of  the  womb  into  two  canals,  the  shortest  and  largest 
of  which  was  inserted  at  the  angle,  whilst  the  smallest  and  longest  opened  into 
the  neck  of  the  womb  near  its  internal  orifice,  it  is  conceivable,  that  this  acci- 
dental canal  might  afford  another  passage  to  the  sperm  than  that  through  the 
cavity  of  the  womb. 

3.  This  first  point  being  once  established,  the  question  naturally  arises,  what 
was  the  influence  exercised  by  the  sperm  upon  the  ovule  of  the  female  during  the 
contact  ?  Now,  numerous  experiments  clearly  prove  that  the  sperm  owes  its 
fecundating  properties  to  the  presence  of  the  spermatic  animalcules,  and  that, 
whenever  it  is  deprived  of  these,  it  immediately  becomes  unsuited  to  its  proper 
function.  But,  unfortunately,  it  is  fav  more  difficult  to  ascertain  the  part  acted 
by  the  spermatozoa,  though  there  have  been  three  hypotheses  started  in  regard 
to  that  subject  deserving  our  consideration.  The  most  ancient  one  is,  that  during 
fecundation  they  penetrate  immediately  to  the  ovule,  and  are  there  developed  as 
a  miniature  embryo,  or,  at  least,  they  constitute  the  central  nervous  system  of 
the  future  being.  This  old  opinion  has  been  recently  sustained  by  Bany,  who 
asserts  that  the  ovule  of  rabbits,  when  at  maturity,  is  furnished,  both  before  and 
during  fecundation,  with  a  fissure  or  opening  in  the  vitelline  membrane,  and  once 
he  was  even  fortunate  enough  to  see  a  spermatozoon  penetrating  this  fissure. 

Again,  according  to  certain  authors,  the  fecundating  power  does  not  belong  to 
the  spermatozoa,  but  to  the  seminal  liquid  interposed  between  them.  In  this 
hypothesis,  the  animalcules  are  the  transjmrters  of  this  fluid,  and  the  object  of 
their  movements  is  to  conduct  it  to  the  ovule. 

Lastly,  in  the  opinion  of  Bory-Saint- Vincent,  Valentin,  and  Bischoff,  the  sper- 
matozoa are  solely  destined  to  maintain  the  chemical  composition  of  the  sperm 
by  their  active  motions.  They  suppose  that  the  spermatic  fluid  is  a  substance 
endowed  with  a  chemical  sensibility  of  such  a  character  that,  like  the  blood,  it 
can  only  preserve  the  fecundating  power  while  it  remains  in  motion ;  whence 
these  active  elements  are  enclosed  in  it  whose  presence  is  indispensable — elements, 
the  movements  of  which  are  never  more  active  than  just  at  the  moment  when 
the  semen  leaves  the  place  of  its  secretion,  and  which  appear  to  exercise  the 
most  favorable  influence  for  the  maintenance  of  its  composition. 

These  are  a  summary  of  the  most  recent  opinions;  and  we  merely  present  them 
as  they  are,  without  any  commentaries,  not  desiring  to  decide  in  so  delicate  a 
matter.  Besides,  whichever  one  may  be  adopted,  the  mind  remains  unsatisfied ; 
for  it  must  be  acknowledged  there  is  still  a  mystery  that  all  the  most  ingenious 
hypotheses  have  not  been  enabled  to  clear  up,  and  which  will  probably  escape  all 
our  researches. 

When  fecundation  takes  place  in  the  ovary,  whether  before  or  after  the  rup- 
ture of  the  Graafian  vesicle,  the  Fallopian  tubes,  which  had  participated  in  the 


OF    CONCEPTION.  99 

state  of  turgescence  of  all  the  other  genital  organs,  retain  their  free  extremity  in 
contact  with  the  ovary,  and  the  ovule,  having  escaped  from  the  vesicle,  imme- 
diately engages  in  their  canal ;  being  pressed  onwards  by  the  peristaltic  contrac- 
tions of  the  tube,  it  advances  step  by  step  through  this  duct,  and  finally  arrives 
in  the  uterine  cavity,  where  its  development  unceasingly  progresses  until  the 
regular  term  of  pregnancy.    (See  the  chapter  on  OvoJogy.') 

Nearly  the  same  phenomena  take  place,  when  the  contact  of  the  fecundating 
fluid  with  the  ovule  is  deferred  until  after  the  latter  has  passed  into  the  tube. 

It  is  extremely  difficult,  not  to  say  impossible,  to  ascertain  the  exact  period  at 
which  the  fecundated  ovule  reaches  the  cavity  of  the  womb.  In  animals,  we 
may  note  without  difficulty  the  time  of  fecundation ;  but  this,  of  course,  is  gene- 
rally impossible  in  the  human  species,  and  this  obstacle  renders  nearly  all  our 
observations  uncertain  and  incomplete.  Further,  very  numerous  researches  have 
clearly  proved  that  the  ovule  in  mammiferae  does  not  always  arrive  at  the  same 
moment  in  the  womb,  and  it  is  exceedingly  probable  that  the  same  variations 
exist  in  the  human  female. 

In  the  present  records  of  our  science,  there  is  no  one  conclusive  fact  that 
proves  the  ovule  to  have  ever  been  seen  in  the  womb  of  a  woman  prior  to  the 
tenth  or  twelfth  day  after  her  conception. 

Baer  examined  a  woman,  who  committed  suicide  eight  days  after  conception; 
the  deciduous  membrane  had  commenced  forming,  and  some  vessels,  coming  from 
the  mucous  membrane,  were  penetrating  it,  but  he  could  not  detect  any  trace  of 
the  ovule  in  the  uterus.  (British  and  Foreign  Neio  Recieu',  Jan.  1836,  p.  328.) 
The  same  occuri'cd  in  the  case  cited  by  Weber  (^Disquisitio  anatomica  uteri  ct 
ovariorum  puellce,  septimo  a  conceptione  die  defanctoi  institntci).  Dr.  Pockels 
speaks,  it  is  true,  of  an  ovum  of  eight  days,  found  in  the  uterus,  and  in  which 
the  foetus  could  easily  he  distinguished ;  but  the  description  furnished  by  him 
evidently  applies  to  an  older  product.  (Allen  Thompson,  in  the  Edinburgh  Med. 
and  Surg.  Journal,  vol.  lii,  p.  122.)  Ovules  of  eleven  days  were  the  youngest 
observed  by  M.  Velpeau. 

After  the  exit  of  the  ovule,  the  Graafian  vesicle  soon  retracts  upon  itself,  and 
thus  contributes  to  the  formation  of  the  corpus  luteum  before  spoken  of  (p.  76). 

We  shall  hereafter  describe  the  modifications  which  the  ovule  undergoes  during 
its  passage  through  the  tube,  and  after  its  arrival  in  the  uterus. 

Conception  is  an  act  that  takes  place  unconsciously,  and  altogether  involun- 
tarily; although  some  females,  more  especially  those  who  have  had  children, 
imagine  that  they  can  distinguish  a  prolific  connection  from  others.  They  say  a 
much  more  voluptuous  sensation  is  then  experienced,  a  spasm  much  better 
marked ;  and  I  have  met  with  too  many  females  who  acknowledged  having  made 
this  obsei'vation,  not  to  believe  there  is  some  truth  in  the  assertion. 

The  same  ignorance  that  prevails  as  to  the  causes  of  fecundation,  likewise 
exists  with  regard  to  those  opposing  its  accomplishment.  For,  though  vices  of 
conformation  or  faulty  position  of  the  uterus,  as  also  obliterations  of  the  neck  or 
tubes,  may  explain  the  sterility  of  some  individuals,  it  is  wholly  impossible  to 
understand  why  some  women  are  barren,  although  well  formed — wh}-,  in  a  con- 


100  GENERATION. 

siderable  number  of  cases,  married  females  have  not  had  children  during  their 
first  marriage,  whereas  they  subsequently  became  enceinte,  when  even  it  has 
been  observed  that  the  first  husband  had  children  by  a  former  bed. 

The  period  at  which  fecundation  is  most  likely  to  take  place,  appears  to  be 
that  immediately  following  the  flow  of  the  menses;  thus  M.  Raciborsky  has  as- 
certained that  the  conception  took  place  a  little  before  or  after  their  appearance, 
in  fifteen  females,  who  could  designate  precisely  the  time  of  the  sexual  approach. 
It  is  indeed  evident,  that  everything  seems  admirably  prepared  at  this  period 
for  the  reproduction  of  the  species ;  but  I  am  fiir  from  concluding,  as  M.  Raci- 
borsky  has  done,  that  the  aptitude  for  fecundation  in  the  human  race  is  limited 
to  a  few  days,  either  preceding  or  following  the  menstrual  terms.  Experience 
has  convinced  me  that  sexual  intercourse  may  be  fruitful,  even  when  it  takes 
place  in  the  middle  of  the  interval  between  the  two  menstrual  epochs.  "Whether 
it  be  that  the  ovule  discharged  by  the  spontaneous  evolution  preserves  its  aptitude 
for  fecundation  for  a  long  time,  or  that  the  excitation  produced  by  coition  may 
be  communicated  to  the  ovarian  vesicles,  and  cause  modifications  in  them  alto- 
gether similar  to  those  experienced  in  the  menstrual  evolution,  the  fact  itself 
appears  to  me  to  be  settled  beyond  a  doubt.' 

'  M.  Coste,  who  also  admits  the  possibility  of  conception  without  regard  to  the  period  at 
which  copulation  takes  place,  is  prepared,  he  says,  to  demonstrate  by  undeniable  proofs,  that 
the  ovum  detached  from  the  ovary  during,  or  towards  the  close  of  menstruation,  loses  all 
capacity  for  fecundation  within  a  very  few  days  after  being  set  free.  Conception  is,  there- 
fore, only  possible  at  other  times  than  near  or  during  the  menstrual  epochs,  when  other  cir- 
cumstances happen  to  produce  in  the  ovary  an  operation  similar  to  that  which  takes  place 
at  the  period  of  heat.  Now  is  this  possible?  Comparative  physiology  replies  in  the  a/Er- 
mative,  by  demonstrating  it  to  be  so  as  regards  certain  animals,  thus  rendering  it  at  least 
very  probable  for  the  human  species  also. 

In  animals  living  in  the  savage  state,  says  the  learned  professor  of  the  College  of  France, 
the  ovaries  accomplish  their  functions  only  at  rare  intervals ;  but,  when  domesticated,  the 
maturation  of  the  eggs  may  become  so  frequent  in  certain  species,  that  the  ovulation  occurs 
almost  daily.  Thus  the  wild  pigeon,  which  deposits  her  eggs  but  once  or  twice  a  year,  sets 
seven  or  eight  times,  when  she  takes  up  her  abode  in  our  dovecotes.  Under  the  influence 
of  an  appropriate  nourishment,  our  domestic  fowls  lay  almost  every  day  for  eight  months  in 
the  year.  The  rabbit  of  the  fields  brings  forth  but  once  or  twice  yearly,  whilst  living  at 
large;  but  in  the  domestic  condition,  she  will  reproduce  as  often  as  seven  times,  if  care  be 
taken  to  wean  the  young  at  the  proper  moment. 

There  are  therefore  conditions  of  shelter,  of  temperature,  and  of  alimentation,  which,  by 
acting  on  the  organism  of  animals,  n)ay  cause  their  ovaries  to  exercise  their  functions  more 
frequently  in  a  given  space  of  time.  To  this  it  may  be  added,  that  in  mammalia,  the  coha- 
bitation of  the  males  is  one  of  the  most  active  accelerating  causes  of  the  dehiscence  of  the 
vesicles.  Thus,  for  example,  a  female  rabbit  when  placed  alone  in  a  cage  where  she  is 
completely  protected  from  the  attempts  of  the  male,  enters  ordinarily  into  heat  about  every 
two  months,  and  when  the  time  of  this  periodic  excitement  is  past,  she  refuses  obstinately 
to  submit  to  coition;  but  if,  instead  of  separating  her  from  the  male,  whom  she  then  repels 
with  violence,  he  be  allowed  to  remain  with  her  for  a  few  days  only,  it  may  be  regarded  as 
certain  that  she  will  not  resist  long,  because  the  solicitations  to  which  she  will  be  incessantly 
subjected  will  provoke  the  return  of  a  condition  which,  in  the  absence  of  this  excitement, 
would  have  been  much  longer  in  appearing. 

There  are,  therefore,  natural  and  ciuirely  s-pontaneous  epochs  for  the  maturation  and  dis- 


OF    GESTATION.  101 

I  shall  not  undertake  to  refute  tlie  opinion  of  those  who  believe  that  either  sex 
can  be  created  at  will ;  yet  I  think  it  not  improbable,  that  the  physical  constitu- 
tion of  the  husband  or  of  the  wife  may  have  some  influence  in  determining  the 
sex  of  the  child.  The  admirable  observations  of  M.  Girou  seem  to  me  to  have 
proved  that  with  the  inferior  animals,  at  least,  the  stronger  the  male  is  in  com- 
parison with  the  female,  the  greater  is  the  chance  of  producing  a  male,  and  vice 
versa.  The  observations  I  have  been  able  to  make  on  the  human  family  since 
reading  the  statistical  results  of  M.  Girou,  have  generally  confirmed  their  con- 
clusions. 

Here  terminates  what  I  had  proposed  to  say  in  reference  to  fecundation.  It 
will  be  seen  that  I  have  limited  it  to  a  very  brief  exposition  of  the  most  generally 
received  views  of  this  point  of  physiology.  The  size,  and  especially  the  object 
of  the  work,  seem  necessarily  to  exclude  more  ample  details. 


BOOK  II. 

OF  GESTATION. 

Preg.vanct  is  the  condition  of  a  woman  who  has  conceived,  and  bears  within 
her  womb  the  product  of  conception. 

This  state  commences  at  the  instant  of  fecundation,  and  terminates  with  the 
expulsion  of  the  body  which  results  from  that  function.  It  continues  for  two 
hundred  and  seventy  days,  or  nine  solar  months.  This  term,  however,  is  not 
invariable,  as  it  is  by  no  means  rare  for  the  pregnancy  to  terminate  sooner,  and 
in  some  very  few  instances  we  find  it  of  longer  duration,  though  some  persons 
have  denied  this  latter  fact,  and  everybody  recalls  the  sharp  discussions  carried 
on  in  France  about  the  middle  of  the  last  century,  and  still  more  recently  in 
England,  on  the  question  of  retarded  births. 

We  have  already  stated  that  the  ovule  originally  exists  in  the  ovary ;  that  a 

charge  of  ova,  and  there  are  also  others  which  may  be  styled  artificial,  because  il  is  possible 
to  produce  them  through  the  means  of  external  agents. 

Now,  is  it  possible  to  suppose  that  the  human  female,  who  commands  all  these  conditions 
at  her  will,  is,  by  an  inexplicable  exception,  enclosed  within  the  impassable  boundaries  of 
her  menstrual  periods'?  And  if,  in  spite  of  her  first  vigorous  resistance  to  the  attempts  of 
the  male,  the  rabbit  finally  yields  to  the  influence  of  his  companionship,  why  in  woman,  who 
of  all  the  females  of  the  mammalia  is  endued  with  the  most  constant  readiness  for  coition, 
should  not  the  sexual  allurements  have  the  same  result? 

This  accidental  evolution  of  a  vesicle  is  not  followed  by  the  menstrual  flow  which  ordi- 
narily accompanies  it;  all  which  is  very  comprehensible,  for  we  must  not  forget  that  the 
same  cause  which  provokes  the  discharge  of  the  ovule,  is  also  that  which  fecundates  it,  and 
that  in  so  doing,  it  arrests  the  tendency  to  hemorrhage  before  it  has  time  to  appear.  (Coste, 
Histoire  gcSn^rale  et  particuli^re  du  developpement  des  corps  organises.)  The  same  thing,  in 
fact,  happens  when  fecundation  occurs  a  few  days  or  hours  only  before  the  appearance  of 
the  menses. 


102  GENERATION. 

short  time  before  or  after  conception  it  is  expelled  from  thence;  and  that  it  then 
traverses  the  tube,  so  as  to  reach  the  uterus,  where  it  is  developed  and  continues 
to  grow  during  the  whole  term  of  gestation.  When  the  succession  takes  place 
in  this  manner  the  pregnancy  is  said  to  be  a  good,  normal,  or  uterine  one ;  but, 
on  the  contrary,  if  the  ovule  be  arrested  at  some  point  of  its  passage,  and  is 
developed  elsewhere  than  in  the  womb,  the  pregnancy  is  denominated  had,  extra- 
ordinary, or  extra-uterine.  The  first,  or  uterine  pregnancy,  has  been  divided 
into, — the  simple,  where  only  a  single  foetus  exists ;  the  compound,  or  double, 
triple,  kc,  where  there  are  two  or  three  children ;  and  the  complicated  preg- 
nancy, or  that  in  which  the  positive  existence  of  a  fcetus  is  coincident  with  that 
of  a  pathological  tumor  of  the  abdomen.  Again,  the  term  fcdse  pregnancy  has 
been  improperly  applied  to  certain  diseases  simulating  pregnancy,  where  this  state 
does  not  really  exist. 


CHAPTEE   I. 

OF    SIMPLE    UTERINE    PREGNANCY. 

In  pregnancy,  there  are  two  orders  of  phenomena  to  be  studied, — those  pre- 
sented by  the  female,  and  those  which  belong  to  the  product  of  conception.  We 
shall  first  consider  the  former. 

The  history  of  pregnancy  in  the  female  comprises  all  the  anatomical  and  phy- 
siological modifications  that  are  developed  in  the  uterus  and  all  other  organs  of 
the  economy ;  the  influence  that  it  exerts  on  the  physical,  intellectual,  and  moral 
health  of  the  individual ;  and  also  the  means  of  preventing  or  curing  the  trouble- 
some accidents  which  may  result  from  it. 


ARTICLE  I. 

ANATOMICAL   CHANGES. 

The  most  remarkable  are  those  which  the  uterus  undergoes,  and  we  shall  com- 
mence our  description  with  them. 

These  modifications  may  either  be  in  the  volume,  form,  situation,  or  direction 
of  the  womb ;  and  hence,  on  account  of  their  great  importance,  we  shall  succes- 
sively study  them  in  the  body  and  in  the  neck ;  then  we  will  point  out  the 
changes  which  the  structure  and  relations  of  the  organ  undergo. 

§  1.   Changes  in  the  Body  of  the  Uterus. 

A.  Volume. — We  have  already  learned  that  under  the  influence  of  the  hemor- 
rhagic congestion  which  the  uterus  undergoes  at  each  menstrual  period,  the  bulk 
of  the  organ  is  increased.  If  conception  takes  place  within  the  few  days  pre- 
ceding or  following  the  flow  of  the  blood,  the  excitement  produced  by  the  fruitful 


OF  SIMPLE  UTERINE  PREGNANCY. 


103 


coition  maiiitaius,  and  soon  increases  the  liypertropliy  of  its  walls.  Thus,  we 
shall  find  further  on  (see  Decichia),  that  the  mucous  membrane  especially  be- 
comes almost  doubled  in  thickness,  so  taat  when  the  fecundated  ovule  arrives  in 
the  cavity  of  the  womb,  it  finds  it  entirely  filled  with  this  membrane,  which  is 
swollen  to  such  an  extent  as  to  be  thrown  into  folds  from  want  of  room  to  deve- 
lope  itself.    (See  page  75.) 

The  same  thing  precisely  occurs  in  those  exceptional  cases  in  which  fecunda- 
tion takes  place  some  time  from  the  menstrual  period.  Here,  the  hypertrophy 
also  begins  under  the  influence  of  the  evolution  of  a  Graafian  vesicle ;  only  the 
evolution,  instead  of  being  spontaneous,  is  the  result  of  a  more  or  less  prolonged 
venereal  excitement. 

As  soon  as  the  ovule  arrives  in  the  womb,  the  latter  begins  to  develope,  and 
its  volume  continues  to  increase  until  the  end  of  pregnancy ;  but  this  progression 
is  not  uniform,  for,  according  to  the  observations  of  Desormeaux,  it  is  much 
slower  in  the  early  months,  and  more  rapid  in  the  latter.  An  accurate  idea  of 
this  increase  maybe  formed  from  the  following  table,  which  represents  the  usual 
dimensions  of  the  uterus  at  the  principal  periods  of  pregnancy. 


Vertical  Diameter. 

Trniisverse. 

Antero-Posterior. 

Third  month,  .... 
Fourth    "         .... 
Sixtli       "         .... 
Ninth      "         .... 

2|         inches 
3f 

12^  to  14^ 

2J  inches 
3f       " 
61       " 
9h       " 

2f         inches 
3f 
61 
8|  to  9J       '' 

The  development  of  the  uterine  walls  is  not  purely  mechanical,  as  has  been 
supposed,  nor  is  their  distension  the  result  of  the  development  of  the  ovum, 
which,  by  pres.sing  upon  the  different  points  of  the  internal  surface,  would  tend 
to  separate  them  more  and  more. 

If  we  consider  the  small  volume  of  the  ovule  in  the  first  weeks  of  pregnancv, 
as  compared  with  the  thickness  of  the  walls  of  the  uterus  at  the  same  period,  we 
shall  not  fiiil  to  be  convinced  that  the  expansive  force  of  the  ovum  would  be 
unable  to  overcome  their  resistance.  The  development  of  the  ovum  and  that  of 
the  uterus  are  simultaneous,  but  effected  by  forces  which  are  inherent  in  each  ; 
in  a  word,  the  growth  of  the  ovum  acts  as  a  phj-siological  cause,  but  not  as  a 
mechanical  agent  in  the  development  of  the  walls  of  the  uterus. 

B.  Shape. — The  shape  of  the  uterus  changes  simultaneously  with  the  altera- 
tion in  its  volume.  Being  flattened,  at  first,  on  its  two  faces,  the  womb  grows 
rounder  and  soon  becomes  pyriform,  then  spheroidal,  and  towards  the  end  of 
pregnancy  it  has  the  form  of  an  ovoid,  which  is  slightly  flattened  from  before 
backwards.  The  anterior  face,  however,  is  much  the  more  convex,  and  the 
posterior  one  is  depressed,  so  as  to  accommodate  itself  to  the  prominence  of  the 
lumbar  vertebras. 

At  the  end  of  pregnancy,  the  superior  extremity  of  the  uterine  ovoid  is  quite 
regularly  rounded ;  that  side  of  the  fundus,  however,  which  is  occupied  by  one 
of  the  extremities  of  the  fa-tal  ovoid,  being  often  more  elevated  than  the  other, 


104  GENERATION. 

which  is  filled  with  fluid  only.  Now,  as  in  the  most  usual  presentations,  the 
trunk  of  the  foetus  is  generally  inclined  towards  the  right,  the  right  side  of  the 
fundus  of  the  uterus  is  commonly  the  most  elevated.  (Hergott.)  Sometimes 
both  sides  are  alike  in  this  respect,  and  there  is  a  depression  upon  the  middle 
and  upper  part  of  the  organ. 

Such  is  the  shape  of  the  uterus  in  the  majority  of  cases  j  but  the  situation  and 
number  of  the  foetuses,  and  the  structure  and  primitive  form  of  the  organ,  may 
produce  important  changes  in  the  shape  which  it  assumes  during  gestation,  and 
which  will  claim  our  attention  hereafter. 

C.  Situation. — It  is  evident  that  the  uterus  cannot  thus  change  in  shape  and 
size,  without  undergoing  a  simultaneous  alteration  in  its  position ;  for  example, 
during  the  first  three  months  of  gestation,  the  womb  remains  sunken  in  the  ex- 
cavation, but  as  its  volume  increases  in  all  directions,  the  fundus  of  the  organ 
rises  towards  the  superior  strait,  whilst  its  inferior  part  and  neck  subside  still 
more  towards  the  floor  of  the  pelvis.  This  depression  of  the  organ  is  produced 
by  its  yielding  to  the  laws  of  gravitation  from  its  own  increased  weight,  as  also 
by  the  augmented  pressure  of  the  intestinal  mass  upon  the  larger  surface,  created 
by  the  change  in  the  fundus.  Hence,  both  its  increase  of  volume  and  its  weight, 
augmented  by  the  pressure  of  the  intestinal  mass,  which  now  has  an  extensive 
point  cVuppui  on  the  fundus,  contribute  to  produce  the  first  change  in  position. 

At  the  same  time,  the  uterus  remains  in  the  sacral  cavity  from  the  greater 
space  found  there,  and,  the  fundus  being  turned  a  little  backwards,  causes  the 
neck  to  advance  slightly.  Besides,  the  presence  of  the  rectum  on  the  left  most 
o-enerally  obliges  the  organ  to  deviate  towards  the  right,  and  the  neck,  in  a  cor- 
responding manner,  to  the  left ;  consequently,  during  the  first  three  months,  the 
cervix  is  directed  downward.s,  forwards,  and  a  little  to  the  left. 

About  the  third  month  and  a  half,  or  the  fourth  month,  the  uterus,  no  longer 
findino'  suflicient  room  in  the  excavation  for  its  continued  development,  rises 
above  the  superior  strait,  then  to  the  level  of  the  umbilicus,  and  reaches  the 
epigastric  region  towards  the  end  of  pregnancy. 

In  tracing  out  the  gradual  elevation  of  the  fundus  uteri,  it  will  be  found,  at 
the  fourth  month,  to  rise  two  or  three  fingers'  breadth  above  the  pubis ;  at  five 
months,  it  is  within  one  finger's  breadth  of  the  umbilicus ;  and  from  the  fifth  to 
the  sixth  month,  it  approaches  and  passes  the  umbilical  depression,  so  that  at 
six  months  it  is  half  an  inch  above  this  ring ;  three  fingers'  breadth  at  seven 
months;  and  four  to  five  at  eight  months;  it  still  continues  ascending  in  the 
commencement  of  the  ninth,  but  in  the  last  fortnight  of  gestation,  the  womb 
seems  to  sink  down,  being,  in  fact,  on  a  lower  level  than  before.  This  last  is  a 
remarkable  occurrence,  though  it  has  been  said  in  explanation  that  the  uterus, 
as  if  overburdened  with  the  weight  of  the  foetus  during  the  latter  period,  col- 
lapses to  some  extent,  and  enlarges  in  the  transverse  and  the  antero-posterior 
diameters.  This  may  be  true  as  regards  some  females  who  have  previously  had 
children,  for  not  unfrcrjuently  they  say  to  us  at  this  time,  "  It  has  all  gone  to  the 
sides;"  but  I  believe  a  more  general  explanation  of  the  fiict  may  be  given;  for, 
in  the  great  majority  of  cases,  if  females  be  "  touched"  near  the  end  of  preg- 


OF     SIMPLE     UTERINE     PREGNANCY.  105 

nancy,  a  voluminous  tumor,  covered  by  the  inferior  and  more  especially  by  the 
anterior  part  of  the  uterine  body,  will  be  readily  felt  occupying  the  excavation. 
This  is  the  head  of  the  foetus,  which  has  descended  in  consequence  of  its  own 
weight,  carrying  the  wall  of  the  uterus  before  it,  and  become  engaged  in  the 
excavation,  sometimes  even  as  low  down  as  the  floor  of  the  pelvis. 

Now,  does  not  this  circumstance,  which  may  be  remarked  whenever  the  head 
presents  regularly,  and  when  there  is  no  malformation  of  the  pelvis,  furnish  us 
a  sufficient  reason  for  the  depression  of  the  entire  uterus  ?  How,  in  fact,  could 
the  superior  do  other  than  follow  the  inferior  part  of  the  organ  ? 

T>.  Direction. — In  passing  up  into  the  abdominal  cavity,  the  uterus  is  obliged 
to  follow  the  direction  of  the  axis  of  the  superior  strait,  and  being  thrown  off  by 
the  lumbar  column,  and  finding  much  less  resistance  from  the  anterior  abdominal 
wall,  it  necessarily  inclines  forward;  but,  owing  to  the  lumbar  projection,  it 
cannot  possibly  remain  on  the  median  line,  and  hence  it  leans  towards  one  side 
of  the  abdomen,  the  right  one,  remarkable  as  it  may  seem,  at  least  eight  times 
in  ten. 

Most  authors,  since  the  days  of  Levret,  have  endeavored  to  explain  this  great 
frequency  of  the  right  lateral  obliquity.  Levret  himself  taught,  that  the  uterus 
always  inclines  towards  the  side  where  the  placenta  is  inserted ;  for  this  point, 
he  said,  being  the  thickest  and  most  vascular  part  of  the  whole  organ,  is  also  the 
heaviest,  and  this  increased  weight,  augmented  by  that  of  the  placenta,  must 
necessarily  draw  the  organ  to  that  side ;  but  experience  has  shown  that  the 
placenta  is  for  from  being  always  inserted  on  the  side  towards  which  the  uterus 
is  inclined.  Again,  according  to  Desormeaux,  the  presence  of  the  iliac  portion 
of  the  colon,  which  is  usually  filled  with  fecal  matters,  prevents  the  womb  from 
leaning  to  the  left,  when  it  commences  ascending  out  of  the  excavation,  and 
thrusts  it  into  the  right  iliac  fossa,  whilst  the  mass  of  the  small  intestines  is 
pushed  to  the  left  side  by  the  ascent  of  the  womb  (where  the  direction  of  the 
mesentery  would  natural/^/  draw  them),  and  this  assists  both  to  maintain  and  to 
increase  the  inclination  of  the  uterus  to  the  right.  But,  as  M.  Paul  Dubois  has 
justly  remarked,  any  influence  which  the  colon,  placed  on  the  left,  may  have,  is 
fully  compensated  by  the  presence  of  the  coecum  on  the  right;  and,  from  the 
observation  of  M.  Velpeau,  the  mesentery  is  directed  from  left  to  right,  and  not 
from  right  to  left,  as  Desormeaux  has  it,  doubtless  by  mistake. 

The  habit  of  using  the  right  arm,  and  of  lying  upon  the  right  side,  has  also 
been  brought  forward  in  explanation  of  this  right  lateral  obliquity,  but  subse- 
quent observation  has  not  sustained  the  assertion ;  thus,  for  instance,  in  seventy- 
six  females,  all  of  whom  had  the  uterus  inclined  to  the  right,  thirty-eight  rested 
on  the  right  side,  twenty  on  the  left,  fourteen  alternately  on  both  sides,  and  four 
on  the  back.  And  we  may  further  remark  that,  down  to  the  present  time,  it  has 
not  been  observed  that  the  uterus  is  placed  upon  the  left  side  of  the  abdomen 
more  frequently  in  those  women  who  habitually  use  the  left  arm  than  in  others. 

Madame  Boivin,  in  my  estimation,  has  given  the  best  explanation  of  this  fact; 
she  asserts  that  the  round  ligament  of  the  right  side  is  shorter,  stronger,  and  cou- 


106  GENERATION. 

tains  more  muscular  fibres  than  that  of  the  left,  and  she  attributes  the  richt  in- 
clination  of  the  organ  to  the  more  powerful  action  of  this  ligament. 

Professor  Cruveilhier  thinks  that  the  shortness  of  the  round  ligament  on  the 
right,  is  the  effect  and  not  the  cause  of  the  uterine  obliquity;  "for  I  have  fre- 
quently had  occasion,"  he  remarks,  "to  observe  that  the  shortening  which  occur- 
red on  the  left,  in  left  lateral  obliquity,  was  constantly  accompanied  by  a  remark- 
able increase  of  volume."  I  must  confess  that  I  do  not  comprehend  upon  what 
M.  Cruveilhier  founds  this  opinion. 

M.  Velpeau  endeavors  to  refute  this  assertion,  by  saying  that  then  the  right 
angle  of  the  womb  should  not  be  as  much  removed  from  the  inguinal  canal  as 
the  left,  but  the  contrary  is  observed;  but  he  commits  a  slight  error  here,  for  the 
ligaments  in  question  do  not  terminate  in  consequence  of  the  development  of  the 
uteiTis  at  a  point  corresponding  to  the  lateral  borders  of  the  empty  organ,  but 
much  more  in  advance,^  so  that  they  are  inseried  on  the  anterior  lateral  region 
of  the  womb ;  and  further,  if  the  right  inclination  is  due  to  the  traction  of  the 
right  round  ligament,  as  Madame  Boivin  teaches,  the  uterus,  in  inclining  to  this 
side,  will  naturally  make  a  movement  of  rotation  on  its  own  axis,  which  carries 
its  anterior  plane  a  little  to  the  right,  and  its  posterior  wall  somewhat  to  the  left. 
Now,  this  is  precisely  what  does  take  place. 

E.  Thickness  of  the  Parietes. — The  earlier  authors  on  this  subject  entertained 
very  different  views  concerning  it :  some,  judging  the  thickness  of  the  body  by 
that  of  the  neck  during  labor,  concluded  that  the  uterus  could  not  be  distended 
without  a  great  diminution  in  the  depth  of  its  walls;  others,  having  had  better 
opportunities  of  examining  the  wombs  of  females  who  died  soon  after  the  ac- 
couchement, observed  the  very  considerable  thickness  exhibited  by  the  uterine 
parietes  at  that  time,  and  therefore  adopted  the  opinion  that  the  latter  become 
much  thicker  during  gestation. 

Both  sides  were  in  error,  for  numerous  autopsies,  made  since  that  period,  of 
women  who  died  during  gestation,  have  established  the  truth  of  the  following 
propositions,  namely : 

1.  In  the  first  three  months,  the  uterine  walls  augment  a  little  in  thickness, 
doubtless  in  consequence  of  the  development  of  their  vascular  and  muscular  ap- 
paratus. 2.  Towards  the  fifth  month,  they  are  about  the  same  as  in  the  normal 
state.     3.  At  term,  the  parietes  are  thicker  than  in  the  natural  condition,  at  the 

'  The  uterus  is  developed  during  pregnancy,  at  the  expenfa  of  the  posterior  wall  particu- 
larly. The  truth  of  this  becomes  clearly  evident  by  marking  the  point  at  which  the  tubes 
are  inserted  at  the  end  of  gestation,  when  two-fifths  of  the  antero-posterior  diameter  of  the 
organ  will  be  found  in  front  of,  and  three-lift!. s  behind  this  mark. 

I  examined,  with  Messrs.  Bonami  and  Helot,  the  womb  of  a  female  who  died  in  the 
seventh  month  of  pregnancy,  under  the  care  of  M.  Recamier,  in  whom  the  round  ligaments 
were  inserted  so  far  forward,  that  four-fifths,  at  least,  of  the  antero-posterior  diameter  were 
behind  a  transverse  line  drawn  between  their  points  of  insertion  (April,  1S43).  In  this 
woman,  no  obliquity  of  the  uterus  existed,  and  the  organ  appeared  to  be  near  the  median 
line,  at  least  in  the  dead  body.  I  carefully  measured  the  comparative  length  of  the  two 
round  ligaments,  and  rnust  acknowledge  I  did  not  find  any  difference  between  them. 
Should  the  absence  of  obliquity,  in  this  case,  be  attributed  to  this  fact? 


OF  SIMPLE  UTERINE  PREGNANCY.  107 

point  corresponding  to  the  insertion  of  the  placenta,  thinner  afc  the  neck,  and 
they  present  but  very  little  difference  throughout  the  remainder  of  their  extent. 

AVe  may  here  notice  some  further  exceptions  :  thus,  M.  Moreau,  having  mea- 
sured the  thickness  of  the  walls  in  a  woman  deceased  at  terra,  found  it  one-sixth 
of  an  inch  at  the  fundus,  one-fourth  of  an  inch  at  the  insertion  of  the  placenta, 
and  one-third  of  an  inch  at  the  neck.  This  singular  anomaly  may  be  explained, 
says  M.  Moreau,  1st,  as  regards  the  thinness  of  the  fundus,  by  the  enormous 
distension  the  uterus  had  undergone  (being  a  twin  pregnancy).  And  2d,  the 
greater  thickness  of  the  neck  resulted  from  the  considerable  retraction  this  part 
had  sustained  from  the  escape  of  the  amniotic  liquid  before  death. 

In  one  instance,  Saviard  found  it  one-third  of  an  inch  at  the  placental  attach- 
ment, and  only  a  line  in  other  parts. 

My  friend.  Dr.  Ripault,  in  performing  the  Cajsarean  operation,  found  the 
uterine  wall  only  one  or  two  lines  thick.  I  have  myself  had  occasion  to  examine 
a  pregnant  woman,  in  whom  the  parts  of  the  infant  were  so  easily  distinguished 
through  the  abdominal  parietes,  that  the  hand  seemed  to  be  only  separated  from 
them  by  a  layer  of  a  few  lines  in  thickness.  Again,  the  thinness  may  be  par- 
tial ;  thus  Hunter  describes  a  uterus,  the  posterior  walls  of  which  exhibited  this 
phenomenon  in  a  remarkable  degree. 

Since  the  thickness  is  not  sensibly  diminished,  it  is  evident  the  whole  mass  of 
the  uterine  walls  must  greatly  increase,  so  much  so,  indeed,  that  towards  the  end 
of  gestation,  the  total  weight  of  the  organ  reaches  two  and  a  half  pounds,  or  even 
more.  The  empty  uterus,  in  the  ca.se  of  M.  Moreau,  just  cited,  weighed  (1750 
grammes)  nearly  four  pounds. 

r.  Density  of  the  Walls. — The  uterine  parietes,  in  the  non-gravid  state,  are 
very  hard  and  resisting,  and  have  nearly  the  consistence  of  fibrous  tissue,  but 
during  pregnancy  this  density  diminishes  and  the  walls  become  soft  and  flabby. 
The  ramollissement  begins  to  show  itself  as  early  as  the  first  mouth,  and  consti- 
tutes at  that  period  one  of  the  best  signs  for  proving  a  commencing  pregnancy 
(see  article  on  Diagnosis'),  because,  instead  of  presenting  the  fibrous  density 
of  the  ordinary  state,  the  walls  have  a  clammy  softness  closely  resembling 
that  of  caoutchouc  softened  by  ebullition,  or  that  of  an  oedematous  limb.  This 
decrease  in  the  consistence  of  the  uterine  walls  constantly  advances,  so  that,  at  a 
later  period,  a  light  pressure  made  on  the  anterior  abdominal  parietes  will  easily 
depress  or  deform  them ;  consequently,  the  extremities  and  other  inequalities  of 
the  foetus  may  be  detected,  and  its  movements  may  even  cause  an  elevation  of 
some  part  or  other ;  the  child,  therefore,  is  not  placed  in  a  cavity  having  immov- 
able walls. 

The  diameters  of  this  cavity  will  vary  with  the  position  taken  by  the  foetus, 
which  can,  in  some  cases,  continue  to  change  them  until  the  end  of  gestation, 
the  flexibility  of  the  walls  permitting  its  long  diameter  to  pass  through  the  small 
ones  of  the  organ ;  and  we  can  readily  comprehend  how  this  flexibility,  this  sup- 
pleness of  the  fibres  of  the  womb,  will  aid  in  preventing  the  disastrous  conse- 
quences which  otherwise  might  result  to  the  child  from  any  violent  blows  on  the 
abdomen,  or  from  the  shocks  experienced  by  the  mother. 


108  generation. 

§  2.   Modifications  in  the  Xeck  of  the  Uterus. 

The  modifications  which  the  neck  undergoes  during  pregnancy,  are  referable  : 
1,  to  the  consistence  of  its  tissue ;  2,  its  volume ;  3,  its  form ;  4,  its  situation 
and  direction. 

1.  As  the  softening  of  the  tissue  of  the  neck  of  the  uterus  seems  to  be  an  all- 
important  fact,  we  therefore  give  it  the  first  place. 

Now,  everybody  knows  that,  in  the  non-gravid  state,  the  uterine  tissue  re- 
sembles the  fibrous  in  its  consistence ;  but  immediately  after  conception,  and 
from  the  sole  fact  of  the  active  congestion  which  the  genital  organs  then  expe- 
rience, this  consistence  begins  to  diminish,  although,  from  being  coincident  with 
the  hypertrophy  of  the  uterine  walls,  it  is  scarcely  sensible  during  the  first  few 
days,  whatever  may  be  the  extent  of  the  neck  examined.  But  towards  the  end 
of  the  first  month  we  may  ascertain  that,  independently  of  this  original  general 
modification,  the  most  inferior,  or  rather,  the  most  superficial  part  of  the  lips  of 
the  OS  tinea?,  begins  to  soften.  It  resembles  more  a  swelling  of  the  mucous 
membrane  than  a  true  "  ramollissement"  of  the  proper  tissue  of  the  lips;  so  that 
by  pressing  slightly  on  this  thickened  membrane  the  finger  first  detects  a  fungous 
softness,  but  soon  reaches  the  proper  tissue  of  the  neck,  which  still  maintains  its 
normal  consistence.  The  sensation  then  experienced  by  the  finger  greatly  re- 
sembles that  communicated  when  it  is  pressed  on  a  table  covered  by  a  soft  and 
thick  cloth ;  and  it  is  only  towards  the  end  of  the  third,  or  beginning  of  the 
fourth  month,  that  the  lips  of  the  os  tincre  are  softened  throughout  their  whole 
thickness  to  the  extent  of  a  line  or  a  line  and  a  half. 

At  the  commencement  of  the  fifth,  the  softening  increases  from  below  up- 
wards, and  at  the  sixth  embraces  the  moiety  of  the  sub-vaginal  portion.  During 
the  last  three  months  it  invades  the  superior  part  by  degrees,  and  last  of  all  the 
ring  of  the  internal  orifice,  so  that,  at  the  end  of  gestation,  the  neck  is  so  soft 
in  certain  females,  that  I  have  frequently  seen  students  have  great  difiiculty  in 
distinguishing  it  from  the  walls  of  the  vagina. 

This  modification  of  the  neck,  which  authors  have  scarcely  spoken  of,  is  one 
of  the  most  important  signs ;  because,  after  a  little  experience,  it  affords  us  one 
of  the  best  means  for  ascertaining  the  different  stages  of  pregnancy;  being  con- 
stant, and  found  in  all  females,  unless  the  neck  should  be  the  seat  of  some  patho- 
logical alteration.  It  is  worthy  of  notice,  however,  that  the  softening  is  not  so 
well-marked,  and  is  much  slower  in  its  progress  in  primipara^,  than  in  women 
who  have  previously  had  children ;  but  in  all,  it  steadily  proceeds  from  below 
upwards. 

As  before  remarked,  we  may  judge  very  nearly  of  the  probable  period  of  preg- 
nancy by  the  extent  of  softening,  as  it  progresses  from  the  inferior  to  the 
superior  part  of  the  neck;  though  there  is  one  important  remark  to  be  made  on 
this  subject,  namely,  that  whenever  females  have  had  a  great  number  of  chil- 
dren, the  sub-vaginal  portion  of  the  neck  loses  the  greater  part  of  its  length;  the 
extremity  then  projecting  into  the  vagina,  and  capable  of  exploration  by  the 
finger,  being  much  shorter.  Now,  as  the  softening  of  the  supra-vaginal  portion 
of  the  neck  is  of  much  more  difficult  detection,  it  may  be  thought  to  be  much 


OF     SIMPLE     UTERINE     PREGNANCY,  109 

less  extensive  than  it  is  in  reality,  whence  wc  may  expect  to  find  a  great  differ- 
ence in  the  extent  of  the  softened  part,  if  a  comparison  be  made  between  the 
necks  in  two  females,  both  advanced  to  the  sixth  month,  one  of  whom  is  pregnant 
for  the  second  time,  and  the  other  had  previously  borne  ten  children.  Where- 
fore it  is  necessary,  in  making  this  appreciation,  to  bear  in  mind  the  number  of 
former  pregnancies,  as  also  the  real  length  of  the  subvaginal  portion  of  the  cervix. 

2.  Volume. — Some  singular  ideas  on  this  subject,  have  been  promulgated  by 
many  authors,  but  the  following  appears  to  be -the  most  constant  rule  :  the  neck 
doubtless  participates  in  the  hypertrophy  of  the  uterine  walls  during  the  earlier 
months,  though  its  development  is  far  less  considerable.  The  neck  becomes 
thicker  and.  grows  more  voluminous,  especially  at  the  superior  part,  but  I  have 
never  observed  its  elongation  to  the  extent  of  two  inches,  as  Madame  Boivin 
apparently  believes,  or  to  two  and  three-quarters  and  three  inches,  as  M.  Filugelli 
has  more  recently  advanced;  for,  as  elsewhere  observed,  these  opinions  result,  in 
my  estimation,  from  an  error.  The  neck,  in  the  commencement,  being  much 
lower,  and  directed  more  in  front  than  in  the  ordinary  condition,  the  finger  can 
easily  explore  a  larger  extent  of  it,  and  thus  an  impression  is  created  of  an  in- 
crease in  its  length  which  really  does  not  exist;  for  frequent  post-mortem  exami- 
nations of  females  who  died  in  the  early  months  of  pregnancy,  have  convinced 
me  that,  even  if  the  neck  is  increased  in  thickness,  its  length  does  not  undergo 
an  appreciable  augmentation  up  to  the  fifth  month. 

But  at  the  commencement  of  this  latter  period,  according  to  most  writers,  the 
cervix  begins  to  diminish.  In  the  sixth  month  (they  say)  it  begins  to  spread 
out  at  the  superior  part,  so  as  to  aid  in  the  enlargement  of  the  body  of  the  womb, 
and  this  spreading  at  the  upper  part  continues  to  advance  in  proportion  as  the 
term  of  gestation  approaches,  and  consequently  the  length  of  the  neck  decreases 
from  above  downwards,  so  as  merely  to  present  at  last,  at  the  close  of  the  ninth 
month,  a  ring  of  variable  thickness.  In  fact,  the  diagnosis  of  the  diflferent 
periods  was  based  on  this  gradual  shortening,  and,  agreeably  to  the  majority  of 
the  French  accoucheurs,  who  have  adopted  the  opinions  of  Desormeaux,  the  neck 
has  lost  at  the  fifth  month  about  one-third  of  its  length,  one-half  at  the  sixth, 
two-thirds  or  three-quarters  in  the  seventh,  three-fourths  or  four-fifths  in  the 
eighth,  and  the  remainder  is  effaced  during  the  course  of  the  ninth  month ;  and 
yet,  I  do  not  hesitate  to  pronounce  all  this  an  entire  error,  which  was  first  pointed 
out  by  M.  Stoltz,  in  1820,- and  to  which  I  also  have  constantly  asked  attention 
since  the  year  1839.  No;  the  neck  does  not  shorten  in  the  way  which  has  so 
long  been  described ;  it  preserves  its  whole  length  until  the  last  fortnight  of 
pregnancy ;  and  it  is  an  easy  matffer,  especially  in  women  who  have  previously 
borne  children,  to  verify  this  remark,  as  we  shall  presently  demonstrate.  But 
during  the  last  few  weeks,  its  length,  which  until  that  time  was  intact,  dimi- 
nishes very  rapidly,  and  even  disappears  by  a  total  efflicement,  and  we  shall  in 
due  season  explain  the  simple  mechanism  of  this  phenomenon. 

But  to  return ;  I  have  frequently  been  enabled  to  prove,  in  pi-imipara),  the 
truth  of  M.  Stoltz's  assertions ;  for  in  these  women  the  neck  does  diminish  a 
little  in  length,  during  the  last  three  months,  although  by  a  process  entirely  dif- 


110  GENERATION. 

ferent  from  that  described  by  Desormeaux.      Thus,  towards  the  seventh  month, 
the  ramollissement  has  invaded  the  whole  intra-vaginal  portion;  the  parietes  of 
the  neck,  havinj^  lost  their  consistence,  are  easily  separated 
by  the  liquids  secreted  upon  their  internal  face,  and  the 
upper  part  of  this  portion  being  turned  outwards,  enlarges 
in  such  a  manner  as  to  cause  the  whole  neck  to  resemble  a 
spindle  in  its  shape ;  the  superior  extremity  of  which  is 
formed  by  the  internal  orifice  (still  closed),  and  the  infe- 
rior is  constituted  by  the  external  one,  which  is  scarcely 
opened  in  primiparae,  even  at  the  end  of  gestation,  as  we 
A  section,  showing  the    shall  hereafter  show, 
neck  oftiie  uterus;  the  an-        Now,  it  is  easily  understood  how  this  bulging  of  the 

terior  and  posterior  lips  are  .  t  ■,-,  ^    ■,  ,  ."".^ 

seen  in  situ,  being  sepa-    middle  part  of  the  neck  can  only  take  place  just  m  propor- 
rated  from  each  other  by    tion  as  the  two  extremities  of  the  latter  approach  each 

the  fusitbrm  cavity  of  the        ,i  .,  r,  i    x        x-  ^     j?  -x      x   x   i 

jjg^j^  other;  thus,  or  course,  detracting  so  much  Irom  its  total 

length.  I  do  not  believe,  however,  with  M.  Stoltz,  that 
the  approximation  of  the  two  orifices  can  be  so  great  as  to  cause  a  material 
shortening  of  the  neck,  though  this  certainly  does  exist  to  some  extent.  The 
shortening  of  the  neck  is  therefore  real,  though  slight,  in  primipara3 ;  being  ac- 
complished, however,  by  a  different  mechanism  from  that  taught  by  most  authors. 
Its  upper  jwrt  does  not  spread  out  so  as  to  contribute  to  the  enlargement  of  the 
cavity  of  the  body,  but  suffers  a  sort  of  collapse,  which  brings  the  two  orifices 
nearer  together,  at  the  same  time  increasing  its  central  cavity,  and  extending  its 
transverse  diameters  at  the  expense  of  the  vertical.  What  has  been  said  con- 
cerning the  rapid  effacement  of  the  neck  during  the  last  few  days  in  multipara;, 
equally  applies  to  primiparae ;  the  process  taking  place  by  the  same  mechanism. 

3.  Form. — The  principal  modifications  in  the  shape  of  the  neck  have  already 
been  presented,  but  they  ought  to  be  studied  in  a  more  special  manner,  according 
to  whether  they  are  found  in  primiparas,  or  in  women  who  have  previously  been 
mothers. 

A.  At  the  commencement,  in  primiparae,  the  cervix  appears  more  contracted 
and  more  pointed,  resulting,  perhaps,  from  the  augmentation  of  its  superior  part 
in  volume;  the  orifice  of  the  os  tineas,  which,  before  conception,  presented  a 
simple  linear  and  transverse  fissure,  now  assumes  a  circular  form,  constituting, 
as  it  were,  a  small  lenticular  fossa.  A  little  later,  as  mentioned  above,  the  middle 
part  of  the  cavity  of  the  neck  enlarges,  so  as  to  give  to  the  whole  cervix  the  form 
of  a  somewhat  elongated  spindle,  rather  than  that  of  a  cone,  which  it  previously 
had.  It  continues  smooth  and  polished  on  the  exterior  surface,  and  the  peri- 
phery of  its  orifice  is  rounded,  without  any  irregularities  or  fissures ;  sometimes 
presenting  a  soft  circumference,  at  others  a  thin  and  sharp  border :  the  latter 
rarely  happens,  however,  before  a  very  advanced  stage.  At  this  time,  it  is  very 
easy  to  ascertain  what  changes  the  neck  has  undergone,  for  although  the  external 
orifice  is  constricted,  it  is  very  much  softened,  and  sometimes  allows  the  finger 
to  pass  with  a  very  slight  effort  and  enter  the  cavity  of  the  neck.  The  base  of 
the  last  phalanx  is  then  felt  to  be  grasped  quite  tightly  by  the  external  orifice, 


OF     SIMPLE     UTERINE     PREGNANCY. 


Ill 


wliil.-it  the  extremity  of  the  finger  is  at  full  liberty  in  the  fusiform  cavity  of  the 
neck.  It  may  also  be  readily  observed  that  the  two  orifices  are  still  widely  sepa- 
rated, for  the  entire  length  of  the  first  phalanx  and  sometimes  more,  are  capable 
of  being  contained  in  the  cavity. 


Fig.  27. 


Fiji.  29. 


These  three  figures  ^ive  an  idea  of  the  gradual  dihitation  wliich  the  cavity  of  tlie  neck  undergoes  at 
various  periods  of  pregjiancy. 

B.  The  form  of  the  neck  is  altogether  diiferent  in  women  who  have  had  chil- 
dren; thus  the  inequalities  and  protuberances  exhibited  by  the  inferior  part  will 
scarcely  permit  us  to  ascertain  whether  it  becomes  more  pointed  or  not,  and  it  is 
equally  difficult  to  determine  whether  the  external  orifice  has  become  more 
rounded ;  because,  having  been  somewhat  patulous  before  pregnancy,  this  orifice, 
in  consequence  of  the  numerous  cicatrices  found  on  it,  presents  a  very  irregular 
opening.  The  only  point  capable  of  demonstration  in  the  early  periods  is,  that 
the  partially  opened  orifice  will  dilate  still  further,  so  as  to  admit  readily  the  ex- 
tremity of  the  fore-finger. 

This  spreading  out  of  the  os  tincre,  and  the  inferior  part  of  the  neck,  con- 
stantly increases  from  below  upwards,  as  the  gestation  progresses;  it  reaches  the 
middle  part  of  the  cervix  about  the  seventh  month,  and  nearly  gains  the  internal 
orifice  by  the  ninth. 

The  enlargement  of  the  cavity  of  the  neck  advances  simultaneously  with  the 
softening  of  its  walls;  and  we  can  easily  prove  by  experiment  that  the  finger  will 
each  month  penetrate  deeper  into  it.  The  shape  of  this  cavity  resembles  in  some 
women  that  of  a  thimble,  in  others,  of  a  funnel,  with  the  base  below  and  the 
apex  above,  the  difference  being  due  simply  to  the  depth  and  number  of  the  rup- 
tures which  had  existed  on  the  external  orifice  before  pregnancy. 

The  part  of  the  neck  not  yet  softened  and  dilated  constitutes  the  summit  of 
the  cone ;  that  is,  every  portion  of  its  length  contributes  in  succession ;  so  that 
the  first,  and  often  even  the  half  of  the  second  phalanx  of  the  finger  can  pene- 
trate into  its  cavity  towards  the  ninth  month,  the  extremity  of  the  finger  being 
only  arrested  by  the  internal  orifice,  which  is  still  closed  and  puckered  like  the 
knot  of  a  purse.  The  ring  at  this  orifice  finally  softens,  becomes  dilated,  and 
permits  the  finger,  which  has  passed  through  a  canal  an  inch  to  an  inch  and  a 
half  in  length,  formed  by  the  cervix,  to  come  into  direct  contact  with  the  naked 
membranes.  If  the  length  of  the  external  surface  of  the  neck  be  compared  at 
this  period  with  the  canal  in  which  the  finger  is  introduced,  the  neck  will  be 
found  much  longer  internally  than  exteriorly,  for  it  is  self-evident  that  the  fin^'cr 


112  GENERATION. 

is  arrested  on  the  outside  by  the  vaginal  insertion,  -whilst  within  it  traverses  the 
whole  space  between  the  two  orifices. 

The  internal  orifice  sometimes  opens  too  soon ;  thus  Desormeaux  declares  that 
he  touched  the  membranes  at  the  end  of  seven  months,  over  a  space  of  an  inch 
and  one-third  in  extent.  I  also  have  verified  the  same  fact,  but  only  in  women 
who  were  subject  to  floodings,  or  in  those  who  submit  to  "the  touch,"  in  our 
public  lessons,  foi",  in  these  latter,  the  frequently  repeated  and  careless  introduc- 
tion of  a  gi'eat  number  of  fingers,  has  appeared  to  me  to  greatly  accelerate  the 
softening  and  dilatation  of  the  neck. 

On  the  whole,  therefore,  the  neck  is  fusiform  in  primiparce,  the  external  orifice 
is  rounded,  and  so  little  dilated  as  to  prevent  the  introduction  of  the  finger  with- 
out some  considerable  effort.  In  females  who  have  had  children,  the  external 
orifice  is  widely  open,  and  the  cavity  in  the  neck  is  funnel-shaped,  the  base  being 
below,  and  continues  to  increase  until  its  apex  reaches  the  internal  orifice.  This 
latter  remains  closed  in  both,  in  a  vast  majority  of  cases,  until  the  beginning  of 
at  least  the  last  month  of  pregnancy. 

These  differences  in  the  form  of  the  neck  in  primiparos  and  of  multipara,  are 
readily  accounted  for  when  we  take  into  consideration  the  condition  of  the  ex- 
ternal orifice  before  pregnancy  in  both  cases.  The  os  tincae  of  women  who  have 
already  had  children,  has  the  continuity  of  its  circumference  interrupted  by  a 
greater  or  less  number  of  ruptures,  so  that  as  soon  as  a  small  part  of  the  neck 
has  become  softened,  each  of  the  divisions  of  the  circumference  being  fixed  only 
by  its  upper  part,  is  turned  outward,  so  as  to  give  to  the  orifice  the  form  of  the 
large  extremity  of  a  trumpet.  In  the  primiparous  woman,  on  the  contrary,  the 
integrity  of  the  ring  is  complete,  and  the  os  tinct^  may  become  softened  wathout 
its  orifice  being  much  enlarged  in  consequence. 

We  have  stated  that  the  whole  length  of  the  neck  disappears  at  the  last,  by 
being  confounded  with  the  cavity  of  the  body.  The  mechanism  of  this  fusion 
is  very  simple;  the  ring  at  the  internal  orifice  having  at  length  lost  all  power  of 
resistance  from  its  ramollissement,  opens  so  as  easily  to  admit  the  extremity. of 
the  finger  (vide  Fig.  29),  and  this  dilatation  gradually  augments  under  the  in- 
fluence of  those  feeble  contractions  by  which  the  uterus,  in  the  last  fortnight  of 
gestation,  seems  to  prelude  the  labor  of  childbirth,  and  as  soon  as  this  is  sufii- 
ciently  advanced  to  permit  the  inferior  part  of  the  ovum  to  engage  in  the  cavity 
of  the  neck,  we  can  understand  that  the  latter  is  promptly  trespassed  upon. 
Again,  there  is  no  projection  found  at  the  upper  part  of  the  vagina,  unless,  per- 
haps, in  those  who  have  had  children,  a  collar  of  variable  thickness  and  softness, 
circumscribing  an  opening  large  enough  to  permit  the  finger  to  reach  the  mem- 
branes, whilst  in  primiparas,  a  sharp,  thin  ring,  in  the  centre  of  which  is  a  much 
more  contracted  orifice,  will  be  encountered. 

4.  We  have  but  little  to  remark  concerning  the  situation  and  direction  of  the 
uterine  neck  during  pregnancy,  and  our  opinions  do  not  difler  from  those  held 
by  the  majority  of  writers  on  this  subject;  hence  we  shall  merely  state,  in  a  few 
words,  that  during  the  first  three  months  the  neck  is  lower,  is  directed  more  in 
front,  and  a  little  to  the  left ;  and  that  this  position  is  the  necessary  consequence 


OF    SIMPLE    UTERINE    PREGNANCY.  113 

! 

of  the  inverse  movement  of  the  body  of  tlie  organ,  by  which  its  fundus  is  carried 

backwards  into  the  sacral  cavity,  and  pushed  to  the  right  by  the  tumor,  which 
the  rectum,  habitually  distended  with  fecal  matters,  forms  behind  and  at  the  left 
part  of  the  excavation. 

In  the  last  six  months,  the  cervix  necessarily  following  the  ascent  of  the  body, 
mounts  upward,  and,  at  the  same  time,  most  generally  looks  backward  and  to 
the  left,  whilst  the  fundus  is  nearly  always  carried  forwards  and  to  the  right. 

I  cannot  pass  over,  however,  a  disposition  of  the  neck  occasionally  met  with  at 
the  end  of  gestation,  that  sometimes  embarrasses  persons  not  familiar  with  this 
kind  of  exploration ;  namely,  in  the  last  month,  the  head  (if  that  is  the  present- 
ing part)  frequently  presses  before  it,  in  engaging  in  the  excavation,  the  anterior 
inferior  portion  of  the  uterus,  and  in  case  the  female  has  a  large  pelvis,  this 
descends  even  perhaps  down  to  the  inferior  floor.  The  neck  will  therefore  neces- 
sarily be  carried  behind  the  tumor  which  then  fills  the  pelvis,  and  the  plane  of 
its  orifice  will  look  towards  the  anterior  face  of  the  sacrum,  and,  of  course,  in 
order  to  penetrate  its  cavity,  the  finger  must  be  bent  like  a  hook  and  be  intro- 
duced from  behind  directly  forwards.  This  posterior  obliquity  of  the  cervix, 
which  differs  essentially  from  that  produced  by  an  anteversion  of  the  womb, 
sometimes  renders  it  very  difficult  of  access,  even  when  the  labor  is  somewhat 
advanced.  The  difficulty  is  still  further  increased,  in  some  cases,  by  the  soften- 
ing of  the  neck  throughout,  in  consequence  of  which  it  becomes  flattened  and 
applied  to  this  tumor,  forming  a  kind  of  fold  or  doubling  on  its  posterior  part. 

Summary. — From  what  has  been  stated,  we  may  now  draw  the  following 
conclusions : 

1st.  That  the  tissue  of  the  neck  begins  to  soften  at  the  very  commencement 
of  pregnancy,  and  the  softening,  although  not  very  apparent  in  the  earlier 
months,  and  limited  to  the  most  inferior  part,  gradually  ascends,  so  as  to  invade 
successively  the  whole  neck  from  below  upwards,  though  it  is  much  less  marked 
and  less  rapid  in  its  progress  in  primiparas  than  in  other  females. 

2d.  The  cavity  of  the  neck  dilates  simultaneously  with  the  softening  of  its 
walls  ;  and  further,  this  enlargement  causes  it  to  be  spindle-shaped  in  primiparai ; 
and,  in  females  who  have  already  borne  children,  to  resemble  a  thimble,  the 
finger  of  a  glove,  or  a  funnel  with  its  base  below. 

3d.  The  external  orifice  remains  either  closed,  or  else  very  slightly  open,  in 
primiparas,  up  to  the  very  term  of  pregnancy,  whilst  in  others  it  is  widely  open, 
and  constitutes  the  base  of  the  funnel. 

4th.  The  whole  length  of  the  neck  disappears  in  the  last  fortnight,  being  lost 
in  the  cavity  of  the  body. 

5th.  Contrary  to  the  opinions  generally  adopted  before  the  time  of  M.  Stoltz's 
publication,  the  neck  preserves  its  whole  length  until  the  last  fortnight;  it  does 
not  shorten  from  above  downward  during  the  last  four  months,  but  the  fusion  of 
the  neck  with  the  body  takes  place  only  within  the  last  few  weeks  of  gestation. 

§  3.  Modifications  in  the  Texture  and  Properties  of  the  Uterus. 
A.    Texture. — Among  the  many  changes  which  the  womb  undergoes  during 


114  GENERATION. 

pregnancy,  the  most  curious  of  all  are  those  exhibited  in  its  texture;  and  we 
shall  study  these  by  successively  examining  the  different  parts  of  its  constituent 
elements. 

1.  Serous  Coat. — The  peritoneum,  forming  the  external  membrane  of  the 
uterus,  spreads  out  in  all  directions.  The  various  folds  formed  by  it  in  the 
neighborhood  of  the  womb,  a  species  of  mesentery,  as  M.  Dubois  calls  them, 
such  as  the  broad  ligaments  and  the  anterior  and  posterior  ligaments,  are  double. 
Many  anatomists  believe  this  doubling  is  even  sufficient  to  accommodate  the  en- 
largement of  the  organ.  But,  to  refute  this  opinion,  it  is  only  necessary  to 
examine  that  portion  of  it  comprised  between  the  commencement  of  the  two 
tubes,  which  covers  the  fundus;  for  this  will  afford  a  convincing  proof  that  it 
cannot  be  furnished  by  the  accession  of  neighboring  parts  of  the  peritoneum, 
because,  as  Desormeaux  remarks,  the  insertion  of  the  tube  and  ligament  of  the 
ovary  upon  each  side  presents  an  obstacle  that  will  prevent  the  gliding  of  the 
adjacent  membrane.  The  peritoneal  tissue,  however,  undergoes  a  considerable 
extension,  and  a  more  active  nutrition  must  necessarily  take  place  to  prevent  its 
attenuation,  since  that  which  covers  the  uterus  during  gestation  quite  equals  in 
its  thickness  the  serous  membrane  of  the  unimpregnated  state.  This  extension 
of  the  peritoneum,  without  a  decrease  in  thickness,  is  not  a  new  fact  in  patho- 
logy, and  it  may  be  seen  in  every  hernia  of  considerable  size. 

The  tissue  uniting  this  membrane  to  the  muscular  substance  appeai-s  to  have 
diminished  in  density ;  for  the  peritoneal  coat  is  movable  on  the  muscular  walls, 
according  to  M.  Dubois,  who  has  met  with  difficulty  from  this  cause  every  time 
he  has  performed  the  Cesarean  operation. 

2.  Mucous  Coat. — Although  the  existence  of  this  coat  in  the  non-gravid  state, 
has  been  denied  by  many  anatomists,  it  becomes  very  apparent  during  pregnancy. 
It  then  grows  redder  and  more  vascular,  and  its  folds  disappear;  but  this  un- 
folding will  not  alone  account  for  the  extension  which  it  undergoes,  and  it  must, 
whatever  be  said  to  the  contrary,  receive,  like  the  peritoneum,  a  more  active 
nutrition. 

All  the  elements  which  we  have  mentioned  (page  61)  as  entering  into  its  com- 
position undergo,  in  reality,  a  considerable  development.  The  nature  of  this 
work  does  not  allow  us  to  enter  into  all  the  details  which  the  subject  demands, 
and  we  prefer  referring  the  reader  to  the  excellent  work  published  by  M.  Robin, 
iu  the  Archives,  for  the  year  1848. 

The  glands  of  the  body  of  the  womb  share  in  the  general  hypertrophy,  and  we 
shall  be  obliged  to  recur  to  this  subject  when  we  come  to  treat  of  the  decidua, 
which  is  nothing  else,  as  must  be  finally  acknowledged,  than  the  mucous  mem- 
brane of  the  uterus  modified  by  the  progress  of  gestation.    (See  Decidua.') 

It  is  easy  to  convince  ourselves,  after  the  accouchement,  that  the  glands  of  the 
neck  had  undergone  an  enlargement.  Their  secretion  is  much  increased,  and  to 
it  is  due  the  gelatinous  plug,  that  is  to  say,  the  elastic,  dense,  semi-transparent, 
and  almost  insoluble  mass  of  mucus,  which  closes  and  fills  the  cavity  of  the  neck 
during  pregnancy.  That  such  is  the  case  may  be  demonstrated  by  examination 
of  the  bodies  of  women  who  die  during  pregnancy,  when,  if  the  mass  be  de- 


OF  SIMPLE  UTERINE  PREGNANCY. 


115 


30. 


tached,  prolongations  will  be  found  passing  from  it  and  entering  the  orifices  of 
the  glands.   (Robin.) 

3.  MkhUe  Coat. — The  fle.shy  portion  of  the  organ,  composed,  in  the  unim- 
pregnated  state,  of  fibres  whose  structure  is  so  difiicult  to  unravel,  becomes  much 
easier  of  study  in  pregnancy;  for  although  the  muscular  nature  of  its  constituent 
tissue  is  very  doubtful  during  the  former  condition,  yet  in  the  latter  it  becomes 
quite  evident.  From  the  able  researches  of  Madame  Boivin,  the  following  dis- 
position of  these  muscular  fibres  has  been  determined.  She  describes  two  planes 
of  fibres  as  existing  in  the  body  of  the  uterus — the  one  exterior,  the  other  inte- 
rior :  the  external  plane  is  composed  of  fibres 
which  run  from  the  middle  line  outwards  and 
downwards  to  the  inferior  third  of  the  organ, 
where  they  terminate  upon  and  aid  in  forming 
the  round  ligaments  situated  there,  while  the 
most  superior  ones  are  distributed  to  the  Fallo- 
pian tubes  and  the  ligaments  of  the  ovary.  An 
exact  idea  of  the  radiated  disposition  of  the  ex- 
ternal fibrous  planes,  at  the  superior  and  lateral 
parts  of  this  organ,  may  be  formed  by  imagining 
the  long  hair  of  the  human  head  to  be  parted 
along  the  whole  middle  line  of  the  cranium,  and 
then  combed  smooth  on  each  side  in  front,  and 
tied  very  tight  opposite  each  ear. 

Another  muscular  plane  is  found  internally, 
having  an  entirely  diiferent  arrangement ;  these 
fibres  are  circular  and  situated  at  the  superior 
angles  of  the  womb.     They  surround  the  inter- 
nal orifice  of  the  tubes  (a  a.  Fig.  30),  describing  concentric  circles,  at  first  very 
small  and  close,  but  gradually  separating  as  the  distance  from  the  angles  increases, 
so  that  the  last  and  largest  border  upon  the  median  line,  and  spread  out  in  the 
direction  of  its  length. 

Between  these  two  planes,  the  external  one  composed  of  longitudinal,  and  the 
internal  one  of  horizontal  fibres,  some  other  muscular  fibres  are  found,  the  course 
of  which  it  is  impossible  to  trace. 

Only  a  single  order  of  fibres,  which  are  semicircular,  exists  at  the  inferior 
part.  They  commence  at  the  median  line  of  this  region,  and  reunite  on  the 
sides  near  the  round  ligaments. 

I  will  remark,  in  terminating  this  short  account  of  the  uterine  structure,  its 
great  resemblance  to  that  of  all  the  hollow  organs,  in  having,  for  instance,  its 
longitudinal  fibres  on  the  exterior,  whilst  the  circular  and  horizontal  ones  are 
internal.  The  fundus  uteri  is  the  part  particularly  concerned  in  the  expulsion 
of  the  foetus,  and  it  is  there  also  that  the  muscular  apparatus  is  the  most  deve- 
loped ;  its  disposition  is  such,  that  all  parts  of  the  uterine  surface  tend  towards 
the  centre  during  contraction.  Lastly,  at  the  inferior  part,  where  the  resistance 
should  be  least,  there  are  only  the  horizontal  fibres,  constituting  a  sort  of  sphincter 


Muscular  fibres  of  the  uterus,  a  a. 
The  iiiternal  orifices  of  the  Fallopian 
tubes. 


116  GENERATION. 

muscle,  wliich  may  be  compared,  on  more  than  one  account,  to  the  sphincter  of 
the  rectum  or  of  the  bhickler. 

Quite  recently,  M.  Dcville,  anatomical  assistant  to  the  Faculty  of  Paris,  has 
studied  the  muscular  arrangement  of  the  uteiiis  in  a  great  number  of  cases  of 
females  who  died  a  few  days  after  labor,  and  the  results  at  which  he  has  arrived, 
differ  much  from  those  previously  acknowledged.  He  has  kindly  exhibited  his 
dissections  to  me,  and  I  confess,  after  an  attentive  examination,  that  it  were  im- 
possible fur  me  not  to  be  of  his  opinion.  This  subject,  in  my  estimation,  requires 
further  examination,  but  whilst  awaiting  an  opportunity  of  dissecting  for  myself, 
the  preparations  of  M.  Deville  appear  so  satisfactory,  that  I  have  obtained  a  drawing 
of  them,  and  introduce  here  the  description  furnished  by  that  skilful  anatomist. 

Examined  on  its  external  surface,  after  the  removal  of  the  peritoneum  and  the 
compact  resisting  layer  that  separates  this  serous  coat  from  the  muscular  fibres, 
the  uterus  seems  to  be  composed  of  two  orders  of  fibres,  which  are  essentially 
muscular,  one  being  transverse  and  the  other  longitudinal. 

The  transverse  fibres  arise  (this  word  to  be  received  in  a  purely  descriptive 
sense)  from  three  sources  :  the  round  ligament.  Fallopian  tube,  and  the  ligament 
of  the  ovary  j  also  from  the  wings  of  the  corresponding  broad  ligament.  The 
mere  removal  of  the  delicate  peritoneal  envelope  of  these  organs,  suffices  to  bring 
the  transverse  fibres  into  view,  and  at  the  same  time  to  reveal  their  muscular 
character. 

The  transverse  fibres,  together  with  certain  vessels  and  nerves,  constitute  the 
intimate  structure  of  the  round  and  ovarian  ligaments,  as  also  the  middle  layer 
of  the  Fallopian  tube,  which  is  therefore  essentially  muscular,  like  the  internal 
membrane,  improperly  called  dartoid,  of  all  the  excretory  canals. 

The  presence  of  a  great  number  of  transverse  uterine  fibres  lying  in  the  thick- 
ness of  the  folds  of  the  broad  ligament,  and  extending  to  its  base,  is  an  impor- 
tant fact  to  be  borne  in  mind;  and  the  question  arises,  where  do  they  terminate? 
I  confess  that  I  have  not  been  able  to  determine  this  in  a  satisfactory  manner. 

However  the  truth  may  be,  the  transverse  fibres  coming  from  these  divers 
origins  spread  out  in  a  radiated  manner  over  the  whole  exterior  surface  of  the 
uterus,  the  anterior  and  posterior  ones  transversely,  or  a  little  downwards  in  an 
oblique  direction,  and  the  superior,  obliquely  upwards,  so  as  to  cover  the  organ 
completely.  Near  the  median  line,  these  fibres  are  crossed  perpendicularly  to 
their  course  by  a  longitudinal  fasciculus,  more  or  less. sinuous  in  character,  and 
three-eighths  to  three-fourths  of  an  inch  wide,  which  arises  near  the  point  of 
union  of  the  body  with  the  neck,  ascends  upon  the  fundus  of  the  organ,  and  de- 
scends on  the  posterior  face,  to  be  lost  at  its  inferior  part  opposite  to  or  a  little 
below  the  point  of  beginning,  that  is,  near  the  union  of  the  body  with  the  neck. 
A  positive  continuity  will  be  observed  between  the  transverse  fibres  of  each  side 
and  the  middle  longitudinal  fasciculus,  if  the  line  of  contact  be  carefully  examined. 
As  the  transverse  fibres  arrive  near  the  median  line,  some  curve  downwards, 
others  upwards,  so  as  to  become  longitudinal,  and  thus  constitute  the  median 
layer.  This  is  particularly  evident  at  its  termination,  both  in  front  and  behind, 
for  the  whole  fasciculus  divides  there  into  two  portions,  one  of  which  curves  to 


OF     SIMPLE     UTERINE     PREGNANCY. 


117 


Fig.  31. 


The  disposition   of  the  triLiscular  fibres  on 
tlie  anterior  luce  oftlie  woml). 


the  right,  the  other  to  the  left,  and  becomes  continuous  with  the  most  inferior 
transverse  fibres  of  the  body. 

This  continual  exchange  of  the  two  series  of  uterine  fibres  takes  place  with 
such  great  uniformity,  that  the  longitudinal  fasciculus  has  nearly  the  same  thick- 
ness everywhere  ;  but  if  this  lamina  be  more  patiently  examined,  it  will  be  found 
to  be  composed  of  very  short  longitudinal 
fibres,  forming  the  central  part  of  a  letter  X, 
which  the  uterine  fibres  describe,  as  T  have 
verified  on  many  of  my  preparations,  in  the 
following  manner : 

Let  us  take  a  layer  of  transverse  fibres  on 
the  right  side  of  the  uterus,  at  the  anterior 
inferior  part  (see  Fig.  31) ;  this  fasciculus 
nearly  approaches  the  median  line,  then 
curves  upwards  and  becomes  confounded 
with  the  longitudinal  lamina;  then,  after  a 
vertical  course,  varying  from  one-third  of  an 
inch  to  two  inches,  it  again  curves  to  the 
left,  to  reassume  a  transverse  direction,  thus 
representing  a  Z,  or,  still  more  exactly,  a 
branch  of  the  letter  X. 

Thus,  the   longitudinal   median   layer  is 
produced  by  the  union  of  the  central  and  vertical  branches  of  the  X  described 
by  the  uterine  fibres. 

It  sometimes  happens,  however,  that  the  transverse  fibres  pass  directly  from 
right  to  left,  without  forming  the  vertical 
branch,  which  fact  should  be  borne  in  mind, 
lest  this  arrangement  existing  on  the  surfoce 
might  give  rise  to  a  belief  of  the  absence  of 
a  median  longitudinal  fasciculus,  whereas,  if 
the  latter  is  not  evident,  it  will  only  be  ne- 
cessary to  raise  carefully  this  layer  of  median 
transverse  fibres,  to  bring  it  into  view.  The 
uterus  exhibits  the  same  disposition  of  mus- 
cular fibres  on  the  internal  face,  which  will 
readily  account  for  the  error  of  jMadame 
Boivin,  who  described  them  as  circular. 

Notable  differences,  however,  exist  be- 
tween the  fibres  on  the  two  surfaces  of  the 
organ.  The  most  remarkable  on  the  exte- 
rior is  the  extreme  breadth  of  the  longitu- 
dinal fasciculus,  which  covers  the  whole  fundus,  extending  from  the  orifice  of  the 
Fallopian  tube  on  one  side  to  the  same  point  on  the  other.  When  this  fiisciculus 
reaches  the  anterior  and  posterior  faces,  it  is  intersected  at  right  angles  by  the 
transverse  fibres  occupying  the  lateral  portions  just  below  the  orifice  of  the  tubes, 


The  disposition  of  the  musculnr  fibres  on 
the  posterior  face  of  the  womb. 


118  GENERATION. 

whicli  act  there  as  on  the  exterior  surface ;  that  is,  some  of  the  fihrcs  curve 
upwards,  others  downwards,  becoming  confounded  with  the  lonp;itudinal  hiyer. 
Lower  down,  near  the  junction  of  the  body  with  the  neck,  the  longitudinal  fasci- 
culus is  very  irregular.  Soiuetimes  it  exists;  sometimes,  though  more  rarely,  it 
does  not. 

At  this  point,  in  fact,  the  continuation,  or  inter-crossing  of  the  transverse 

fibres  from  one  side  to  the  other,  occurs  in  an  irregular 

Fig.  33.  manner,  either  forming  the  vertical  branches  of  an  X,  or 

taking   an    oblique    direction,   or   again    going   directly 

across,  the  fibres  preserving  a  transverse  course. 

A  third  layer  exists  between  the  two  just  described, 
but  I  am  not  sufficiently  acquainted  with  the  disposition 
of  its  fibres  to  give  an  exact  account  of  them. 

All  these  particular  details  do  not  interfere  with  the 
general  law  of  inter-cromng,  or  passage  of  uterine  fibres 
from  one  side  to  the  other,  and  in  this  respect,  the  uterus 
may  justly  be  ranged  in  the  same  class  with  all  the  other 
hollow  muscular  organs  whose  structure  is  also  regulated 
b}'  the  fundamental  law  of  muscular  inter-crossing. 
Hence,  it  would  not  be  difficult  to  demonstrate  that  the 

Shows  the  inter-erossing 

of  the  uieriiie  fibres.  human  uterus,  as  just  described,  approaches  in  its  struc- 

ture (juite  a.s  well,  perhaps  better,  to  that  of  the  same 
organ  in  other  mammiferte,  than  the  arrangement  pointed  out  by  Madame  Boivin. 
But  such  a  discussion  would  be  out  of  place  here. 

In  conclusion,  I  will  observe,  that  the  same  dispositions  in  the  muscular  ar- 
rangement are  found  in  the  neck  and  inferior  part  of  the  body.  Inter-crossings 
occur  there  also,  the  fibres  passing  directly  from  one  side  to  the  other,  or  be- 
coming more  or  less  oblique  at  the  moment  of  crossing,  and  still  oftener  forming 
the  branches  of  an  x  with  the  median  vertical  parts.  This  last  disposition  gives 
rise  to  the  peculiar  formation,  which  has  improperly  been  called  the  arhor  vitce. 

4.  Vascular  Apparatus. — Towards  the  end  of  pregnancy,  the  utcras  exhibits 
an  astonishing  development  of  its  vascular  system.  My  friend.  Dr.  Jacquemier, 
has  for  fifteen  years  paid  much  attention  to  this  subject,  and  I  submit  the  result 
of  his  labor.  "  In  studying  the  development  of  the  vascular  system  in  its  whole 
extent,  we  shall  find,  he  says,  that  the  augmentation  in  the  size  of  the  arteries 
only  becomes  considerable  as  they  approach  the  uterus.  Whilst  advancing  be- 
tween the  peritoneum  and  the  external  face  of  the  organ,  and  before  giving  off 
their  first  divisions,  they  dilate  and  swell  up,  and  then  they  furnish  branches  to 
the  anterior  and  lateral  parts,  which  ramify  ad  infinitum  ;  they  are  not  situated 
immediately  below  the  peritoneum,  but  are  separated  from  it  by  a  delicate  layer 
of  muscular  tissue.  All  these  ramifications  anastomose  freely  and  penetrate 
through  to  the  internal  surface,  where  they  generally  terminate,  but  a  large 
number  of  those,  corresponding  to  the  placental  insertion,  traverse  the  mucous 
membrane,  and,  according  to  M.  Jacquemier,  enter  the  inter-utero  placental 
deciduous  membrane. 


OF     SIMPLE     UTERINE     PREGNANCY.  119 

The  beautiful  injections,  which  M.  Bonaiui  has  kindly  shown  me,  evidently 
prove  that  these  ramifications  even  penetrate  the  structure  of  the  cotyledons  as 
far  as  the  foetal  face  of  the  placenta.    (See  Placenta.^ 

If  the  venous  trunks  be  examined,  from  the  point  of  quitting  the  uterus  to 
their  terminations  in  the  hypogastric  vein  and  in  the  vena  cava  inferior,  a  great 
increase  in  capacity  will  be  noticed,  for  the  ovarian  veins  are  almost  as  large  as 
the  external  iliacs,  and  the  uterine  are  but  little  less.  In  the  substance  of  the 
womb,  the  venous  system  presents  itself  as  a  series  of  canals,  situated  in  the 
centre  of  the  muscular  tissue,  at  nearly  an  equal  distance  from  the  internal  and 
the  external  faces :  at  this  point,  the  uterus  is  traversed  by  a  great  number  of 
canals  coming  from  all  directions,  which  anastomose,  and  form  large  sinuses  at 
their  junction;  the  whole  constituting  a  grand  plexus,  several  divisions  of  which 
are  large  enough  to  receive  the  extremity  of  the  little  finger. 

These  canals  are  much  larger  opposite  the  insertion  of  the  placenta  than  else- 
where, and  they  diminish  in  size  as  they  recede  from  it.  There  is  a  certain  por- 
tion of  the  uterine  walls,  determined  by  the  placental  insertion,  where  the  venous 
canals  of  the  uterus  traverse  the  mucous  membrane  in  order  to  be  distributed  to 
the  placenta.  There,  in  the  thickness  of  the  mucous  membrane  itself,  which  has 
become  the  maternal  placenta  (or  inter-utero  placental  decidua),  these  vessels 
form,  through  an  enormous  dilatation  of  all  their  branches,  the  large  sinuses 
which  exist  at  the  adherent  surface  of  the  placenta.  These  sinuses  communi- 
cate so  freely  with  each  other  as  to  form,  so  to  speak,  a  pool  of  blood,  divided  up 
by  numerous  partitions.  A  proportionally  small  number  of  orifices  exist  at  in- 
tervals, through  which  this  reservoir  of  blood  communicates  with  the  sinuses  of 
the  muscular  walls.  When  the  after-birth  is  detached,  the  whole  placental  sur- 
face of  the  uterus  is  found  to  be  riddled  with  holes,  which  look  as  though  they 
had  been  made  with  a  punch.  These  orifices,  which  are  oblique,  like  the  section 
of  a  quill  in  making  a  pen,  close  of  them.selves  through  the  depression  of  one  of 
the  membranous  lips  of  the  opening  against  the  other.     (See  Placenta.) 

An  enlargement  of  the  arteries  and  veins  like  this,  cannot  be  the  result  of  a 
simple  unfolding,  since  their  flexuosities  are  in  a  great  measure  preserved ;  they 
must,  therefore,  undergo  a  transformation  analogous  to  that  of  the  fleshy  tissue. 

When  we  come  to  treat  hereafter  of  the  decidua,  we  shall  find  that  the  arran ce- 
ment of  the  vessels  of  the  mucous  membrane  properly  so  called,  undergoes 
changes  during  the  course  of  gestation ;  the  vascular  network  of  the  internal 
surface,  which  is  highly  developed  in  the  early  stages,  showing  signs  of  a  com- 
mencing atrophy  at  the  end  of  the  second  month,  and  diminishing  to  vessels  of 
very  small  calibre  by  the  end  of  the  pregnancy. 

A  very  delicate  yet  distinct  web  of  areolar  tissue  envelopes  the  uterine  arteries. 
The  veins,  on  the  contrary,  have  only  their  internal  coat,  Avhich  adheres  inti- 
mately to  the  muscular  substance,  and  no  valves  are  found  in  their  interior. 

From  what  has  been  stated,  it  is  evident  that  the  blood  flows  to  the  uterus  in 
very  large  quantities,  and  consequently  its  heat  and  nutrition  are  augmented,  for 
such  an  amount  of  blood  must  certainly  contribute  to  the  growth  of  its  walls. 
But  the  question  then  arises,  is  the  circulation  much  more  active,  as  many  authors 


120  GENERATION. 

have  tliought  ?  In  reply,  it  would  appear  from  the  late  researches  of  M.  Jacque- 
mier,  that  the  venous  cireulation  especially  must  exhibit  an  unusual  slowness, 
but  I  confess  the  reading  of  this  last  part  of  his  memoir  has  not  convinced  me 
on  that  point.     (See  art.  Senior rhac/e.) 

The  lymphatic  vessels  also  acquire  a  very  considerable  calibre  and  form  several 
planes  in  the  uterine  substance,  the  superficial  of  which  are  the  most  developed; 
they  divide  into  two  groups,  those  of  the  neck,  which  run  to  the  pelvic  ganglia, 
and  those  of  the  body,  going  to  the  lumbar  ganglia.  The  hypogastric  absorbent 
trunks,  according  to  Cruikshank,  who  has  described  and  figured  them,  are  as 
large  as  a  goose-quill,  and  the  vessels  themselves  so  numerous,  that,  when  in- 
jected with  mercury,  the  uterus  appears  to  be  a  mass  of  lymphatic  vessels.  A 
common  dissection,  made  a  few  days  after  delivery,  will  afford  convincing  proofs 
of  their  volume  and  number. 

5.  The  nerves  of  the  womb  have,  of  latter  time,  been  the  subject  of  numerous 
researches,  among  others,  by  Drs.  Robert  Lee,  Jobert,  Rendu,  and  Boulard. 
Agreeably  to  the  latter  anatomists,  whose  conclusions  closely  correspond  with 
those  of  the  English  accoucheur,  the  nerves  are  derived  from  three  sources : 
1st.  From  the  ovarian  plexus — few  in  number,  and  distributed  to  the  angles  and 
fundus  uteri.  2d.  From  the  hypogastric  plexus — these  are  specially  destined  to 
the  neck ;  and  3d.  Some  filaments  of  the  great  sympathetic,  which  accompany 
the  uterine  arteries,  and  are  apparently  lost  upon  the  neck  and  lateral  parts  of 
the  womb.  Among  the  filaments  constituting  the  ovarian  plexus,  there  are  a 
few  which  seem  to  follow  the  course  of  the  bloodvessels  passing  near  the  ovar}', 
and  reaching  the  border  of  the  uterus  at  its  superior  part.  The  filaments  then 
penetrate  into  its  substance  along  with  the  vessels — but  it  is  impossible  to  trace 
them  through  the  uterine  tissue,  either  from  the  adherence  of  the  vessels  to  this 
tissue,  or  from  the  tenuity  of  the  filaments  themselves,  and  the  same  is  true  of 
tho.se  accompanying  the  uterine  arteries,  which  come  from  the  nerves  that  follow 
the  divisions  of  the  hypogastric  artery. 

The  hypogastric  plexus  furnishes  some  nervous  filaments  as  the  urethra  crosses 
its  anterior  part ;  these  nerves  are  few  in  number,  and  ascend  along  the  lateral 
portions  of  the  neck  (but  not  following  the  vessels),  giving  off  branches  here  and 
there  which  enter  the  uterine  walls,  but  M.  Rendu  has  not  been  able  to  trace 
them  beyond  the  neck.  These  nerves  differ  essentially  from  the  preceding,  both 
in  origin  and  distribution,  for  they  come  from  a  plexus  whose  branches  are  not 
distributed  with  the  vessels,  and  which  has  frequent  anastomoses  with  the  sacral 
nerves  or  nerves  of  animal  life. 

The  whole  body  of  the  uterus,  therefore,  receives  the  nerves  of  organic  life 
exclusively,  whilst  the  nervous  apparatus  of  the  neck  alone  has  communications 
with  the  spinal  nerves.  Like  the  lymphatic  and  sanguineous  vessels,  the  nerves, 
according  to  some  authors,  undergo  a  considerable  development  during  gestation. 
In  the  preparations  exhibited  by  Robert  Lee  to  the  inspection  of  the  Royal  So- 
ciety, and  also  in  the  two  figures  given  by  him,  large  nervous  bands  are  seen 
below  the  serous  tunic,  and  these  bands  are  so  voluminous  that  many  anatomists 
have  doubted  their  true  structure,  and  regarded  them  as  furnished  by  a  gelati- 


OF     SIMPLE     UTERINE     PREGNANCY.  121 

nous  or  cellular  membrane,  placed  between  the  peritoneum  and  the  muscular 
coat.  Consequently,  in  accordance  with  this  view,  the  uterine  nerves  do  not 
form  an  exception,  as  was  for  a  long  time  supposed,  to  the  hypertrophy  seen  in 
all  other  parts  of  the  organ  during  pregnancy — for  they  likewise  are  developed 
in  every  way,  and  return  after  the  delivery  to  their  normal  size.  (See,  for  fur- 
ther details,  the  memoir  of  Dr.  Eobert  Lee,  ''  On  the  Gamjlia  and  the  other 
Nervous  Structures  of  the  Uterus."^ 

I  must  acknowledge,  for  my  own  part,  that  I  have  never  been  able  to  discover 
anything  like  the  above;  and  the  case  is  the  same  with  M.  Jobert,  who  does  not 
believe  in  the  growth  of  the  nerves  during  gestation,  since  he  has  been  unable 
to  discover  any  difference  between  the  nerves  of  the  pregnant  and  those  of  the 
unimpregnated  uterus. 

We  said,  whilst  describing  the  non-gravid  uterus,  that  notwithstanding  the 
researches  of  M.  Jobert,  we  retained  doubts  as  to  the  manner  in  which  the  nerves 
are  distributed  in  the  neck.  Now  the  pi-eparations  deposited  by  M.  Boulard  in 
the  Museum  of  the  Faculty,  have  convinced  us,  that  exceedingly  fine  filaments 
are  prolonged  even  to  the  lowest  parts  of  the  os  tincae,  and,  consequently,  that 
no  portion  of  the  organ  is  entirely  destitute  of  them. 

B.  Properties. — In  the  ordinary  non-gravid  state,  the  sensibility  of  the  uterus 
is  so  obscure  that  it  may  be  touched,  struck,  or  cauterized,  with  bare  conscious- 
ness on  the  part  of  the  female.  During  pregnancy,  the  sensibility  is  somewhat 
increased,  but  it  still  remains  almost  a  nullity.  Though  I  have  heretofore  stated, 
in  accordance  with  other  authors,  that  the  sensibility  becomes  much  exalted 
during  gestation,  it  was,  as  M.  Jacquemier  has  pointed  out,  because  I  had  attri- 
buted to  animal  sensibility  what  was  really  and  exclusively  due  to  the  sensibility 
of  the  nerves  of  organic  life.  The  latter,  which  in  fact  scarcely  exists  in  the 
unimpregnated  organ,  is  manifestly  present  during  pregnancy. 

The  body  of  the  uterus  appears  to  be  almost  insensible.  I  am  aware  that  most 
women  feel  the  motions  of  the  child,  but  are  these  movements  perceived  by  the 
walls  of  the  abdomen,  or  by  the  uterine  parietes?  The  fact  that  in  women 
affected  wnth  ascites,  the  active  motions  are  much  more  obscure  than  in  other 
females,  tempts  us  to  accept  the  former  hypothesis.  I  have,  besides,  frequently 
known  women  to  pass  through  the  whole  course  of  gestation  without  feeling  the 
motions;  for  instance,  I  saw  a  patient  at  La  Charite,  in  August,  1839,  who, 
although  advanced  to  seven  months,  doubted  her  pregnancy  because  she  had  not 
felt  the  child  stir.  I  saw  her  frequently  afterward  between  this  time  and  near 
the  last  of  October,  when  her  labor  occurred,  yet,  although  the  child  was  quite 
strong  and  healthy,  she  had  never  observed  its  motions. 

We  have  said  that  the  organic  sensibility  or  irritability,  which  hardly  exists 
in  the  unimpregnated  state,  becomes  considerably  greater  during  gestation ;  to 
it  is  due  the  kind  of  sympathetic  relation  which  is  established  between  the  fibres 
of  the  neck  and  those  of  the  body  of  the  uterus,  and  in  consequence  of  which, 
any  rather  active  and  prolonged  excitement  of  the  neck  of  the  organ  reacts  upon 
the  fibres  of  the  fundus. 

Even  the  premature  expulsion  of  the  foetus  is  often  a  consc(|ucnce  of  contrac- 


122  GENERATION. 

tions  produced  by  excitations  of  the  cervix,  and  it  is  owing  to  this  cause,  accord- 
ing to  Delamotte,  that  repeated  coition  has  frequently  caused  abortion,  and  that 
females  who  are  used  in  our  amphitheatres  for  practising  '^  the  touch,"  are  so 
often  delivered  before  term. 

This  irritability  of  the  cervix,  and  its  influence  upon  the  contractility  of  the 
body,  is  in  some  cases  turned  to  profit  in  the  practice  of  our  art;  thus  it  is  well 
known,  that  one  of  the  surest  and  most  generally  employed  methods  of  inducing 
premature  labor,  consists  in  the  introduction  and  retention  of  a  foreign  body  in 
the  neck  of  the  womb. 

The  uterus  acquires  some  entirely  new  properties,  independent  of  the  sensi- 
bility which  existed  a  little  before,  but  became  more  highly  developed  during 
the  gestation :  I  allude  to  the  organic  contractility,  and  the  contractility  of  its 
tissue.  The  first  is  a  faculty  inherent  in  the  uterine  fibres,  of  contracting  upon 
the  body  they  enclose  to  effect  its  expulsion  from  the  cavity;  it  is  a  true  con- 
traction, precisely  similar  to  the  muscular  contraction  of  the  hollow  organs  (blad- 
der, rectum,  stomach),  and  is  never  developed  excepting  under  the  influence  of 
a  stimulant  or  irritant  of  some  kind.  The  second  is  a  property  by  which  the 
womb,  after  having  been  emptied,  returns  gradually  to  its  former  state,  and 
thereby  has  its  cavity  nearly  obliterated;  it  is  a  true  elasticity.  Its  principal 
function  is  to  cause  a  great  diminution  in  the  calibre  of  the  vessels  which  ramify 
in  the  substance  of  the  uterine  walls,  and  an  obliteration  of  those  that  have  large 
open  mouths  on  the  internal  surface  of  the  organ  after  the  separation  of  the 
placenta,  and  which  would  prove  a  source  of  fatal  hemorrhage  to  the  mother,  if 
nature  had  not  provided  against  so  terrible  an  accident  by  this  contractility  of 
the  tissue. 

The  exercise  of  the  organic  contractility  is  always  accompanied  by  pain,  which 
is  usually  very  great  in  the  human  species,  but  does  not  exist  at  all  in  wild 
animals,  and  is  only  observed  to  a  very  feeble  degree  in  our  domesticated  ones. 
As  a  general  rule,  the  uterine  contraction  is  not  painful  in  the  different  species 
of  animals,  unless  an  accident  or  some  disease  renders  a  greater  energy  of  action 
necessary  on  the  part  of  the  organ,  and  the  pains  then  experienced  by  the  female 
are  altogether  similar  to  those  of  women. 

If,  therefore,  the  contraction  is  only  painful  accidentally,  as  it  were,  in  animals, 
and  merely  in  consequence  of  a  particular  morbid  condition  of  the  uterine  fibre, 
are  we  not  justified  in  referring  the  pain  in  the  human  species  to  the  same  cause  ? 
Now  can  this  predisposition  be  the  result  of  the  refinements  of  civilization  ?  It 
would  of  course  be  impossible  to  prove  this,  but  there  are  strong  grounds,  at 
least,  for  believing  that  such  is  the  fact,  when  we  reflect  that  our  domestic  ani- 
mals, which,  like  ourselves,  have  been  translated  from  their  primitive  normal 
condition,  often  suffer  much  more  during  parturition  than  those  in  a  savage  state. 
This  organic  contractility  resides  especially  in  the  fibres  of  the  body;  its  in- 
tensity is  exceedingly  variable  in  different  females,  being  very  strong  in  some, 
and  scarcely  existing  in  others;  but  its  energy  bears  no  relation  to  that  of  the 
external  muscular  system,  for  some  strong  muscular  women  have  extremely  weak 
contractions  during  labor,  and  oftentimes  the  contrary  is  observed. 


OF  SIMPLE  UTERINE  PREGNANCY.  123 

The  exercise  of  this  function  takes  place  independently  of  the  will,  at  least,  in 
a  great  majority  of  cases,  which,  indeed,  we  can  readily  understand  must  be  the 
fact,  from  the  origin  and  nature  of  the  nerves  distributed  to  the  body  of  the 
uterus,  since  we  have  just  learned  that  its  fundus  receives  filaments  from  the 
great  sympathetic  alone.  I  am  well  aware  the  books  furnish  some  cases  of 
women  who  had  the  power  of  suspending  the  contraction  at  will,  but  if  the  facts 
have  even  been  well  observed,  they  have  failed  perhaps  to  receive  the  most 
rational  interpretation.  In  the  cases  related  by  Baudelocque  and  Yelpeau,  in 
which  the  labor  ceased  when  the  students  were  summoned  to  witness  it,  and 
began  again  when  these  numerous  observers  retired,  the  will  had  probably  less  to 
do  than  the  imagination  and  modesty,  with  the  alternations  of  retardation  and 
acceleration ;  for  though  the  influence  of  the  will  may  be  reasonably  doubted,  it 
cannot  be  denied  that  moral  disturbances  appear  to  affect  the  contractility  of  the 
uterus ;  thus,  a  violent  emotion  has  often  sufficed  to  arouse  it  long  before  the 
ordinary  term  of  gestation,  and  it  is  not  at  all  uncommon  for  the  contraction  to 
diminish  or  disappear  for  several  hours,  or  even  days,  under  the  operation  of 
such  causes.  Dewees  knew  the  pains  to  be  suspended  in  this  manner  for  two 
weeks  in  a  woman  who  was  greatly  affected  by  his  sudden  and  unexpected 
arrival.  Betschler  cites  a  case  in  which  the  pains  were  suddenly  suspended  by 
a  violent  tempest,  so  that  the  neck,  though  widely  dilated,  closed  again,  nor  did 
the  labor  recommence  until  nineteen  days  had  elapsed. 

Every  day,  indeed,  we  witness  a  suspension  of  the  pains  for  half  an  hour,  and 
sometimes  even  for  several  hours,  upon  visiting  women  whose  modesty  is  shocked 
by  our  presence. 

The  exercise  of  this  function  is  seldom  of  long  duration,  lasting  for  a  few 
seconds  only — rarely  beyond  one  or  two  minutes,  and  then  the  organ,  which  was 
so  strongly  contracted  and  hardened,  gradually  regains  its  primitive  state,  and 
remains  in  repose,  until,  under  the  influence  of  the  same  stimulus,  it  is  again 
thrown  into  action.  The  organic  contractility,  like  all  muscular  power,  is  ex- 
pended by  a  prolonged  exercise,  and  hence  we  can  understand  why  the  pains  so 
often  become  at  once  more  slow  and  feeble,  or  even  cease  altogether  after  a 
prolonged  labor.  Lastly,  opiates  have  a  marked  influence  over  them;  for  by 
employing  these  preparations,  we  may  suspend  the  uterine  contraction  nearly  at 
will,  for  several  hours  during  labor  at  term,  and  indefinitely,  in  a  case  of  prema- 
ture delivery  or  abortion. 

This  contractility  may  be  excited  by  natural,  accidental,  or  artificial  stimuli; 
thus,  all  the  causes  of  labor  constitute  the  first;  the  second  are  those  of  abor- 
tion and  premature  labor;  and  the  third  comprise  all  irritations  whatever  of  the 
neck  or  body  of  the  womb ;  as  electricity,  ergot,  and,  in  a  word,  all  the  means 
employed  when  it  is  desirable  to  deplete  the  organ. 

On  the  contrary,  it  may  be  weakened  by  an  over-distension  of  the  uterus,  by 
prolonged  contractions,  or  vivid  moral  impressions. 

An  observation  of  M.  Brachet's  might  lend  to  the  supposition  that  the  organic 
contractility  of  the  uterus  would  be  weakened,  or  even  totally  destroyed,  by 
lesions  of  the  spinal  marrow.     It  is,  however,  proved  by^^umcrous  cases  of  para- 


124  GENERATION. 

plegia  in  females,  as  well  as  by  experiinents  on  animals,  that  labor  is  in  no  respect 
impeded  by  alterations  of  the  cord,  and  that  the  want  of  action  of  the  voluntary 
muscles  is  more  than  compensated  for  by  the  paralysis  of  those  of  the  perineum, 
the  slight  resistance  of  which  renders  the  last  stage  of  the  foetal  expulsion  both 
more  easy  and  rapid. 

This  result  might  indeed  have  been  anticipated  from  the  known  absence  of  all 
nerves  of  animal  life  from  the  body  of  the  uterus. 

The  contractility  of  the  uterus,  like  that  of  all  the  viscera  of  organic  life,  is 
retained  for  some  time  after  death,  and  thus  serves  to  explain  the  occasional  ex- 
pulsion of  a  foetus  several  hours  subsequent  to  the  decease  of  the  mother,  as  also 
the  posthumous  contraction  of  the  uterus  in  Caesarean  operations  performed  im- 
mediately after  the  mother  has  expired. 

The  contract ilitij  of  tissue  exists  chiefly  in  the  fibres  of  the  body.  Dewees 
supposed  it  to  be  seated  more  especially  in  the  circular  ones  that  constitute  the 
internal  plane  of  the  uterine  muscular  layer,  and  it  is  scarcely  observable  at  the 
inferior  parts,  and  in  the  neck.  It  was  certainly  a  wise  provision  on  the  part  of 
nature  to  place  it  in  a  region  where  the  habitual  attachment  of  the  placenta 
causes  a  more  considerable  development  of  the  vascular  apparatus.  This  holds 
so  true,  that  it  is  easy  to  detect  the  retracted  fundus  in  the  hypogastric  region 
after  delivery,  as  a  hard,  irregular  tumor,  whilst  to  the  vaginal  touch,  the  neck 
appears  soft,  flexible,  and  not  the  least  contracted.  Therefore,  whenever  the 
placenta  is  inserted  on  the  neck,  a  hemorrhage  is  not  only  to  be  dreaded  during 
labor,  but  also  at  the  time  of,  and  for  a  short  period  subsequent  to  the  delivery 
of  the  after-birth.  In  most  females,  the  contractility  of  tissue  accompanies  the 
organic  contractility,  and  these  two  properties  are  successively  in  action  at  the 
period  of  labor,  and  during  the  gradual  depletion  of  the  uterus.  In  fact,  if  after 
the  contraction  which  has  caused  the  expulsion  of  a  certain  part  of  the  body  en- 
closed in  the  uterine  cavity,  the  walls  of  this  organ  did  not  retract  promptly  to 
fill  up  the  void,  it  would  constitute  inertia  of  the  womb. 

The  contractility  of  the  tissue,  which  is  a  true  elasticity,  should  be  carefully 
distinguished  from  the  organic  contractility,  with  which  M.  Jacquemier  was 
disposed  to  confound  it.  It  has  for  its  object  the  restoration  of  the  uterus  to  its 
primitive  size,  through  a  shortening  of  its  fibres  and  consequent  expression  of 
the  fluids  which  had  collected  in  its  walls.  The  operation  is  a  slow  and  con- 
tinuous one,  and  is  prolonged  throughout  the  period  of  the  getting  up.  When 
it  takes  place  in  a  regular  manner,  it  is  unaccompanied  by  pain,  as  we  sec  in  the 
cases  of  many  primiparous  women,  in  whom  the  retraction  is  accomplished  with- 
out their  being  aware  of  it. 

The  contractility  of  the  tissue  is  not,  however,  always  equal  to  this  eff"ect,  at 
least  during  the  first  days  after  labor.  Its  insufliciency  may  perhaps  be  due  to 
over-distension,  or  to  a  protracted,  or  too  rapid  labor,  in  which  case  the  uterine 
fibre  loses  its  elastic  property,  as  Leroux  expresses  it,  or  else  it  may  be,  that  the 
presence  of  a  foreign  body,  whether  solid  or  fluid,  re(iuires  the  intervention  of  a 
more  active  force.     Here,  then,  the  organic  contractility  is  called  into  exercise, 


OF    SIMTLE     UTERINE     PREGNANCY.  125 

and  the  retraction  of  the  uterus  is  effected  by  a  true  intermittent  and  painful 
contraction. 

This  diminution  of  the  contractility  of  the  tissue  is  generally,  however,  of 
short  duration,  for  after  four  or  six  days  at  the  furthest,  the  organic  contractility 
is  no  longer  required,  unless  a  new  clot  should  happen  to  form  in  the  uterus. 
The  elasticity  of  the  uterine  fibres,  assisted  by  the  process  of  absorption,  which 
goes  on  unceasingly,  and  also  by  the  lochial  discharge,  are  thenceforth  sufficient 
to  restore  the  organ  to  its  normal  condition. 

The  contractility  of  the  tissue  is  far  from  being  equally  powerful  in  all  women, 
nor  is  it  always  easy  to  give  a  good  reason  for  the  difference.  For  example,  it  is 
much  less  active  in  multiparas  than  after  a  first  labor,  and  this  explains  why 
after-pains  are  much  more  common  with  the  former  than  in  the  latter  case,  for 
the  pains  are  a  consequence  of  the  exercise  of  the  organic  contractility,  and  the 
uterus  returns  more  slowly  to  its  habitual  volume.  Great  over-distension  of  the 
womb,  and  a  too  rapid  or  too  prolonged  expulsion,  also  seem  to  diminish  its  action. 

Another  circumstance  which  also  destroys,  or  at  least  suspends  its  exercise,  is 
acute  or  chronic  inflammation  of  the  uterus  and  its  annexes.  Whilst  the  in- 
flammation continues,  the  contraction  of  the  womb  appears  to  be  suspended,  and 
very  often  the  organ  begins  to  diminish  in  size  only  when  the  inflammation  is 
overcome. 

Finally,  even  under  the  most  favorable  circumstances,  the  retraction  of  the 
womb  is  far  from  being  uniformly  regular,  for  after  having  gradually  decreased 
in  size,  it  may  remain  stationary  for  several  daj'S,  and  then  begin  again  its  pro- 
cess of  diminution. 

If  it  be  indisputable  that  there  are  circumstances  which  diminish  the  elasticity 
of  the  uterine  fibres,  it  is  also  fully  proved  that  we  possess  certain  agents  capable 
of  exciting  its  action.  Thus,  external  or  internal  irritations  acting  on  the  neck 
and  body  (such  as  cold  or  frictions),  and  the  administration  of  ergot,  often  have 
this  happy  effect. 

C.  Relations. — At  term,  the  uterus  is  in  relation — 1.  In  front,  with  the  vagina, 
the  posterior  face  of  the  neck  and  body  of  the  bladder,  and  superiorly,  with  the 
anterior  abdominal  wall.  This  last  is  not  always  immediate,  for  occasionally  a 
portion  of  the  intestinal  mass  slips  between  the  uterus  and  the  ventral  parietes, 
as  occurred  in  the  woman  upon  whom  iM.  Dubois  practised  the  Cossarcan  opera- 
tion in  1839 ;  and,  as  the  professor  has  remarked,  the  operator  should  be  very 
prudent  in  making  his  incisions,  from  the  possibility  of  encountering  this  anomaly. 
2.  Behind,  with  the  rectum,  sacro-vertebral  angle,  and  vertebral  column  below, 
and  with  the  mesentery  and  intestinal  mass  above.  3.  On  the  right,  with  the 
corresponding  side  of  the  pelvis,  the  iliac  vessels,  psoas  muscle,  coecum,  and  right 
abdominal  wall.  4.  On  the  left,  with  that  part  of  the  pelvis,  the  iliac  vessels 
and  aorta,  the  sigmoid  flexure,  the  psoas  muscles,  and  the  whole  body  of  intes- 
tines which  separate  it  from  the  abdominal  wall. 


126  GENERATION. 

ARTICLE   II. 

CHANGES   IN    THE   NEIGHBORING   PARTS. 

We  can  readily  imagine  that  the  strange  modifications  just  studied,  do  not  take 
place  in  the  uterus  without  affecting  the  neighboring  parts,  and  the  changes  in 
these  will  next  engage  our  attention. 

1.  As  the  uterus  gradually  rises  in  the  abdomen,  its  surrounding  peritoneum 
is  carried  along  with  it;  the  folds,  called  the  hroad  ligaments,  then  disappear, 
and  consequently,  the  Fallopian  tubes  and  ovaries  are  drawn  nearer  to  the  body 
of  the  uterus,  where  they  lie  very  nearly  in  a  vertical  direction;  the  fundus  be- 
comes rounded,  its  angles  diminish  and  finally  disappear.  The  Fallopian  tubes, 
which  in  the  unimpregnated  state  are  inserted  at  the  apex  of  the  angles,  and  on  the 
same  horizontal  line  with  the  fundus,  are  no  longer  implanted  upon  the  highest 
part,  but  correspond  to  the  upper  fourth,  or  even  to  the  middle  of  the  total  length 
of  the  organ.  The  round  ligaments  are  then  composed  of  short  linear  fibres, 
among  which  a  great  number  of  muscular  ones,  prolongations  of  those  of  the 
uterus,  may  be  distinguished.  M.  Velpeau  asserts  that  he  discovered  and 
watched  their  contraction  in  three  different  females,  during  the  efforts  of  the 
uterus  to  expel  the  after-birth.  The  greater  development  of  the  anterior  than  of 
the  posterior  wall  of  the  uterus,  removes  the  insertion  of  the  round  ligaments 
from  the  lateral  position  which  they  occupy  in  the  unimpregnated  organ,  to  a 
point  so  much  farther  in  front,  that  they  are  implanted  at  about  the  union  of  the 
anterior  fifth  with  the  posterior  four-fifths  of  the  antero-posterior  diameter. 

2.  As  the  womb  and  upper  part  of  the  vagina  are  intimately  associated,  the 
latter  is  necessarily  shortened  as  the  former  enlarges  in  the  early  periods  of  preg- 
nancy, whilst  the  vagina  becomes  longer  when  the  womb  rises  above  the  superior 
strait.  The  venous  system  in  the  vaginal  walls  is  considerably  developed,  owing 
to  the  greater  activity  of  their  circulation.  This  dilatation  of  the  veins  is,  doubt- 
less, the  consequence  of  a  greater  vitality  in  the  genital  organs,  but  it  is  also  due 
in  part  to  the  stasis  of  the  blood,  which  is  impeded  in  its  course  by  the  uterine 
development. 

The  varicose  state,  and  the  nodosities  frequently  encountered  by  the  finger  on 
the  vulva  and  vagina  towards  the  end  of  pregnancy  (described  by  M.  Deneux 
under  the  name  o^  thrombus),  which  certainly  predispose  females  to  hemorrhagic 
accidents,  may  probably  be  attributed  to  the  same  cause ;  and  this  congestion 
even  affects  the  capillaries ;  for  otherwise  it  would  be  difiicult  for  me  to  explain 
the  livid  spots  or  discolorations,  resembling  wine-lees,  presented  by  the  vaginal 
mucous  membrane,  and  to  which  attention  has  again  been  recently  called  as 
affording  a  sign  of  pregnancy.'     But  unfortunately  this  sign  can  only  be  ser- 

'  This  discoloration  is  evidently  owing  to  the  greater  activity  of  the  circulation  in  the 
genital  organs,  and  consequently  it  ought  to  be  met  with  in  all  cases  predisposing  to  a  vas- 
cular congestion  of  the  genito-urinary  apparatus.  Mr.  Montgomery  has  detected  it  in  a 
female  at  the  menstrual  period,  and  it  is  a  well-known  fact,  that  cattle-breeders  ascertain 
whether  an  animal  is  in  heat  or  not,  by  examining  the  orifice  and  internal  surface  of  the 
vagina,  which  is  almost  as  black  as  ink  under  such  circumstances. 


OF    SIMPLE    UTERINE    PREGNANCY.  127 

viceable  in  a  medico-legal  case,  because  in  private  practice  very  few  females 
would  permit  such  explorations. 

In  practising  the  "  touch,"  the  finger  frequently  detects  some  arterial  pulsa- 
tions at  the  upper  part  of  the  vagina,  though  they  are  more  frequently  found  on 
some  point  of  the  supra-vaginal  portion  of  the  uterus,  and  are  evidently  due  to 
the  great  hypertrophy  of  the  vaginal  and  uterine  arteries.  Doctor  Osiander,  of 
Gottingen,  attaches  great  importance  to  this  as  a  diagnostic  sign,  and  has  called 
it  the  vaginal puhe.'^ 

It  is  not  uncommon  to  find  the  mucous  membrane  of  the  vagina  covered,  about 
the  seventh  or  eighth  month,  throughout  its  whole  extent,  with  myriads  of  little 
pimples  as  large  as  a  pin's  head.  These  small  granulations,  which  I  have  fre- 
quently mot  with,  not  only  line  the  vagina,  but  also  cover  the  neck  on  its  exte- 
rior, and  even  on  its  interior  surface.  Now  is  this  to  be  attributed  to  an  abnormal 
development  of  the  mucous  follicles?  I  am  the  more  disposed  to  consider  it  in 
this  light,  because  their  presence  always  coincides  with  a  marked  increase  of  the 
vaginal  secretion. 

The  vaginal  mucosities  are  always  secreted  abundantly  during  pregnancy,  but 
the  time  of  their  appearance  is  very  uncertain.  Usually,  however,  they  are  more 
copious  in  the  advanced  stages,  and  the  women  then  say,  "  they  are  losing  the 
milk;"  an  opinion  unworthy  of  refutation.  In  some,  this  flow  appears  in  the 
early  months,  then  ceases,  and  again  reappears  several  times;  though  perhaps 
not  at  all,  or  else  only  at  a  very  late  period. 

3.  The  bladder  is  gradually  pushed  above  the  superior  strait,  the  meatus 
urinarius  is  drawn  out  and  elongated,  and  its  orifice,  from  being  so  high  up,  is 
concealed  behind  the  border  of  the  symphysis  pubis,  thereby  rendering  the  in- 
troduction of  an  instrument  very  difficult.  The  urethral  canal  is  more  curved 
than  usual,  and  the  curvature  is  sometimes  so  great  that  the  male  catheter  can 
more  readily  be  used ;  because  the  bladder  being  strongly  pushed  forwards,  and 
above  the  pubis,  by  the  developed  uterus,  draws  this  canal  upwards,  and  causes 
it  to  be  applied  against  the  posterior  face  of  the  pubic  symphysis,  thus  producing 
a  curvature  of  the  urethra  having  its  concavity  in  front.  Lastly,  as  the  upper 
part  of  this  canal  is  compressed  by  the  enlarged  womb,  the  circulation  in  its 
inferior  parts  is  impeded,  and  the  whole  tube  becomes  greatly  tumefied.  It  is 
placed  behind  the  osseous  projection  produced  by  the  posterior  part  of  the  arti- 
cular surfaces  of  the  pubis,  and  these  two  superposed  eminences  form  a  consi- 
derable tumor  in  the  interior  of  the  pelvis ;  I  have  frequently  known  students 
who  were  practising  the  toueh,  to  be  unable  to  explain  the  remarkable  tumefac- 
tion encountered  by  the  finger  behind  the  symphysis. 

An  annoying  vesical  tenesmus  is  often  produced  by  the  pressure  exercised  on 
the  body  and  neck  of  the  bladder,  tormenting  the  female  with  frequent  ineifec- 
tual  desires  to  urinate;  these  demands  are  always  very  urgent,  and  are  satisfied 
by  the  discharge  of  a  few  drops  of  urine,  but  are  again  reproduced  with  equal 

'  Tliis  hypertrophy  of  the  vessels  of  the  vagina  and  of  the  vulva,  sometimes  renders 
wounds  of  these  parts  very  dangerous.  Profuse  hemorrhage  has  been  known  to  occur  in 
consequence  of  it. 


128  GENERATION. 

intensity  some  minutes  after.  Some  persons,  judging  from  this  frequent  mictu- 
rition, have  thought  the  urinary  secretion  was  augmented. 

In  certain  cases,  the  swelling  of  the  urethral  walls,  and  possibly  also  the  com- 
pression they  sustain,  produces  its  complete  obliteration  and  renders  catheterism 
necessary. 

M.  Yelpeau  avers,  that  he  has  frequently  known  the  bladder,  from  the  fact  of 
its  being  more  compressed  above  the  fundus  than  below  it  during  the  last  fort- 
night of  pregnancy,  to  project  into  the  upper  part  of  the  vagina  so  as  to  form  a 
true  vaginal  cystocele.  I  think,  however,  that  it  is  of  rare  occurrence  during 
pregnancy,  since  I  have  met  with  but  two  instances  of  it. 

4.  The  pressure  of  the  uterus  upon  the  vascular  trunks,  which  go  to  or  return 
from  the  inferior  extremities,  genital  organs,  and  lower  part  of  the  rectum,  inter- 
rupts the  venous  and  lymphatic  circulation  in  those  parts;  whence  it  frequently 
happens  that  a  considerable  adema  of  the  limbs  and  sexual  organs  is  produced, 
as  well  as  the  development  of  some  hemorrhoidal  tumors. 

5.  Pregnant  women  are  habitually  costive;  hence  a  voluminous  tumor  is 
formed  at  the  lateral  posterior  part  of  the  excavation  by  the  rectum  distended 
with  fecal  matters.  The  pressure  of  the  uterus  upon  the  entire  mass  of  the  in- 
testines, frequently  gives  rise  to  colic  and  disorders  of  digestion. 

6.  The  base  of  the  thorax  is  enlarged  and  projects  in  front;  the  diaphragm  is 
pressed  upward  by  the  uterus  and  intestinal  mass,  having  its  concavity  increased 
in  consequence ;  so  much  so,  indeed,  as  to  obstruct  respiration,  and  the  circula- 
tion in  the  heart  and  great  vessels. 

7.  The  skin  of  the  abdomen  is  very  much  distended,  and  is  marked,  especially 
towards  its  inferior  part,  by  some  streaks  of  a  brown  or  bluish  color,  which  form 
parallel  curved  lines  with  the  convexity  towards  the  pubis  and  groins.  These 
are  very  numerous  in  some  women,  but  in  others  they  scarcely  exist;  they  be- 
come paler,  but  do  not  disappear  altogether  after  the  delivery ;  sometimes  they 
are  continued  even  to  the  upper  and  internal  part  of  the  thighs. 

Besides  these  marks,  a  brownish  line  is  observed  upon  the  skin,  extending 
from  the  pubis  to  the  umbilicus,  where  it  mostly  stops,  though  it  sometimes  ex- 
tends beyond  it  in  dark  brunettes.  This  line  may  generally  be  regarded,  espe- 
cially in  a  primiparous  female,  as  a  certain  sign  of  pregnancy;  it  may,  however, 
in  some  exceptional  cases,  exist  in  non-pregnant  females  or  even  in  males.  (Jose 
Cormack,  Guz.  Med.,  March,  1845.) 

The  muscles  and  aponeuroses  of  the  abdominal  walls  become  thinner,  the  recti 
muscles  are  removed  from  each  other,  and  the  aponeurotic  space  which  separates 
them,  instead  of  being  a  narrow  band,  as  usual,  is  at  least  four  and  a  quarter 
inches  wide,  on  a  level  with  the  navel.  The  umbilical  depression,  which  in  the 
two  first  months  seems  deeper,  disappears  gradually  as  gestation  progresses ;  the 
ring  becomes  distended,  and  most  generally  the  skin  exhibits  a  protuberance  in- 
stead of  a  pit  in  its  place.  This  eminence  is  particularly  well  marked  when  the 
female  exerts  herself,  owing  to  the  engagement  of  a  small  piece  of  epiploon  in  it, 
constituting  a  temporary  hernia. 

Not  unfrequently  an  oblong  tumor  appears  on  the  median  line  after  delivery, 


OF     SIMPLE     UTERINE     PREGNANCY. 


129 


34. 


produced  by  a  projection  of  the  bowels  in  consequence  of  the  great  separation  of 
the  aponeurotic  fibres.  The  tumor  is  especially  evident  during  any  exertion ; 
and  increases  in  size  with  each  succeeding  pregnancy,  until  it  finally  becomes  an 
infirmity,  which  obliges  the  woman  to  have  recourse  to  a  bandage. 

8.  The  relaxation  of  the  pelvic  symphyses  is  a  frequent  occurrence ;  when 
existing  to  a  great  extent,  it  constitutes  a  disease  that  will  be  more  fully  detailed 
in  the  pathological  history  of  pregnancy. 

9.  The  manujicr,  which  must  also  be  considered  as  an  appendage  to  the  genital 
organs,  undergo,  during  gestation,  some  modifications  preparatory  to  the  accom- 
plishment of  the  great  function  to  which  they  are  destined  after  the  accouche- 
ment ;  thus,  in  the  very  commencement,  most  women  find  their  breasts  to  become 
tender  and  larger,  and  with  some,  this  is  so  constant  a  sign  that  they  do  not  hesi- 
tate to  consider  themselves  enceinte  as  soon  as  it  is  perceptible.  The  enlarge- 
ment is  frequently  attended  by  certain  pricking  sensations  or  positive  pains, 
sometimes  even  by  engorgements  of  the  axillary  ganglia.  It  is  by  no  means 
uncommon  for  the  swelling  to  diminish  towards  the  fourth  or  fifth  month,  but  it 
reappears  again  near  the  end  of  pregnancy,  and  is  then  considerably  larger  than 
before.  In  some  women  it  is  accompanied  by  fever,  analogous  to  the  milk  fever, 
and  this  may  even  be  carried  to  the  extent  of  producing  an  inflammatory  en- 
gorgement of  its  substance,  followed  by  an  abscess.  More  rarely,  the  breast, 
which  was  at  first  slightly  enlarged,  sub- 
sides, and  remains  flaccid  and  soft  until 
after  delivery.  In  general,  this  is  an 
unfortunate  circumstance,  because,  from 
the  observations  of  my  friend,  Dr.  Donne, 
such  women  prove  very  poor  nurses  on 
account  both  of  the  bad  quality  and  the 
small  quantity  of  their  milk. 

About  the  end  of  the  second  month, 
according  to  Mr.  Montgomery,  but  in 
my  own  opinion  a  little  later,  the  nipple 
swells,  and  becomes  more  erectile,  sensi- 
tive, and  projecting;  its  color  also  is 
deeper.  The  surrounding  skin  becomes 
the  seat  of  a  larger  afflux  of  liquid,  and 

assumes  an  almost  emphysematous  appearance.  This  skin  is  also  discolored, 
exhibiting  at  first  a  light  yellowish  tint,  but  in  the  course  of  the  two  succeeding 
months  the  areola  is  completed,  and  the  skin  of  the  mamma  then  presents  the 
following  characters  :  A  circle  around  the  nipple,  the  color  of  which  varies  in 
depth  of  shade  according  to  the  individual,  being  generally  darker  in  persons 
who  have  black  hair  and  eyes,  and  in  brunettes,  than  in  blondes,  or  in  feeble  and 
delicate  women.  The  circle  is  from  three-quarters  of  an  inch  to  one  inch  and  a 
quarter  in  extent,  but,  like  the  intensity  of  the  discoloration,  it  increases  with  the 
advancement  of  gestation.     In  the  negress,  the  areola  likewise  becomes  darker. 

At  the  centre  of  the  areola,  but  more  especially  at  that  portion  of  it  which 

9 


130  GENERATION. 

surrounds  the  base  of  the  nipple,  a  number  of  small  a-landules,  varying  from 
twelve  to  twenty,  soon  appear,  and  attain  an  elevation  of  one  to  two  lines  above 
the  cutaneous  surface.  These  little  glands  apparently  have  an  excretory  duct, 
because,  by  pressing  upon  them,  a  serous,  or  sero-lactescent  liquid  may  be  made 
to  ooze  out. 

Some  small  irregularly  circular  spots  begin  to  show  themselves  about  the  fifth 
month,  situated  immediately  around  the  areola  just  described,  and  resembling 
the  stains  created  by  the  aspersion  of  a  colored  liquid,  thus  constituting  another 
spotted  and  stained  areola.  This  latter  is  much  more  limited  in  extent  than  the 
first,  though  not  unfrequently  it  invades  a  great  part  of  the  skin  covering  the 
breast. 

About  the  same  period  a  number  of  large  venous  trunks  are  seen  distributed 
over  the  surface  of  the  bosom,  and  sending  numerous  ramifications  towards  the 
areola,  some  of  which,  indeed,  traverse  it.  Along  the  course  of  these  vessels, 
we  may  occasionally  observe  some  shining  silvery  lines,  closely  resembling  those 
found  on  the  skin  of  the  abdomen,  though  they  are  more  marked  in  those  females 
whose  mammae  were  but  slightly  developed  prior  to  conception,  and  had  expe- 
rienced a  sudden  increase  in  size  after  it,  than  in  others.  These  silvery  streaks 
remain  for  a  longer  or  shorter  period  after  the  accouchement.  They  are  further 
serviceable  in  proving  that  the  female  has  had  a  child,  but  they  cease  to  be  of 
any  value  as  a  diagnostic  sign  of  her  subsequent  pregnancies. 

These  modifications  usually  persist  during  lactation,  though  where  the  woman 
does  not  suckle  her  infant  they  diminish  after  the  delivery,  but  do  not  wholly 
disappear.  Consequently,  they  are  more  conclusive  in  primiparre  than  in  others; 
and  although  we  must  not  always  anticipate  their  existence  in  pregnancy,  yet, 
whenever  they  are  found,  they  constitute  an  almost  certain  sign  of  that  condition. 


ARTICLE   III. 

DIAGNOSIS    OF   PREGNANCY. 

The  signs  of  pregnancy  are  divided  into  the  rational  and  the  sensible. 

The  first  comprise  all  those  characters  pointed  out  by  authors  as  existing  in  the 
earliest  periods,  by  which  they  assert  a  conception  may  be  justly  suspected;  then 
in  the  subsequent  stages, — the  suppression  of  the  menses,  the  enlargement  of 
the  abdomen,  the  pouting  of  the  navel,  the  phenomena  just  studied  in  the  breasts, 
the  symptoms,  or  rather  the  functional  disturbances  in  the  digestive  organs,  the 
condition  of  the  pulse,  the  modifications  in  the  urine,  and  lastly,  certain  changes 
that  occur  in  the  woman's  habits,  as  well  as  in  her  moral  and  intellectual  faculties. 

§  1.  Rational  Signs. 

According  to  Aristotle,  there  is  some  ground  for  believing  the  woman  has  con- 
ceived, if  no  fluid  oozes  out  from  the  vagina  after  coition,  and  if  the  penis  is 
unusually  dry  when  withdrawn  ;  and  the  opinion  seems  to  be  universally  received 
by  shepherds,  that  the  retention  of  the  semen  is  an  evidence  of  impregnation. 


OF    SIMPLE    UTERINE    PREGNANCY  131 

Agreeably  to  Hippocrates,  the  eyes  become  more  sunken,  more  languishing,  and 
are  surrounded  by  a  bluish  circle,  and  spots  of  different  sizes  appear  on  the  face. 
Acain,  since  the  days  of  Democritus,  a  swelling  of  the  neck  is  also  enumerated 
as  a  sign  of  conception.  However,  all  these  symptoms  have  but  little,  if  any 
value,  and  I  accord  far  greater  importance  to  the  more  voluptuous  sensation,  the 
more  general  erethism  experienced  by  some  females  during  a  prolific  coition,  by 
which  a  few  of  them  can  recognize  with  a  degree  of  certainty  that  they  have 
become  pregnant. 

1.  Siq^pression  of  (he  Menses. — Females  cease  to  be  regular  during  pregnancy; 
and  this  is  a  law  of  such  general  truth,  that  whenever  it  occurs  in  a  healthy 
woman,  without  a  known  cause,  and  not  attended  with,  or  followed  by  any  mor- 
bid symptom,  it  is  justly  regarded  as  a  probable  sign  of  gestation ;  but  as  this 
suppression  might  be  produced  by  a  number  of  other  causes,  whenever  a  physi- 
cian is  consulted  about  it,  he  ought  carefully  to  inquire  into  all  the  circumstances, 
past  or  present,  which  may  have  produced  such  an  effect.  It  would  be  out  of 
place  now  to  enter  into  this  diagnosis,  but  we  may  reiterate  an  observation, 
already  made  by  several  authors,  and  which  our  experience  has  frequently  veri- 
fied, namely,  that  in  some  young  matried  women,  who  had  hitherto  been  quite 
regular,  the  menses  become  at  once  suppressed,  and  continue  so  for  several 
months,  without  any  known  cause;  and  this  suppression,  resulting  probably  from 
the  irritation  or  derangement  produced  in  the  genital  organs  by  the  first  conjugal 
approaches,  is  frequently  accompanied  by  an  augmented  volume  of  the  abdomen, 
and  a  more  exalted  sensibility  of  the  mammary  glands;  and,  as  the  mind  so 
readily  believes  what  it  most  ardently  desires,  nothing  more  than'this  is  wanted 
to  found  a  hope  of  a  commencing  pregnancy.  Hence  the  physician  must  exer- 
cise great  discretion  in  his  diagnosis,  when  consulted  on  so  delicate  a  subject. 

The  menses  may  continue  during  pregnancy ;  thus  they  frequently  appear  in 
the  earlier  months,  more  rarely  during  the  first  five  or  six  months,  and  what  is 
still  more  unusual  by  far,  they  may  exist  during  the  whole  period  of  gestatioa. 

Numberless  observations  of  this  kind,  recorded  by  authors,  prove  the  truth  of 
these  assertions,  and  we  also  can  bear  testimony  to  the  same  point ;  thus,  we  saw 
some  females  in  1837-38,  who  were  evidently  pregnant,  and  in  whom  the  menses 
flowed  at  the  usual  periods,  and  lasted  for  the  same  number  of  days ;  one  of  them 
assured  us  that  she  menstruated  during  the  first  five  months,  and  that  her  courses 
appeared  on  the  second  of  each  month,  and  lasted  for  two  days,  just  as  she  had 
them  previously.  Again,  two  females  came  under  my  observation  at  the  Hotel 
Dieu,  whose  cases  have  already  been  published  in  my  thesis,  who  were  regular 
throughout  the  whole  term  of  pregnancy.  Haller  and  3Iauriceau  likewise  cite 
similar  cases;  but  notwithstanding  all  this,  some  accoucheurs  still  deny  that 
women  can  be  regular  whilst  pregnant. 

M.  Moreau,  who  professes  this  belief,  has,  however,  often  known  females  to 
have  sanguineous  discharges  at  variable  periods  during  gestation,  but  the  irre"-u- 
larity  of  their  appearance,  the  qualities  of  the  blood  itself,  and  the  greatness  or 
smallness  of  its  amount,  serve  to  distinguish  these,  in  his  estimation,  from  a  true 
menstrual  discharge.     The  remark  of  M.  Moreau  is  certainly  applicable  to  many 


132  GENERATION. 

cases,  but  the  instances  above  cited,  and  numbers  of  others  that  might  be  quoted 
from  various  writers,  do  not  permit  me  to  entertain  a  doubt  that  a  woman  may 
menstruate  during  pregnancy. 

On  the  other  hand,  females  may  become  pregnant  without  ever  having  had 
their  menses  j*  and  the  same  is  true  of  some  others  in  whom  they  are  suppressed 
either  by  accident,  from  the  progress  of  age,  or  in  consequence  of  nursing. ^^ 

All  these  anomalies  will  be  understood  without  difficulty,  if  we  do  but  recollect 
that,  although  the  appearance  of  the  menses  is  always  connected  with  the  ovarian 
evolution,  the  latter  may  take  place  without  being  accompanied  by  the  menstrual 
flow.      (See  Menstruation.^ 

Deventer,  Baudelocque,  and  Chambon  furnish  accounts  of  women  who  were 
regular  only  during  gestation  ;  the  case  cited  by  Deventer  is  particularly  curious, 
from  the  opportunity  he  had  of  observing  this  fact  in  four  successive  pregnancies 
of  the  same  woman.  Finally,  Desormeaux  believes  from  his  observations,  that 
in  certain  years,  and  often  without  any  apparent  cause,  a  greater  number  of 
women  have  their  menses  dui-ing  gestation,  even  where  they  were  completely  sup- 
pressed during  former  pregnancies.  Does  this  result,  as  he  appears  to  think, 
from  atmospheric  influence,  or  is  it  pure  cl»ance  ?  For  my  part,  I  am  unable  to 
decide  the  question. 

Though  it  is  important  to  be  aware  of  these  exceptional  cases,  it  is  equally 
necessary  to  guard  against  the  general  tendency  to  a  belief  of  the  marvellous.  It 
should  not  be  forgotten,  that  the  continuance  of  the  menses  during  pregnancy  is 
of  rare  occurrence,  and  that  although  their  suppression  is  of  great  value  as  a  point 
of  diagnosis,  it  may  nevertheless  be  the  result  of  a  variety  of  causes. 

2.   Enlargement  of  the  Abdomen. — An  increase  in  the  size  of  the  abdomen 

'  A  young  woman  presented  all  the  signs  of  pregnancy,  and  although  she  had  never  men- 
struated previous  to  that  period,  her  courses  then  appeared  and  continued  during  the  whole 
of  gestation.     (Perfect,  Cases  of  Midwifery,  vol.  ii,  p.  71.) 

A  lady,  aged  twenty-four  years,  during  eight  of  which  she  had  been  married,  was  never 
regular  except  during  pregnancy,  and  each  appearance  of  her  menses  proved  to  be  a  certain 
sign  that  she  was  enceinte. 

A  woman,  who  married  at  twenty-one,  had  never  been  regular;  two  years  afterwards  she 
experienced  some  gastric  distress,  and  the  flow  appeared.  Nine  months  subsequently,  she 
was  delivered  of  a  healthy  child,  notwithstanding  the  menses  did  not  fail  to  appear  every 
month.    (Churchill,  Obscrv.  on  the  Diseases  of  Pregnancy,  p.  30.) 

2  Dr.  Flechner,  of  Vienna,  relates  that  a  young  woman  of  twenty-two,  had  always  been 
regular,  but  the  menses  never  reappeared  after  the  first  accouchement,  being  replaced  each 
month  by  an  intense  headache,  accompanied  with  a  feeling  of  oppression  and  heat  in  the 
forehead  and  parietal  regions.  During  the  succeeding  thirteen  years,  she  gave  birdi  to  six 
healthy  children.    {Gaz.  Med.,  p   91,  1841.) 

Dewees  states,  that  a  woman  who  had  been  married  for  several  months,  suffered  some 
gastric  distress.  She  had  never  been  regular  but  three  times,  and  for  a  number  of  years 
there  was  a  complete  suppression.  He  directed  rhubarb  i)ills,  which  purged  her  slightly, 
but  did  not  relieve  her;  six  months  afterwards,  the  abdomen  being  somewhat  enlarged,  he 
was  enabled  to  ascertain  that  she  was  six  months  advanced  in  pregnancy;  and  soon  after 
the  menses  returned,  and  continued  regularly  until  term.  During  lactation,  which  lasted  a 
year,  the  courses  did  not  appear;  she  then  weaned  the  child,  and  in  a  short  period  again 
became  regular,  and  this,  like  the  former,  was  the  announcement  of  a  new  pregnancy. 


OF     SIMPLE     UTERINE     PREGNANCY.  loS 

may  be  produced  by  so  many  different  causes  tbat  its  slight  value  as  a  sign  will 
be  readily  foreseen.  There  is,  however,  something  peculiar  in  its  shape  and 
mode  of  development  in  gestation.  Thus  the  abdomen  swells  somewhat  in  the 
first  month,  but  this  is  owing  to  a  collection  of  gas  in  the  inteSfinal  cavity,  which, 
after  remaining  a  few  weeks,  diminishes  and  disappears,  whence  the  woman  often 
seems  smaller  at  the  end  of  the  second  month  than  during  the  first ;  but  when- 
ever this  slight  tympanitis  is  not  manifested,  the  abdomen  is  flatter  the  first 
month  than  before,  probably  because  the  uterus  settles  down  in  the  excavation. 
At  the  beginning  of  the  third  month,  or  at  three  months  and  a  half,  the  hypo- 
gastric region  evidently  becomes  more  salient,  and  the  enlargement  is  thenceforth 
regular  and  always  increasing  until  term.  Consequently,  the  tumefaction  begins 
to  show  itself  just  above  the  symphysis  pubis,  being  more  considerable  at  first  on 
the  median  line  than  elsewhere,  while  the  sides  appear  flattened  ;  after  the  fourth 
month,  the  upper  extremity  of  the  uterine  tumor  may  be  clearly  perceived  through 
the  abdominal  wall,  especially  in  thin  subjects,  by  placing  the  woman  on  her  back 
and  the  abdominal  muscles  in  a  state  of  relaxation;  but  if  the  parietes  be  thick 
and  tense,  palpation,  practised  in  the  manner  hereafter  described,  will  become 
necessary  to  ascertain  this  point. 

The  modifications  in  the  size  of  the  abdomen,  at  diff'erent  periods  of  gestation, 
have  already  been  described ;  but  its  development  is  not  always  regular,  being, 
for  instance,  muchmore  rapid  in  twin  pregnancies,  and  in  dropsies  of  the  amnios 
than  in  other  cases.  Besides,  the  relation  between  the  volume  of  the  abdomen 
and  the  stage  of  pregnancy,  is  not  always  maintained;  thus,  some  women  are  no 
larger  at  seven  or  eight  months  than  others  are  at  five,  owing  either  to  their  high 
stature,  their  breadth  of  pelvis,  or  to  the  small  degree  of  projection  in  the  ver- 
tebral column  and  upper  part  of  the  sacrum.  On  the  contrary,  in  small  women, 
more  especially  in  those  having  a  contracted  pelvis,  and  in  whom  the  womb  is 
therefore  necessarily  raised,  during  the  early  months,  above  the  superior  strait, 
the  abdominal  protuberance  is  premature,  if  I  may  so  express  it,  and  is  much 
better  marked  at  quite  an  early  period  than  ordinary. 

The  nmbili'cal  depression  at  first  appears  deeper,  its  bottom  seeming  to  be 
drawn  downward  and  backward  in  consequence  of  a  tension  of  the  urachus,  occa- 
sioned by  the  fundus  of  the  bladder  following  the  descent  of  the  uterus  in  the 
excavation.  The  circumference  of  the  ring  becomes  at  the  same  time  the  seat 
of  a  distressing  dragging  sensation,  and  is  more  sensitive  to  pressure ;  and  this 
sensibility  is  sometimes  extended  over  a  considerable  portion  of  the  abdominal 
wall.  But  about  the  end  of  the  third  month,  that  is,  as  soon  as  the  uterus  gets 
above  the  superior  strait,  the  umbilicus  resumes  its  normal  condition ;  at  the 
fourth  month,  it  is  less  hollow  than  before  conception — then  its  bottom  becomes 
more  and  more  superficial  during  the  fifth  and  the  sixth,  and  the  whole  depres- 
sion is  eff"aced,  and  is  found  on  the  same  level  as  the  skin  by  the  seventh  month, 
and  in  some  cases,  the  umbilical  ring  is  sufficiently  dilated  to  receive  the  end  of 
a  finger;  finally,  in  the  last  two  months,  the  navel  forms  a  protuberance.  Not 
unfrequently,  small  portions  of  the  epiploon  become  engaged  in  the  ring  during 
the  exertions  of  the  female  and  project  externally. 


134  GENERATION. 

These  changes  in  the  umbilicus  afford  a  rational  sign  of  gi'cat  value,  because 
they  are  almost  constant.  I  say  almost,  for  in  a  case  observed  by  M.  Blot,  there 
existed  a  depression  three-eighths  of  an  inch  in  depth,  the  woman  being  at  term 
and  of  ordinai'y  eftibonpoint.  Though  these  alterations  of  the  umbilical  depres- 
sion uiay  be  produced  by  a  pathological  tumor  of  considerable  size,  or  by  an 
accumulation  of  fluid  in  the  peritoneum,  it  is  equally  true,  that  they  almost 
always  exist  in  advanced  pregnancy,  and  that  their  absence  is,  in  a  majority  of 
cases,  conclusive  against  the  existence  of  a  foetus  of  seven  or  eight  months. 

3.  The  presence  of  the  streaks,  and  especially  of  the  brown  line,  which  ex- 
tends, as  we  have  stated,  between  the  pubis  and  umbilicus,  are  very  important  to 
the  diagnosis,  especially  in  a  primiparous  female. 

4.  The  phenomena  presented  by  the  mammae,  aiford,  in  the  opinion  of  Mr. 
Montgomery,  a  certain  sign  of  pregnancy.  Smellie  and  Hunter  also  considered 
the  changes  in  the  areola  as  a  positive  evidence  of  this  condition.  The  latter 
surgeon,  indeed,  did  not  hesitate  on  one  occasion,  when  examining  a  dead  body, 
to  declare  from  this  sole  indication,  the  uterus  to  be  enlarged  by  the  product  of 
conception ;  as  the  examination  proceeded  the  hymen  was  found  intact,  but  even 
this  did  not  change  his  opinion,  and  when  the  womb  was  opened  its  correctness 
was  fully  confirmed.  This  fact,  with  many  others  which  might  be  cited,  prove 
the  value  of  these  signs  when  they  exist,  which  unfortunately  is  not  always  the 
case;  any  one  of  them,  indeed,  may  be  wanting,  and  sometimes  they  are  totally 
absent.  Thus,  in  1837, 1  saw  a  strong  and  vigorous  young  brunette  at  La  Clbiiqiic, 
who  had  advanced  to  the  end  of  gestation,  without  any  of  the  indicated  marks 
appearing  around  the  nipple  \  and  1  have  since  made  the  same  observation  on 
several  different  occasions.  Their  absence  is  not  therefore  an  absolute  proof  of 
the  non-existence  of  pregnancy,  so  that  their  importance  in  this  respect  has  been 
exaggerated  by  some  English  surgeons.  These  cases,  however,  are  rare,  and  I 
should  diagnosticate  as  almost  certain  the  existence  of  pregnancy  in  a  young 
woman  who  had  never  borne  children,  and  whose  breasts  presented  both  a 
brownish-colored  areola,  the  tubercles,  and  the  freckled  characters  before  de- 
scribed. But  in  those  who  have  had  children,  it  is  very  difficult  to  determine 
whether  these  signs  result  from  the  modifications  of  the  breast  in  former  preg- 
nancies, or  from  a  new  conception.  In  such  cases  we  have  only  the  testimony 
of  the  women  themselves  to  rely  on,  and  this  more  especially,  if  but  a  short  time 
has  elapsed  between  the  last  and  the  present  suspected  gestation. 

5.  I  have  never  been  able  to  appreciate  the  reputed  value  of  the  signs  founded 
on  the  state  of  the  pulse  of  pregnant  women,  for  although  it  has  always  seemed 
more  developed,  fuller,  and  harder,  I  could  discover  nothing  further  concerning  it. 

The  disorders  of  digestion,  as  well  as. of  the  moral  and  intellectual  faculties, 
are  of  but  secondary  diagnostic  importance ;  they  can  do  little  more  than  direct 
the  attention  to  the  possibility  of  a  doubtful  pregnancy,  but  as  they  belong  more 
properly  to  the  pathology  of  gestation,  they  will  be  studied  hereafter. 

6.  Alterations  of  the  Urine. — For  several  years  past,  the  attention  of  a  number 
of  physicians  has  been  directed  to  the  peculiar  phenomena  exhibited  by  the  urine 
of  pregnant  women.     Thus,  M.  Nauche,  and  after  him,  Messrs.  Eguisier  and 


OF     SIMPLE     UTERINE     PREGNANCY.  135 

Tanchou,  in  France,  Dr.  Letheby  (^London  Med.  Gazette,  December,  1841), 
and  Mr.  Stark  (^The  Edlnhuryh  Med.  and  Sai'ij.  Journal,  January,  1842),  in 
Great  Britain,  and  Dr.  Elisha  Kane,  in  America  (^Ani.  Journal  of  the  Medical 
Sciences,  July,  1842),  have  submitted  the  result  of  their  observations  to  the 
public,  after  arriving  at  the  conclusion  that  pregnancy  may  be  detected  by  the 
inspection  of  the  urine  alone.  This  question,  however,  is  not  of  such- recent 
origin  as  many  seem  to  believe,  for  several  of  the  ancient  authors,  Avicenna  in 
particular,  had  previously  described  the  characteristics  of  this  fluid  in  gestation, 
and  their  writings  frequently  exhibit  a  special  attention  to  the  subject.  But  we 
may  add,  that  their  observations  were  far  less  precise,  and,  in  ^ct,  had  become 
altogether  forgotten,  when  M.  Nauche  undertook  his  researches.  We  shall  now 
present  the  principal  results  which  have  been  recently  obtained. 

If  the  urine  of  a  pregnant  woman  be  received  in  a  wineglass,  and  then  be  per- 
mitted to  settle  in  a  light,  airy  place,  the  following  peculiarities  will  be  observed  : 
When  first  excreted,  the  urine  is  acid,  whitish,  somewhat  clouded,  and  of  a 
nauseous  odor;  frequently  little  white  corpuscles,  readily  distinguishable  by  a 
glass,  are  held  in  suspension,  but,  in  a  few  moments,  these  subside  in  the  form 
of  cloudy  flakes,  either  on  the  bottom  or  sides  of  the  glass,  the  urine  meanwhile 
becoming  more  limpid  and  transparent.  Agreeably  to  the  observations  of  Dr. 
Kane,  this  primary  deposit  does  not  always  occur,  nor  is  it  peculiar  to  the  preg- 
nant state,  for  it  cannot  be  distinguished  from  the  mucous  deposits  so  often  seen 
in  the  ordinary  urine.  No  change  is  visible  on  the  surface  during  this  period, 
but,  in  the  course  of  eighteen  or  twenty-four  hours,  a  number  of  small,  brilliant, 
crystalline  granules,  irregularly  isolated,  appear  there,  in  numerous  cases;  and  in 
some  instances,  these  granulations  unite  so  as  to  constitute  a  thin,  transparent, 
and  iridescent  layer,  which  is  only  visible  in  certain  positions. 

The  urine  remains  in  that  state  for  several  days,  though  it  soon  begins  to  ma- 
nifest the  peculiar  signs  of  gestation;  thus,  upon  the  second  day,  or  during  the 
course  of  the  third,  according  to  M.  Eguisier,  sometimes  sooner,  but  rarely  later, 
its  transparency  diminishes,  the  original  clouded  appearance  returns  with  in- 
creased intensity,  the  odor  becomes  stronger,  and  a  pellicle  may  be  discerned 
forming,  at  first  like  a  nebulous  streak,  but  soon  acquiring  larger  dimensions. 
All  of  these  characters  are  more  evident  on  the  third  and  fourth  days,  and  some 
small  debris  fall  from  the  pellicle  to  the  bottom  of  the  glass.  By  the  fifth  or 
sixth  day  the  pellicle  is  almost  entirely  destroyed  ;  its  debris  precipitate  and  form 
a  white  crust  upon  the  sediment.  It  is,  however,  replaced  successively  by  new 
pellicles  less  white  than  the  former,  and  studded  with  minute  brilliant  points 
having  a  crystalline  lustre  ;  a  greenish  tint  also  supplants  the  milky  appearance. 

In  the  succeeding  days,  as  the  evaporation  of  the  urine  progresses,  its  turbidity 
and  green  color  increase;  putrefaction  commences,  and  the  second  pellicle  is 
destroyed  to  give  way  in  its  turn  to  a  third,  which  resembles  more  or  less  that 
which  putrefaction  engenders  upon  ordinary  urine. 

Dr.  Kane,  who  has  observed  these  changes  almost  hourly,  furnishes  the  fol- 
lowing account  of  their  progress  : — The  pellicle  appears  at  a  variable  period ;  I 
have  seen  it  sometimes  at  the  end  of  thirty-six  hours — at  others,  as  late  as  the 


136  GENERATION. 

eighth  day ;  it  is  scarcely  perceptible  at  first,  but  soon  a  light  cloud  of  a  milky 
or  bluish-white  appearance  is  seen  at  the  centre  or  sides  of  the  glass;  at  the  be- 
oinning,  in  some  cases,  it  is  uniformly  deposited  on  the  surface,  constituting  there 
a  transparent  layer,  which  becomes  more  and  more  distinct;  at  other  times,  it  is 
not  so  well  characterized  in  the  early  stages,  presenting  only  a  few  striated,  irre- 
o-ular  circular  lines,  resembling  a  web,  but  these  stria)  become  condensed,  and 
about  the  fifth  day  are  resolved  into  a  true  pellicle.  It  now  presents  a  creamy, 
opaline  layer,  of  a  light  yellow  color,  which  grows  thicker  and  thicker ;  its  exter- 
nal surfoce  is  rendered  unequal  and  ragged  by  the  presence  of  small  granulations, 
which  are  whiter  in  color  and  crystalline.  The  pellicle  then  resembles  the  layer 
of  fat  that  floats  on  the  surface  of  cold  broth,  and  it  retains  these  characters  for 
a  long  time.  On  the  subse(|uent  days,  the  sides  of  the  glass  are  covered  with 
small  whitish  streaks,  varying  from  a  line  to  a  fourth  of  an  inch  in  extent,  which 
attest  the  descent  of  the  pellicle  during  the  evaporation.  The  pellicle,  especially 
when  thick,  gives  ofi"  a  strong  cheesy  odor,  according  to  Dr.  Bird,  and  thus  faci- 
litates the  diagnosis ;  but  Dr.  Kane  has  verified  this  observation  in  only  seven 
cases  out  of  twenty-five,  and  he  has  not  remarked  that  any  relation  exists  between 
the  thickness  of  the  pellicle  and  the  intensity  of  the  odor. 

After  standing  for  several  days,  the  pellicle  seems  first  to  give  way  at  the 
centre,  and  fissures  extend,  somewhat  later,  from  this  point  toward  the  circum- 
ference. Gradually,  small  particles  separate  from  the  debris  and  fall  to  the  bot- 
tom of  the  glass;  the  pellicle  thus  diminishes  in  thickness,  but  it  seldom  disap- 
pears altogether  before  the  putrefaction  of  the  liquid  takes  place;  and  the  primary 
deposit  at  the  bottom  is  thus'  increased  by  all  the  detached  portions  of  pellicle, 
which  gradually  settle  down. 

The  substance  forming  the  pellicle  has  been  denominated  ki/esteine  (from 
zury^j?,  £o)q,  gestation),  the  product  of  pregnancy,  by  M.  Nauche.  The  globules, 
held  in  suspension  when  the  urine  is  excreted,  gradually  aggregate,  mount  to  the 
surface,  and  constitute  the  pellicle  above  described.  This  pellicle  rarely  fails  to 
develope  itself  in  the  urine  of  pregnant  women  ;  thus,  for  instance,  in  eighty-five 
cases  examined  by  Dr.  Kane,  it  appeared  in  sixty-eight  with  all  its  characteris- 
tics, in  eleven  it  was  not  well-marked,  and  in  six  only  it  failed  to  appear.  One 
of  the  last  six  had  a  mammary  abscess,  and  was  convalescent  from  typhoid  fever; 
another  was  very  much  enfeebled  by  previous  hemorrhages,  and  only  four  could 
be  regarded  as  true  exceptions  to  the  rule. 

^Vithout  denying  the  existence  of  the  modification  which  we  are  studying,  I 
cannot  accept  the  opinion  of  the  American  accoucheur  in  regard  to  the  fre- 
quency of  its  occurrence.  With  the  view  of  determining  this  point,  I  have 
examined  the  urine  of  a  great  number  of  pregnant  females,  and  I  can  certify, 
that  although  it  did  present  the  characters  indicated  in  a  certain  number  of  cases, 
yet  very  frequently,  and  especially  in  the  later  months,  nothing  of  the  kind  was 
discoverable. 

I  confess,  also,  that  were  I  to  depend  upon  the  result  of  my  latest  investiga- 
tions, I  should  be  inclined  to  regard  the  existence  of  this  pellicle  as  altogether 
exceptional  in  the  last  six  weeks  of  gestation  ;  for  I  have  examined  (September 


OF     SIMPLE     UTERINE     PREGNANCY.  137 

and  October,  1849)  the  urine  of  fifteen  women  without  observing  it.  I  do  not, 
however,  forget  that  I  have,  in  former  years,  proved  the  correctness  of  the  ob- 
servations of  my  predecessors,  and  I  am  unable  to  exphiin  this  difference  in  the 
result  of  experiments  performed  in  absolutely  the  same  manner.  Can  it  be  due, 
as  M.  Regnauld  supposes,  to  the  preservation  of  its  acidity  much -longer  than 
usual,  instead  of  becoming  alkaline  within  two,  three,  or  four  days,  as  is  cus- 
tomary?    I  acknowledge  that  my  attention  was  not  directed  to  this  point. 

The  urine  of  healthy  women  who  are  not  pregnant,  exhibits  nothing  similar 
to  this,  and  if  at  any  time  it  furnishes  a  pellicle,  it  has  not  the  distinctive  charac- 
ters of  kyesteine.  Some  years  ago,  it  was  my  custom  to  examine  comparatively 
the  urine  of  non-pregnant  females,  which  I  placed  in  the  same  kind  of  vessels, 
and  under  the  same  conditions  of  temperature  and  atmospheric  exposure;  and 
every  tixue  that  I  met  with  kyesteine  in  the  urine  of  pregnancy,  that  of  the  other 
woman  presented  nothing  similar. 

In  certain  pathological  conditions,  the  urine  is  sometimes  covered  with  a  pel- 
licle which  might  prove  a  source  of  error,  though  some  authors  have  pretended 
to  be  able  to  distinguish  it  from  that  which  is  due  to  pregnancy.  For  instance, 
the  pellicle  which  occasionally  forms  on  the  urine  of  persons  laboring  under 
phthisis,  articular  diseases,  vesical  catarrh,  or  a  metastatic  abscess,  does  not  ap- 
pear before  the  fifth  or  sixth  day,  that  is,  at  about  the  period  when  putrefaction 
begins,  and  having  once  commenced,  its  development  is  completed  in  the  course 
of  a  few  hours ;  whereas,  the  true  kyesteine  appears  on  the  second  day,  is  then 
developed  but  very  slowly,  and  apparently  quite  independent  of  putrefaction. 
Again,  this  latter  has  a  greater  specific  gravity  than  that  produced  by  any  patho- 
logical state  whatever. 

According  to  the  views  of  M.  Regnauld,  which  we  shall  give  shortly,  it  will 
be  seen,  that  inasmuch  as  it  is  due  to  the  same  cause,  the  pathological  pellicle 
ought  to  present  the  same  characters,  and  that  writers  have  been  deceived  as  to 
the  value  of  the  differential  signs  just  mentioned. 

The  chemical  characters  of  kyesteine  will  serve  to  distinguish  it  from  all  the 
mucous  or  albuminous  matters  found  in  the  urine.  These  properties,  agreeably 
to  M.  Eguisier,  are  nearly  all  negative ;  thus,  it  is  neutral,  insoluble  in  alcohol, 
ether,  water,  and  ammonia,  and,  unlike  albumen,  it  is  not  soluble  in  alkaline 
fluids,  nor,  like  mucus,  in  a  mixture  of  soap  and  ammonia,  neither  in  boiling- 
alcohol  and  ether  like  fat.  Further,  the  urine  containing  it  will  not  coagulate 
by  boiling,  as  albuminous  urine  does,  but  deposits  a  copious  white  powder  on 
cooling;  nor  will  it  coagulate  by  the  addition  of  nitric  acid. 

Kyesteine  has,  however,  many  of  the  properties  of  these  substances;  for,  being 
evidently  of  an  organic  nature,  it  is  precipitated  by  the  deuto-chloride  of  mer- 
cury, by  most  strong  acids,  and  the  astringent  solutions.  Finally,  in  the  present 
state  of  our  knowledge,  it  must  be  regarded  as  a  new  substance,  which  is  con- 
sidered by  MM.  Bonastre  and  Nauche  as  gelati no-albuminous.  (Eguisier.)  We 
shall  find  further  on,  that  the  researches  of  M.  Regnauld  tend  to  establish  the 
contrary. 

Although  writers  on   the  subject  agree  very  nearly  as  to  the  physical  and 


138  GENERATION, 

chemical  properties  of  kyestcine,  they  differ  widely  in  regard  to  its  microscopical 
characters.  Thus,  MM.  Eguisier,  Golding  Bird,  Kane,  and  Donn6  disagree  as 
to  the  size,  form,  and  number  of  the  globules.  M.  Simon,  who  has  very  fre- 
quently subjected  the  pellicle  to  microscopic  examination,  gives  the  following  as 
the  result  of  his  researches.  It  is  found  to  contain  the  following  elements : 
1,  an  amorphous  matter,  formed  of  small  opaque  points ;  2,  numerous  vibriones 
in  active  motion ;  3,  crystals  of  ammoniaco-magnesian  phosphate ',  4,  if  the  exa- 
mination be  made  at  a  still  later  period,  it  will  contain  an  abundance  of  monads. 

The  most  difficult  point  of  the  subject  to  determine  is  the  following  :  To  what 
is  the  presence  of  kyesteine  in  the  urine  of  pregnant  females  to  be  attributed  ? 

After  having  endeavored  to  prove  that  it  could  not  result  from  a  particular 
action  in  the  kidney,  from  the  functional  derangement  of  the  respiratory  appa- 
ratus, from  any  modification  whatever  in  the  digestive  action,  or  from  the  new 
functions  of  the  mammary  glands,  M.  Eguisier  concluded  that  it  must  be  owing 
to  the  passage  of  the  amniotic  liquor,  or  a  part  of  its  elements,  into  the  urine, 
and  he  thought  that  the  two  following  propositions  (which  are  more  fully  detailed 
in  his  memoir)  proved  the  correctness  of  his  conclusions  in  a  satisfactory  man- 
ner, namely  : 

A.  There  is  a  continual  exhalation  and  absorption  going  on  upon  the  external 
flice  of  the  amnios,  the  products  of  which  are  removed  from  the  organism  through 
the  urinary  passages. 

B.  The  admixture  of  a  certain  quantity  of  the  liquor  amnii  with  the  urine  of 
a  healthy  person,  not  pregnant,  confers  upon  it  many  of  the  properties  of  kyes- 
teinic  urine. 

The  truth  of  this  proposition  being  admitted,  it  readily  explains,  he  says,  1, 
why  the  urine  only  begins  to  be  charged  with  it  at  a  period  when  the  amniotic 
liquor  is  abundant  enough  for  us  to  suppose  that  its  passage  into  the  urine  would 
be  appreciable;  2,  why  the  kyesteinic  characters  are  not  so  evident  at  the  end 
of  gestation,  a  period  when  the  liquor  amnii  is  less  abundant,  or  less  charged 
with  animal  matters;  and  3,  why  they  suddenly  disappear  after  the  evacuation 
of  the  waters. 

But  Dr.  Kane  does  not  admit  this  explanation,  plausible  as  it  seems;  for  he 
believes  that  the  kyesteine  is  intimately  associated  with  the  lacteal  secretion,  and 
appears  to  attribute  it  to  an  admixture  of  milk  with  the  urine.  "  In  fact,"  he 
continues,  "  I  have  frequently  proved  the  presence  of  kyesteine  in  the  urine,  at 
different  periods  of  lactation,  notwithstanding  the  formal  proposition  of  M.  Egui- 
sier ;  for  in  forty-four  suckling  women,  out  of  ninety-four,  the  perfect  kyesteinic 
pellicle  was  developed,  with  all  the  characters  it  exhibits  during  gestation ;  and 
it  was  nearly  always  in  those  cases  where  the  flow  of  milk  is  limited,  or  rendered 
difficult  by  some  particular  circumstance,  and  in  which  the  breasts  were  conse- 
quently more  or  less  engorged,  that  kyesteine  appeared  in  the  urine,  but  it  was 
found  much  more  rarely  whenever  the  mother  nursed  her  infant,  and  her  breasts 
were  properly  drawn.  In  a  word,"  says  Dr.  Kane,  "the  existence  of  kyesteine 
during  pregnancy,  and  even  after  the  accouchement,  up  to  the  establishment  of 
the  mammary  secretion ;  its  rare  existence  during  lactation,  and  its  reappear- 


OF     SIMPLE     UTERINE     PREGNANCY.  139 

auce,  when  the  hitter  is  suspended  or  impeded,  at  the  time  of  weaning,  for  in- 
stance, establish  an  intimate  rehition  between  the  functions  of  the  mamnux;  and 
the  kyesteinic  urine."  Golding  Bird,  Simon,  and  Lehmann  entertain  nearly 
similar  views. 

An  attentive  study  of  the  facts  pertaining  to  this  subject  has  led  my  colleague 
and  friend,  M.  Regnauld,  to  the  following  opinion  : 

Normal  urine  holds  in  solution  a  certain  amount  of  azotized  matter,  originating, 
probably,  in  an  incomplete  combustion  of  albuminous  substances,  which  in  the 
blood  are  transformed  into  uric  acid,  or,  by  a  higher  degree  of  oxygenation,  into 
urea. 

Now  we  may  readily  assure  ourselves,  that  during  pregnancy  there  is  a  hyper- 
secretion by  the  kidney  of  an  analogous,  if  not  of  an  identical  matter;  and  it  is 
to  the  action  of  the  air  upon  this  azotized  matter  in  its  abnormal  proportions, 
that  the  several  phenomena  before  described  appear  to  be  due. 

The  first  cloudiness  of  the  fluid  is  due  to  the  separation  of  carbonate  of  lime, 
formed  by  the  reciprocal  reaction  of  the  carbonate  of  ammonia,  resulting  from 
the  decomposition  of  the  urea,  and  of  the  phosphate  of  lime,  which  already 
existed  in  the  urine.  In  proportion  as  the  decomposition  giving  rise  to  ammonia 
progresses,  the  fluid  loses  its  acidity,  until  the  brilliant  crystals  of  ammoniaco- 
magnesian  phosphate,  which  are  so  readily  recognized  by  microscopic  examina- 
tion, begin  to  appear  upon  its  surface. 

It  is  singular,  that  whilst  these  reactions  are  going  on,  such  a  multitude  of 
microscopic  animalcules  (vibriones)  should  be  developed  in  the  urine  as  to  cause 
the  whitish  layer,  when  examined  with  a  proper  magnifying  power,  to  seem 
composed  entirely  of  them,  in  connection  with  crystals  of  ammoniaco-magnesian 
phosphate. 

In  order  to  prove  that  the  formation  of  the  pellicle  of  which  we  are  speaking 
is  really  due  to  the  action  of  the  oxygen  of  the  air  upon  one  of  the  elements  of 
the  urine,  it  will  only  be  necessary  to  observe  what  takes  place  in  two  equal 
quantities  of  the  same  urine,  one  of  which  is  exposed  to  the  air,  whilst  the  other 
is  removed  from  its  influence  by  being  placed  in  an  atmosphere  of  hydrogen,  of 
carbonic  oxide,  &c.  The  first  will  present  the  characters  described,  whilst  the 
other  will  exhibit  no  such  phenomena. 

M.  Regnauld  does  not  regard  these  properties  of  the  urine  as  due  to  a  special 
matter  contained  in  it,  but  as  a  consequence  of  the  presence  of  an  over-proportion 
of  an  element  which  is  common  to  all  urine;  whence  it  seems  reasonable  to  sup- 
pose, that  this  excess  of  azotized  matter  might  exist  under  other  circumstances, 
and  then  give  rise  to  the  same  phenomena. 

The  period  at  which  the  kyesteine  appears  in  the  urine  of  pregnant  women,  is 
stated  by  writers  to  be  exceedingly  variable.  M.  Eguisier  says  that  the  charac- 
ters which  we  have  described  usually  begin  to  show  themselves  in  the  course  of 
the  second  month,  and  acquire  their  greatest  development  from  the  third  to  the 
sixth  month  ;  after  the  seventh,  they  generally  decline  until  the  end  of  gestation, 
so  that  in  the  course  of  the  ninth,  and  sometimes  even  of  the  eighth  month,  they 
are  hardly  more  marked  than  in  the  second.     M.  Tanchou  has  observed  them  in 


140  GENERATION. 

women  who  had  missed  their  courses  but  once.  Dr.  Kane  saw  them  on  one 
occasion  before  the  fourth  week,  once  before  the  fifth  week,  and  often  before  the 
end  of  the  third  month.  (Dr.  Elisha  Kane,  Amerivan  Journal  of  the  Med. 
Sciences,  July,  1842.) 

I  think  that  the  facts  which  I  have  observed,  and  the  details  which  I  have 
given,  justify  the  following  conclusions  : 

1.  That  the  pellicle  described  by  Nauche  is  not  composed  of  a  matter  of  new 
formation. 

2.  That  it  is  due  to  an  oversecretion  of  azotized  matter  which  exists  in  small 
quantity  in  normal  urine,  and  to  the  action  of  the  atmosphferic  oxygen  upon  it. 

3.  That  it  is  far  from  being  always  present  at  any  period  of  the  pregnancy, 
and  that  it  is  very  rare  in  the  latter  months. 

4.  That  it  may  appear  in  certain  pathological  conditions,  and  then  differs  in 
no  respect  from  that  which  is  observed  during  pregnancy. 

5.  That  although  the  views  of  certain  authors  who  regard  it  as  a  certain  diag- 
nostic sign  cannot  be  sustained,  its  presence  in  the  urine  of  an  otherwise  healthy 
woman  is  nevertheless  an  important  rational  sign. 

Finally,  it  will  be  perceived  that  no  one  of  the  rational  signs  whose  diagnostic 
value  has  just  been  discussed  is  conclusive,  when  taken  singly ;  excepting,  how- 
ever, the  changes  undergone  by  the  breasts,  which,  if  well  marked  in  a  primi- 
parous  female,  may  of  themselves  remove  all  doubts  as  to  pregnancy. 

But  although  singly,  these  various  signs  may  only  give  rise  to  doubts,  their 
union  furnishes  a  sum  of  probabilities  nearly  equivalent  to  certainty,  a  certainty 
which,  however,  could  never  be  complete  until  after  a  determination  of  the  sen- 
sible signs,  which  we  shall  next  proceed  to  examine. 

§  2.  Sensible  Signs. 

All  the  sensible  si2:ns  of  pi'egnancy  arc  derived  either  from  auscultation  or  the 
touch.  Hence,  we  must  carefully  study  these  two  means  of  exploration,  as  well 
as  the  results  which  they  furnish. 

A.  Of  the  Touch. — The  touch,  considered  in  an  obstetrical  sense,  is  the  art  of 
ascertaining  the  condition  of  the  various  hard  and  soft  parts  in  the  female,  which 
contribute  to  the  great  act  of  reproduction ;  and  it  consists  in  the  exploration  of 
those  parts  by  aid  of  the  finger  and  hand  applied  to  the  vulva,  vagina,  and  rec- 
tum, or  upon  the  abdomen. 

The  touch  is  practised  under  various  circumstances,  for  the  purpose  of  ascer- 
taining the  existence  and  stage  of  the  gestation ;  the  imminence  of  an  approach- 
ing accouchement;  the  progress  of  the  travail;  the  presentation  and  position  of 
the  foetus;  the  nature  and  energy,  or  the  feebleness  of  the  contractions;  and  the 
character,  volume,  and  situation  of  obstacles  presented  by  the  hard  or  soft  parts, 
which  might  prevent  the  spontaneous  termination  of  labor,  and  demand  the  re- 
sources of  art.  The  ftict  that  any  moment  in  the  life  of  the  accoucheur  )nay  call 
for  its  exercise,  is  of  itself  an  evidence  of  its  great  importance,  and  of  the  neces- 
sity for  practising  it.     With  some  experience,  any  one,  whatever  be  the  shape  or 


OF  SIMPLE  UTERINE  PREGNANCY.  141 

size  of  his  finger,  may  acquire  such  a  degree  of  skill  in  the  touch  as  will  bear 
him  through  the  most  difficult  cases  in  practice. 

Let  no  student,  therefore,  be  dislieartened  by  the  difficulties  met  at  the  com- 
mencement, or  by  the  groundless  fears  of  too  short  a  finger,  for  this  becomes  longer 
hy  exercking  the  touch;  and  those  pedants  are  unworthy  of  credence,  who  seize 
a  hand,  and  after  examining  it  gravely,  reject  it  with  disdain,  exclaiming,  "  You 
will  never  be  an  accoucheur  with  such  a  hand  as  that."  Women,  generally,  have 
shorter  fingers  than  ourselves,  yet  they  become  very  perfect  in  the  touch ;  and  I 
repeat,  that,  unless  there  is  a  malformation  of  the  hand  or  fingers,  anybody  may 
learn  by  practice  to  touch,  and  to  touch  well. 

The  touch  comprises  the  exploration  of  the  vagina  and  of  the  rectum,  as  also 
palpation  of  the  abdomen. 

1.  Vaginal  Touch. — The  index  finger  is  usually  employed  for  this  purpose; 
after  being  extended,  it  is  entered  horizontally  in  the  fissure  between  the  nates, 
until  arrested  by  the  soft  parts,  and  the  index  is  then  drawn  forwards,  as  far  as 
the  opening  of  the  vulva.  I  prefer  this  method  to  the  one  in  which  the  finger 
is  carried  from  before  backwards,  in  such  a  manner  as  to  pass  over  the  clitoris 
and  the  meatus  urinarius,  because  friction  against  these  parts  should  always  be 
avoided  with  the  greatest  care.  In  bringing  the  finger  from  behind  forwards,  it 
would  not  be  possible,  except  through  gross  negligence,  to  confound  the  anal 
orifice  with  the  vaginal  opening,  and  this  being  once  found,  the  index  is  first 
pressed  almost  directly  backwards,  until  one-third  of  it  has  penetrated  into  the 
vagina,  and  then  by  strongly  depressing  the  wrist,  the  operator  gives  his  finger  a 
nearly  vertical  direction,  so  that  the  thumb  may  be  applied  against  the  anterior 
face  of  the  symphysis,  the  radial  border  of  the  index  be  directed  in  front,  and  its 
cubital  border  be  placed  against  the  anterior  perineal  commissure,  which  it  serves 
to  push  backwards.  The  other  three  fingers  vary  in  position,  according  to  the 
case,  and  more  especially  to  the  object  in  view;  for  example,  if  desirable  to  ex- 
plore the  parts  situated  on  the  posterior  plane  of  the  excavation  with  the  index, 
it  is  better,  in  my  opinion,  to  extend  them  on  the  perineum,  pressing  the  latter 
up  by  the  radial  border  of  the  medius ;  but  if,  on  the  other  hand,  we  wish  to 
perform  the  ballottement,  or  to  explore  the  parts  on  the  anterior  plane,  it  will  be 
more  convenient  to  flex  the  thumb  and  the  other  three  fingers  into  the  palm,  the 
index  alone  being  extended,  with  its  palmar  portion  directed  in  front.  Stein 
directs  the  medius  to  be  joined  with  the  forefinger,  but  this  is  generally  useless, 
and  often  inconvenient,  for  although  the  two  fingers  may  possibly  penetrate  a 
little  deeper,  the  sensation  is  not  so  clear  as  that  obtained  by  one. 

Physicians  should  accustom  themselves  to  touching  with  both  hands,  for  there 
are  some  diseases  of  women,  and  some  positions  of  the  foetus,  which  compel  the 
accoucheur  to  use  the  left  hand.  Or,  it  may  also  happen  that  a  wound  upon  the 
right  will  necessarily  require  the  left  to  be  substituted,  though,  for  all  ordinary 
purposes,  the  right  is  sufficient. 

The  woman  should  be  placed  cither  in  the  erect,  or  the  recumbent  position 
during  the  examination,  according  to  circumstances.  In  the  commencement  of 
pregnancy,  it  is  better,  as  a  general  rule,  to  have  her  lying  down;  because,  in 


142  GENERATION. 

this  position,  the  head  being  propped  up,  and  the  inferior  extremities  flexed  and 
separated,  the  abdominal  muscles  are  thrown  into  a  state  of  relaxation,  and  thus 
the  development  of  the  uterus  can  more  easily  be  determined.  Again,  such 
diseases  as  prevent  the  female  from  standing  erect,  may  also  require  the  same 
posture.  But  at  a  more  advanced  period,  either  position  may  be  used  indiffer- 
ently, thouirh  most  frequently  the  ballottement  can  be  accomplished  better  while 
the  woman  is  standing.  In  this  latter  case,  her  loins  should  lean  against  a  wall 
or  some  piece  of  furniture ;  a  chair  must  be  placed  at  each  side  for  her  hands  to 
rest  upon,  and  the  upper  part  of  her  body  is  to  be  slightly  flexed  forward. 

Where  any  difficulties  are  encountered  in  the  exploration,  it  is  advisable  to 
touch  in  both  positions. 

Before  operating,  the  accoucheur  should  anoint  his  finger  with  some  unctuous 
substance,  fat,  butter,  oil,  mucilage,  &c.,  for  the  double  object  of  rendering  the 
introduction  easier  and  less  painful  to  the  woman,  and  to  protect  himself  from 
the  contagion" of  any  diseases  she  may  be  affected  with. 

When  the  female  is  standing,  he  should  place  himself  before  her,  resting  on 
one  knee — in  my  opinion,  it  is  not  wholly  immaterial  which — for,  as  a  general 
rule,  the  knee  opposite  to  the  operating  hand  is  preferable,  because  the  other  one 
will  then  furnish  a  point  of  support  for  the  elbow  to  lean  upon ;  though,  if  the 
woman  be  very  short,  it  would  be  better  to  flex  the  right  knee,  if  the  right  hand 
is  used. 

When  the  patient  is  recumbent,  the  accoucheur  places  himself  at  her  side,  the 
right  one,  if  he  intends  using  the  right  hand,  and  on  the  left,  if  the  other  is  to 
be  employed.  One  hand  is  then  placed  upon  the  abdomen,  while  the  other  is 
engaged  in  the  vaginal  exploration  ;  and  this  precaution  is  especially  advisable, 
when  the  ballottement  is  practised,  in  order  to  fix  the  fundus  uteri,  and  keep  it 
steady.  In  passing  the  finger  over  the  perineum,  and  before  entering  the  vagina, 
we  ascertain  the  presence  or  absence  of  the  fourchette,  or  the  inequalities  that 
supply  its  place  after  a  labor;  and  as  the  index  enters  the  vagina,  it  should  ex- 
amine the  condition  of  the  external  labia,  the  length  and  width  of  the  vagina,  its 
mucous  membrane,  whether  smooth  or  rugous,  the  various  diseases,  tumors,  or 
de"-enerations  that  may  exist  on  the  surface  or  in  the  substance  of  its  walls,  and 
the  condition  of  the  rectum,  whether  full  or  otherwise.  Hereafter,  we  shall  have 
occasion  to  speak  of  this  process  as  a  means  of  diagnosis  in  the  various  vices  of 
conformation. 

All  these  explorations  being  made,  the  next  step  is  to  examine  the  neck  of  the 
uterus,  and  learn  its  modifications  in  form,  consistence,  situation,  direction,  and 
in  the  dimensions  of  its  cavity ;  all  which  have  been  carefully  described.  (See 
page  108,  et  seq.)  The  finger  may  detect  the  development  of  the  body  of  the 
uterus,  by  ascertaining  the  spreading  out  of  its  inferior  part.  Until  toward  the 
third  month,  the  organ  is  almost  wholly  within  the  excavation,  it  having  at  that 
early  period  increased  so  much  in  size  as  to  occupy  almost  all  the  true  pelvis. 
Its  mobility  is,  however,  very  slight,  in  consequence  of  its  restrained  position, 
whilst  in  the  ordinary  unimpregnated  state,  it  may  be  carried  to  the  right  or  left, 
forward  or  bac 'cward,  by  simply  presiding  with  the  finger  on  the  side  of  the  neck. 


OF     SIMPLE     UTERINE     PREGNANCY.  143 

The  restraint  of  the  body  during  pregnancy  renders  the  neck  immovable,  so  that 
it  becomes  impossible,  or  at  least  very  difficult,  to  produce  such  motions ;  the 
uterus  will  also  be  found  much  heavier  if  an  attempt  be  made  to  raise  it. 

2.  Pdlpation  of  the  Abdomen. — An  exploration  of  the  abdomen,  says  Schmitt, 
is  of  great  importance  in  diagnosis,  and  should  always  be  resorted  to  when  it  is 
desirable  to  ascertain  whether  pregnancy  exists.  It  is  often,  indeed,  more  in- 
structive, and  furnishes  surer  results,  than  the  internal  examination. 

Some  obstacles  are,  however,  met  with  in  this  mode  of  research.  Thus  : 
1,  the  walls  of  the  abdomen  may  be  too  thick ;  2,  its  muscles  may  be  very  tense; 
3,  the  bladder  may  be  greatly  distended  with  urine,  and  the  intestines  with  gas 
or  fecal  matter;  4,  lastly,  a  fixed  pain  in  the  hypogastric  region,  rendering  any 
pressure  there  often  insupportable  to  the  patient. 

The  too  creat  thickness  of  the  walls  of  the  abdomen  is  the  only  one  of  -these 
difficulties  which  is  permanent,  but  which,  nevertheless,  frequently  renders  the 
palpation  of  the  abdomen  entirely  fruitless;  for  as  the  tension  and  sensibility  of 
the  walls  are  but  temporary,  the  exploration  may  be  deferred  to  a  more  favorable 
opportunity,  and  the  bladder  and  rectum  may  always  be  evacuated  beforehand. 

These  obstacles  are  of  rare  occurrence,  the  examination  being  generally  quite 
easy,  owing  to  the  flexibility  of  the  walls  of  the  abdomen. 

In  order  to  practise  it,  the  female  must  lie  down  in  such  a  way  that  her  hips 
shall  be  elevated,  the  head  flexed  on  the  chest,  and  the  thighs  on  the  abdomen ; 
in  a  word,  so  as  to  relax  the  abdominal  muscles  completely.  Whilst  in  this  posi- 
tion, the  abdomen  should  be  first  examined  with  both  hands,  so  as  to  ascertain 
its  form,  size,  tension,  resistance,  and  hardness,  especially  in  the  sub-umbilical 
region.  In  the  earlier  months  of  gestation,  if  the  parietes  are  not  too  thick,  a 
round  tumor,  of  fleshy  consistence,  can  be  detected  rising  out  of  the  pelvis,  some- 
times in  the  middle,  and  at  others  a  little  towards  the  right  or  the  left  side; 
during  the  first  two  months  it  seems  to  rise  higher  above  the  pubis  than  in  the 
course  of  the  third,  which  fact  is  readily  accounted  for  by  the  sinking  down  of 
the  organ,  occasioned  by  its  increasing  weight  and  volume.  This  tumor,  which 
is  the  womb,  rises  gradually  toward  the  epigastrium  as  gestation  progresses,  and 
it  often  becomes  necessary,  in  order  to  form  some  idea  of  the  time  at  which  labor 
will  probably  occur,  to  ascertain  the  exact  amount  of  its  elevation.  The  following 
is,  I  think,  the  best  mode  of  accomplishing  this  object:  Place  the  ends  of  the 
eight  fingers  immediately  above  the  symphysis,  and  then  continue  to  ascend  gra- 
dually, so  long  as  they  feel  any  resistance,  for  when  the  fundus  uteri  is  gained, 
the  resistance  suddenly  ceases,  and  the  fingers  sink  deeper  as  they  glide  over  the 
convexity,  which  is  thus  recognized  without  difficulty. 

The  uterine  tumor,  which  is  at  first  quite  resisting,  becomes  less  so  as  gestation 
advances;  sometimes,  however,  it  is  so  soft  as  to  be  barely  distinguishable.  An 
attentive  examination  will  enable  us  to  detect  the  following  characters:  1.  It 
always  remains  circumscribed  and  retains  its  oval  form ;  2.  It  presents  a  certain 
amount  of  elasticity,  similar  to  that  of  a  cyst  filled  with  serum  ;  3.  If  this  manual 
exploration  be  continued  in  the  same  direction,  the  examiner  will  detect  greater'^ 
and  lesser  parts  of  a  single  irregular  mass,  which  are  movable  and  easily  dis- 


144  GENERATION. 

placed  like  bodies  suspended  in  water.     Often,  indeed,  these  movable  parts  may 
be  recognized  as  belonging  to  the  fa^tus. 

As  a  part  of  the  abdominal  exploration  should  also  be  reckoned  the  sign  fur- 
nished by  percussion,  namely,  a  dull  sound  over  every  part  of  the  abdomen  occu- 
pied by  the  developed  uterus,  instead  of  the  resonance  perceived  at  other  points. 
Some  care  is  necessary  in  percussing,  during  the  first  four  or  five  months,  not 
to  be  misled  by  the  dulness  which  a  distended  bladder,  or  a  pathological  tumor 
of  considerable  size  might  produce.  It  should  also  be  borne  in  mind,  that 
although  the  uterus  may  have  risen  to  near  the  umbilicus,  a  clear  sound  will  be 
yielded  on  percussion  throughout  the  greater  part  of  the  sub-umbilical  region, 
provided  a  few  folds  of  intestine  be  interposed  between  the  walls  of  the  abdomen 
and  the  womb. 

Sometimes  the  uterus  is  above  the  superior  strait  in  the  earliest  months.  I 
had  an  opportunity  of  observing  a  case  of  the  kind  at  the  Clinic,  with  Professor 
Dubois,  in  a  woman  who  was  advanced  six  weeks  or  two  monihs ;  the  uterus  was 
so  elevated,  being  found  in  the  right  iliac  fossa,  that  at  first  we  doubted  the 
existence  of  pregnancy,  which  however  was  real,  as  was  proved  more  positively 
several  weeks  after,  and  fully  justified  by  the  event  of  the  case. 

The  palpation  of  the  abdomen  and  the  vaginal  touch,  are  in  most  cases  prac- 
tised simultaneously;  we  shall,  therefore,  point  out  the  signs  which  this  joint 
investigation  furnishes  at  the  diiferent  periods  of  pregnancy. 

1.  In  the  first  three  or  four  months,  the  uterus  either  remains  wholly  within 
the  lesser  pelvis,  or  else  its  fundus  projects  somewhat  above  the  superior  strait. 
In  the  first  case,  it  will  be  easily  discovered  by  the  vaginal  touch  that  the  entire 
excavation  is  occupied  by  a  slightly  movable  tumor,  with  a  smooth  and  regular 
external  surface.  In  the  second  case,  the  lower  half  of  the  lesser  pelvis  is  empty, 
but  the  examination  of  the  abdomen,  conducted  according  to  the  rules  above 
mentioned,  discovers  the  tumor  formed  by  the  womb  in  the  hypogastrium.  The 
first  point  to  be  ascertained  is  the  exact  size  of  the  uterus,  and  this  can  only  be 
.  determined  by  the  double  exploration  spoken  of:  the  finger,  having  been  intro- 
duced into  the  vagina,  is  applied  directly  on  the  neck,  or,  still  better,  against  the 
anterior  or  posterior  portion  of  the  inferior  segment  of  the  uterus,  while  the  other 
hand,  placed  above  the  pubis,  presses  down  the  muscular  walls,  and  searches  for 
the  tumor  formed  by  the  fundus  uteri ;  the  womb  is  thus  included  between  the 
finger  in  the  vagina  and  the  hand  on  the  hypogastrium,  and,  of  course,  the 
volume  of  the  organ  may  be  thus  ascertained,  and  a  comparison  made  between  it 
and  the  uninipregnated  uterus.  Moreover,  its  displacement  in  mass  can  be  very 
easily  i-ecognized  in  this  position.  To  accomplish  this,  the  finger  should  remain 
applied  as  above  stated,  and  when  the  hand  slightly  depresses  the  fundus,  the 
finger  in  the  vagina  recognizes  the  depression ;  and  the  counter-proof  may  be 
made  by  endeavoring  to^aise  the  uterus  from  below,  by  pressing  strongly  on  the 
inferior  part,  which  is  found  deep  in  the  excavation. 

But  the  tumor  which  is  felt  in  the  lesser  pelvis,  or  in  the  hypogastric  region, 
may  be  cither  formed  by  the  uterus,  or  developed  in  the  adjacent  parts.  In  the 
latter  case,  the  womb  will  generally  be  found  to  be  displaced,  and  pressed  by  the 


OF  SIMPLE  UTERINE  PREGNANCY.  145 

tumor  against  one  of  the  sides  of  the  pelvis ;  and  if  the  neck  be  traced  fi'om 
below  upwards,  the  finger  will  detect  a  line  of  demarcation  between  the  wall  of 
the  uterus  and  the  pathological  tumor;  sometimes,  it  can  even  be  insinuated  be- 
tween them.  The  motions  to  which  the  neck  is  subjected  are  not  usually  com- 
municated to  the  tumor,  and  vice  versa.  Finally,  the  neck  will  exhibit  none  of 
the  changes  peculiar  to  pregnancy. 

Hitherto  we  have  only  demonstrated  that  the  uterus  is  developed ;  but  the 
question  arises  what  is  the  cause  of  that  development?  The  solution  is  nearly 
always  difficult ;  we  may  state,  however,  that  when  the  womb  is  enlarged  by  a 
product  of  conception,  its  walls  are  generally  more  flexible  than  if  the  enlarge- 
ment were  dependent  upon  some  chronic  disease ;  and  that,  after  a  little  practice, 
this  suppleness  can  be  detected  by  carrying  the  finger  to  the  posterior  surface  of 
the  body,  which  mdy  be  done  in  consequence  of  the  depression  and  retroversion 
of  the  fundus.  The  uterine  wall  then  offers  about  the  same  resistance  as  an 
cedematous  limb,  ojpperhaps  still  nearer,  that  of  caoutchouc  when  slightly  softened 
in  hot  water. 

The  tumor  detected  either  by  the  vaginal  touch,  or  by  depressing  the  ventral 
parietes,  is  rounded  and  smooth  throughout,  and  does  not  present  any  of  those 
irregularities  observed  in  cancerous  or  fibrous  degenerations  of  its  walls;  and  this 
fact,  together  with  the  preceding  observation,  will  serve  to  distinguish  a  morbid 
state  from  a  true  gestation. 

It  certainly  will  not  prove  quite  so  easy  to  determine  whether  the  enlargement 
is  caused  by  a  foetus,  or  the  presence  of  a  mole  in  the  cavity;  in  foct,  I  do  not 
believe  this  diagnosis  is  possible,  except  at  a  very  advanced  stag^,  and  then  the 
absence  of  the  foetal  inequalities,  the  non-appearance  of  its  movements,  auscul- 
tation, &c.,  might  suffice  to  remove  the  doubts  on  the  subject. 

In  some  women,  the  womb  becomes  congested  and  considerably  tumefied  at 
the  menstrual  periods.  Now  this  state  may  readily  be  confounded  with  a  com- 
mencing pregnancy,  the  more  particularly,  because  at  those  epochs  the  neck 
usually  becomes  softer  and  dilates  a  little ;  and  I  know  no  way  of  escaping  this 
error,  if  the  woman  insists  that  she  is  pregnant,  and  experiences  the  various 
rational  signs  of  that  condition.  In  two  cases  of  the  kind  I  have  met  Avith,  I 
only  succeeded  in  detecting  the  folsity  of  my  diagnosis  by  examining  the  woman 
a  second  time,  two  or  three  weeks  after ;  for  these  females,  who  were  used  as 
subjects  for  practising  the  touch  at  the  Clinique,  wished  to  be  considered  preg- 
nant ;  but,  unhappily  for  them,  the  fortune  which  aided  in  the  first  examination, 
deserted  them  at  the  second ;  for,  being  ignorant  of  the  cause  of  my  mistake, 
they  returned  at  a  time  still  more  distant  from  their  menstrual  period. 

On  the  whole,  then,  there  is  no  certain  sign  of  pregnancy  during  the  first 
three  or  four  months ;  yet  it  becomes  almost  certain,  when  the  sensible  signs 
above  indicated  coincide  with  the  presence  of  the  rational  ones,  in  a  healthy 
woman  who  can  have  no  intention  of  deceiving  us  as  to  her  condition;  still,  in  a 
medico-legal  case,  the  physician  should  express  his  doubts,  and  demand  a  new 
examination  at  a  more  advanced  period.  But  if  it  is  not  always  possible  at  the 
beginning  of  a  gestation  to  prove  that  it  does  exist,  we  can,  at  least  in  the  great 

10 


146  GENERATION. 

majority  of  cases,  satisfy  ourselves  positively  that  it  does  not;  for,  most  frequently, 
the  unimpresnated  state  of  the  organ  can  be  readily  made  out. 

2.  The  existence  of  pregnancy  is  announced  during  the  last  five  months  by 
certain  signs  that  ai-e  far  more  reliable  than  any  of  thpse  hitherto  mentioned,  and 
which  are  revealed  by  the  double  exploration  just  described;  these  are  the  foetal 
movements,  which  have  improperly  been  called  the  active  and  passive,  but  better 
designated  by  M.  Stoltz  as  the  movements  proper  and  the  communicated  ones. 

Active  Movements. — The  woman  generally  perceives  the  foetal  movements  at 
about  four  months  and  a  half,  although  the  muscles  of  the  infant  had  contracted 
long  ere  this,  unconsciously  to  her ;  for  every  accoucheur  must  have  detected 
these  motions  by  placing  his  hand  upon  the  abdomen,  at  a  time  when  the  mother 
herself  still  doubted  her  own  pregnancy.  Now  these  movements  are  excessively 
feeble  at  first,  and  produce  a  kind  of  tickling,  or  rather  a  sensation  analogous  to 
that  of  the  crawling  of  a  spider;  they  gradually  become  more  characteristic,  and 
may  then  be  classified  in  two  species.  One  of  these  is  prdjhced  by  the  move- 
ments of  the  whole  trunk,  or  some  of  its  parts,  the  first  of  which  are  recognized 
by  a  quivering  that  is  perceptible  to  the  female,  while  the  partial  motions  give 
rise  to  quite  large  projections,  which  are  even  visible  through  the  abdominal 
walls ;  the  other,  on  the  contrary,  are  blows,  certain  small,  short  strokes,  which 
at  times  are  violent  enough  to  elicit  cries  from  the  sufferer,  and  these  shocks  are 
evidently  produced  by  the  action  of  the  thoracic  or  inferior  extremities  of  the 
child.  Such  movements,  so  distinct  and  clear  to  the  mother,  would  seem  to  be 
an  infallible  sign  of  gestation,  and  yet  such  is  by  no  means  the  case,  since  it  is 
not  at  all  uncoii^non  to  find  women,  whose  veracity  is  beyond  question,  asserting 
that  they  have  felt  them  for  a  long  period,  and  sometimes  the  motions  have  even 
been  perceived  by  the  husband  or  other  persons,  yet  without  their  being  pregnant. 
The  history  of  one  of  the  English  queens  is  well  known,  who,  believing  she 
had  felt  the  motions  of  a  child,  despatched  couriers  with  the  happy  news  to  all 
the  foreign  courts,  but  proved  to  be  only  the  commencement  of  a  dropsy  !  Such 
errors  are  frequent,  and  there  are  but  few  accoucheurs  who  have  not  met  with 
many  of  them  in  practice.  Consequently,  the  physician  should  not  rely  in  this 
matter  upon  the  statement  of  the  woman,  but  should  perceive  them  for  himself 
before  hazarding  an  opinion.  It  would  seem,  indeed,  that  in  some  cases,  the 
intestinal  movements,  the  rapid  passage  of  gas  in  the.  intestines,  certain  partial 
and  irregular  contractions  of  the  abdominal  muscles,  and  the  pulsation  of  a  large 
artery,  especially  when  situated  behind  any  tumor  which  it  raises  at  every  beat, 
have  often  deceived  not  only  the  patient,  but  even  her  medical  attendant. 

Some  females,  from  the  desire  of  simulating  pregnancy,  have  acquired  the 
power  of  contracting  their  abdominal  muscles  in  so  singular  a  manner,  that  many 
able  accoucheurs  have  been  deceived,  and  believing  that  they  felt  the  foetal 
movements,  have  consequently  pronounced  them  pregnant.  (Montgomery,  p.  84.) 
These  motions  may  be  detected  by  the  vaginal  touch  in  certain  positions  of  the 
breech,  or  even  of  the  trunk,  but  we  must  rely  chiefly  on  the  abdominal  palpa- 
tion for  their  detection.  In  general,  it  is  only  necessary  to.  place  the  hand  flat 
on  the  abdomen,  or  to  make  use  of  slight  pressure,  to  perceive  them;  though  if 


OF    SIMPLE     UTERINE    PREGNANCY.  147. 

they  are  feeble  and  infrequent,  it  is  better  to  dip  the  hand  in  some  very  cold 
liquid,  and  then  place  it  suddenly  upon  the  skin.  This  rapid  change  in  the  tem- 
perature of  the  abdomen  probably  reacts  upon  the  infant,  for  it  generally  moves 
convulsively.  I  believe,  with  Dr.  Tyler  Smith,  that  the  sudden  impression  of 
cold  is  more  likely  to  produce  a  rapid  contractioo  of  the  abdominal  muscles  or 
uterus,  than  to  act  directly  upon  the  foetus,  and  that  its  use  might  readily  deceive 
as  to  the  nature  of  the  motions  which  it  occasions. 

I  prefer  placing  a  hand  upon  one  of  the  sides  of  the  abdomen,  and  striking 
with  the  other  on  a  point  opposite ;  for  the  foetus  then  rarely  fails  to  move  briskly 
as  though  to  resist  the  impulse. 

As  before  stated,  the  movements  begin  to  be  felt  about  tlie  end  of  the  fourth, 
month.  To  this  law,  however,  there  are  numerous  exceptions;  thusysome  women 
perceive  them  as  eally  as  the  latter  half  of  the  third  month,  others  not  before 
the  fifth,  sixth,  seventh,  or  eighth  months  of  gestation.  One  woman,  who  had 
advanced  to  the  ^^//^  period,  was  brought  to  the  Clinique,  in  consequence  of  a 
fall  in  the  street,  aSishe  assured  us  that  she  had  never  felt  the  movement  prior 
to  the  accident.  We  have  already  alluded  to  the  person,  seen  by  us  at  La 
Charite,  under  the  care  of  Professor  Fouquier,  who  was  delivered  at  term  of  a 
very  healthy  child,  but  the  motions  of  which  were  neither  perceptible  to  the 
mother  nor  ourselves. 

Mauriceau,  Delamotte,  and  many'  others,  bring  forward  similar  cases.  But 
the  most  remarkable  of  all  is  the  one  reported  by  Campbell.  I  knew  a  lady,  he 
says,  the  mother  of  nine  children,  who,  excepting  in  her  first  pregnancy,  never 
perceived  any  motions  of  the  foetus;  but  she  was  herself  very  inanimate  and  pas- 
sive, and  what  was  still  more  singular,  the  children  were  equally  nonchalant  as 
herself.  Whenever  an  ascites  complicates  the  pregnancy,  these  motions  are  very 
indistinct,  thus  affording  an  evidence  that  it  is  the  abdominal  walls,  and  not  the 
uterus,  which  perceive  the  impulse. 

After  the  movements  have  been  distinctly  felt,  they  sometimes  diminish  with- 
out any  appreciable  cause,  both  in  frequency  and  intensity,  and  then  altogether 
disappear,  which  circumstance  demands  the  most  serious  attention  of  the  accou- 
cheur, as  it  is  in  general  an  unfortunate  symptom. 

I  believe  this  spontaneous  cessation  of  the  active  movements  may  usually  be 
referred  to  a  plethoric  state  of  the  mother,  which  reacts  on  the  child's  health. 
But  whatever  may  be  the  value  of  this  opinion,  it  is  quite  certain  that  bleeding, 
under  such  circumstances,  has  always  produced  a  favorable  result;  for  when  not 
delayed  too  long,  the  movements  reappeared  soon  after,  and  hence  I  cannot  re- 
commend the  measure  too  highly. 

The  Passive  Movements,  or  Ballottement. — This,  according  to  most  authors,  is 
an  analogous  sensation  to  that  produced  by  placing  a  ball  of  marble  in  a  bladder 
full  of  water,  and  theu  striking  the  bladder  with  the  finger  just  under  the  spot 
where  the  ball  rests,  when  the  latter  is  thrown  up,  and  falls  back  from  its  own 
weight  upon  the  finger  which  displaced  it.  This  comparison,  however,  only  holds 
good  at  a  certain  period  of  gestation,  and  we  shall  again  take  occasion  to  refer 
more  particularly  to  this  point.    To  perform  the  ballottement,  M.  Yelpeau  directs 


148  '  GENERATION. 

tlie  index  fin2;cr  of  one  hand  to  be  placed  under  the  cervix,  and  the  palmar  face 
of  the  other  hand  over  the  fundus  uteri;  then,  by  a  sudden  movement  of  the 
finger  in  the  vagina,  the  uterus  is  to  be  pushed  upwards ;  being  movable,  free, 
and  the  only  solid  body  in  the  amniotic  liquid,  the  foetus  ascends,  strikes  the 
point  diametrically  opposite,  and  falls  back  upon  the  finger  which  gave  it  the 
impulse. 

But  as  this  mode  will  not,  I  believe,  afford  any  satisfactory  results  in  the  ma- 
jority of  cases,  I  recommend  students  to  pursue  the  following  plan  in  performing 
the  operation ;  the  vaginal  finger  should  not  be  placed  under  the  cervix,  because 
it  will  then  be  separated  from  the  foetus  by  the  whole  length  of  the  neck,  and  of 
course  the  finger  cannot  recognize  so  clearly  the  descent  of  the  displaced  body ; 
but  rather  in  front  of,  or  behind  the  neck  (according  to  the  woman's  position), 
upon  the  walls  of  the  body  itself  j  for  then  the  index  is  only  removed  from  the 
substance  to  be  examined  by  the  very  thin  walls  at  the  inferior  region  of  the 
uterus,  and  it  detects  very  readily  the  least  motion  of  the  ^|o8ed  foetus. 

If  the  woman  is  standing,  the  index  should  be  introduced  in  a  vertical  posi- 
tion, with  its  palmar  face  turned  forward,  and  the  other  three  fingers  flexed  into 
the  palm,  and  as  the  symphysis  pubis  scarcely  exceeds  an  inch  and  a  half  in 
length,  the  digital  extremity  of  the  forefinger  easily  passes  its  superior  part,  and 
reaches  the  body  of  the  organ,  where  it  almost  always  encounters  a  hard  globular 
tumor  formed  by  the  head  of  the  foetus ;  then  a  light,  quick  blow  is  to  be  given 
by  it,  after  which  the  finger  must  remain  immovable  on  the  part  struck.  This 
shock  should  be  made  in  a  direction  from  below  upwards  and  from  behind  for- 
wards by  suddenly  flexing  the  first  phalanx.  This  last  recommendation  I  deem 
very  important ;  for  in  the  great  majority  of  cases,  the  uterus  is  inclined  forwards, 
its  long  diameter,  like  that  of  the  foetus,  corresponding  very  nearly  to  the  axis  of 
the  superior  strait.  Now,  if  under  these  circumstances,  the  shock  be  communi- 
cated to  the  presenting  part  of  the  child  from  below  upwards,  and  from  before 
backwards,  as  generally  done,  it  is  evident  that  the  motion  given  to  it  will,  at 
furthest,  be  but  a  slight  movement  of  displacement  or  jolting,  but  never  one  of 
ascension,  which  in  fact  would  be  impossible,  because  by  the  direction  of  the 
blow  the  foetus  is  pushed  against  the  posterior  uterine  wall,  and  not  along  the 
axis  of  its  cavity. 

The  ballottement  may  also  be  effected  when  the  woman  is  recumbent,  by  acting 
in  the  manner  I  have  just  indicated,  but  it  is  then  generally  necessary  to  place 
the  finger  upon  a  point  somewhat  nearer  to  the  neck,  sometimes  before,  but  at 
others  behind  it.  The  erect  position,  howevci^  is  usually  the  more  favorable  for 
the  perception  of  the  ballottement,  and  therefore  preferable. 

It  sometimes  happens,  about  the  fifth  month  of  gestation,  that  if  the  woman 
be  standing,  the  vaginal  touch  does  not  afford  the  sensation  of  ballottement ;  but 
if  she  be  directed  to  lie  down,  and  the  vaginal  finger  be  applied  upon  the  uterine 
wall,  whilst  the  body  of  the  womb  is  forcibly  depressed  by  the  other  hand  placed 
near  the  umbilicus,  the  vaginal  finger  is  struck  by  some  part  or  other  of  the 
foetus,  which  is  displaced  by  the  external  pressure. 

At  an  early  period  of  pregnancy,  it  is  sometimes  possible  to  perceive  the  bal- 


OF  SIMPLE  UTERINE  PREGNANCY.  149 

lottement  by  simply  feeling  the  abdomen.  If  the  woman  be  placed  on  her  side, 
in  a  horizontal  position,  the  foetus,  in  obedience  to  gravity,  descends  to  the  lowest 
points.  If  the  hand  be  then  glided  beneath  the  side  of  the  abdomen  which 
touches  the  bed,  some  part  of  the  foetus  will  be  distinguished  and  may  be  readily 
displaced,  but  soon  returns  to  its  original  situation. 

This  sign  usually  becomes  valuable  about  the  fourth  month,  for  before  that 
period  the  foetus  is  generally  too  small,  and,  possibly,  the  uterine  walls  are  too 
thick.  Again,  it  varies  much  after  that  time  j  for  instance,  our  search  is  not 
always  successful  in  the  fifth  month,  the  small  size  of  the  child  permitting  it  to 
change  position  very  easily;  on  one  day  it  is  found  without  difficulty,  and  on  the 
following  it  defies  all  efforts  at  detection. 

Towards  the  seventh  month,  the  ballottement  is  in  general  the  most  clearly 
recognized,  since  it  is  at  this  period,  especially,  that  the  finger  perceives  the  solid 
mass,  enclosed  and  swimming  in  a  liquid,  to  rise  up  and  shortly  afterwards  to  fall 
back  upon  it;  but  tke  sensation  is  no  longer  perceptible  at  the  end  of  the  eighth 
or  the  beginning  of  the  ninth  month,  unless  there  happens  to  be  an  unusual 
amount  of  water,  for  then  the  foetus  has  become  too  large.  The  finger  can  in- 
deed raise  it,  but  the  friction  against  the  walls  of  the  uterus  almost  destroys  the 
tendency  to  ascend.  The  mobility  of  the  tumor  is  readily  detected,  but  it  now 
leaves  the  finger  which  impels  it ;  it  is  a  displacement  in  mass  rather  than  bal- 
lottement. Finally,  iu  the  latter  periods  of  gestation,  the  head  pushing  the 
uterine  wall  before  it,  engages  in  the  superior  strait,  sometimes  even  gets  low 
down  in  the  excavation,  thus  becoming  jammed  in,  as  it  were,  and  of  course  the 
ballottement  is  then  altogether  impossible. 

Writers  declare  this  sign  to  be  a  certain  indication  of  pregnancy;  but  the  pro- 
position is,  perhaps,  somewhat  too  absolute ;  for  example,  it  is  possible  for  a  stone 
resting  in  the  .bas-fond  of  the  bladder  to  lead  to  an  error,  and  I  once  met  with  a 
case  which  might  readily  cause  a  mistake  of  this  kind.  During  the  time  I  acted 
at  the  obstetrical  clinic,  as  chef  de  dutlqiic,  a  woman  was  subjected  to  the  touch, 
who  declared  herself  pregnant,  and  advanced  three  or  four  months;  at  first,  I 
examined  her  in  the  recumbent  position,  and  found  all  the  negative  signs  of  ges- 
tation, but  one  of  my  advanced  pupils  then  performed  the  same  manipulation  in 
the  standing  posture,  and  declared  that  he  perceived  the  ballottement,  when  I 
re-examined  her,  and  found  the  following  condition  of  things :  The  neck  was 
strongly  pushed  backwards  and  a  little  to  the  left,  it  was  slightly  softened,  and 
sufficiently  patulous  to  admit  the  extremity  of  the  finger.  (This  woman  alter- 
wards  acknowledged  she  was  delivered  only  four  months  previously.)  As  the 
finger  left  the  cervix,  and  advanced  just  behind  the  symphysis  pubis,  it  encoun- 
tered a  large  resisting  surface,  which  was  evidently  the  body  of  the  organ,  and 
then,  by  giving  a  slight  blow,  a  movable  body  was  felt  there,  which  immediately 
fell  back  upon  the  finger,  exactly  as  the  foetus  would  in  the  fourth  month.  I 
confess  that  at  first  I  believed  her  enceinte,  and  re-touching  her  in  the  recum- 
bent state,  I  once  more  remarked  the  negative  signs,  but  my  finger  could  not  now 
detect  the  substance  that  had  been  so  easily  moved  when  she  was  standing.  At 
tiie   third  examination,  I  discovered  an  aiitcversion  of  the  womb,  so  complete 


150  GENERATION. 

that  its  anterior  face  liad  become  inferior  or  horizontal,  and  it  was  over  nearly 
the  whole  extent  of  this  face  the  finger  had  passed  in  examining;  and  further, 
I  found  that  the  fundus  uteri,  situated  behind  the  symphysis  pubis,  was  the  light 
movable  body  which  had  produced  the  sensation  of  ballottement. 

If  a  similar  case  should  occur  again,  it  might  give  rise  to  uncertainty  in  diag- 
nosis, and  on  that  account  I  concluded  to  make  it  public  through  this  work. 

There  are  also  some  particular  positions  of  the  foetus  in  which  the  ballottement 
would  be  of  little  service ;  for  instance,  in  those  of  the  breech  it  is  generally  very 
difficult,  and  nearly  impossible  in  those  of  the  trunk.  In  two  cases,  however,  I 
succeeded  in  detecting  a  small  part,  which,  from  its  diminished  size,  must  have 
been  an  elbow,  wrist,  or  heel ;  and  this,  together  with  the  other  signs,  satisfied 
Die  that  it  was  a  position  of  the  trunk ;  M.  Hatin,  who  attended  one  of  these 
women  in  her  accouchement,  found  a  presentation  of  the  left  shoulder;  the  other 
was  delivered  at  the  Clinique,  and  like  the  first,  verified  my  diagnosis. 

3.  The  Anal  Examination. — The  accoucheur  is  very  selibm  obliged  to  intro- 
duce his  finger  into  the  rectum,  but  still  a  partial  obliteration  of  the  vagina  may 
render  such  an  exploration  necessary;  it  might  also  be  useful  where  there  were 
reasons  for  supposing  a  young  girl  to  be  pregnant  who  insisted  upon  her  virginity. 
For  the  necessity  of  sparing  the  hymen,  which  may  possibh/  be  intact,  renders 
the  vaginal  touch  very  difficult.  In  cases  where  a  tumor  exists  at  the  posterior 
part  of  the  vagina,  it  is  sometimes  difficult  to  decide  whether  the  enlargement 
is  located  in  the  recto-vaginal  septum,  or  is  attached  to  the  bony  structure.  Here 
the  diagnosis  is  vei"y  important,  for  the  course  to  be  pursued  in  the  two  cases 
would  be  widely  different,  and  all  doubt  may  be  removed  at  once  by  introducing 
the  index  into  the  rectum,  and  the  thumb  into  the  vagina. 

I  can  recall  but  few  other  circumstances  where  an  accoucheur  would  feel 
obli"-ed  to  resort  to  the  anal  examination,  although  I  am  well  aware  that  it  is 
frequently  recommended  for  certain  cases  of  doubtful  diagnosis  in  the  earlier 
months ;  but  most  women  arc  so  shocked  by  this  mode  of  examination,  that,  in 
truth,  they  are  unwilling  to  submit  to  it,  unless  from  motives  of  strong  interest 
or  necessity. 

B.  0/  AuscuUntion  as  applied  to  Pregnancy. — M.  Mayor,  of  Geneva,  first 
detected  the  pulsations  of  the  foetal  heart  by  auscultation ;  but  this  discovery, 
originally  published  by  him  in  1818,  had  been  entirely  forgotten,  when  M.  de 
Kenraradec  announced,  in  1823,  that  if  the  abdomen  of  a  woman  who  has  passed 
the  first  half  of  her  pregnancy  be  carefully  auscultated,  two  sounds,  which  are 
perfectly  distinct  in  character,  will  be  recognized ;  one  of  them,  consisting  of 
double  pulsations,  or  rather  of  redoubled  ones,  according  to  the  expression  of  M. 
Stoltz,  is  evidently  produced  by  the  movements  of  the  foetal  heart,  and  has  been 
compared,  with  some  rea.son,  to  the  ticking  of  a  watch  enveloped  in  a  napkin; 
the  other  is  a  kind  of  rustling,  unattended  by  shocks,  and  consequently  without 
beating,  being  characterized  by  simple  pulsations,  accompanied  by  the  souffle, 
which  have  been  successively  compared  to  the  sibilant  murmur,  or  to  the  sound 
of  an  erectile  tumor,  or  varicose  aneurism;  this  is  called  the  bellows  sound  (bruit 
de  sov^e.y 

1  The  nature  of  this  work  will  not  allow  me  to  enter  into  the  historical  details  having  re- 


OF     SIMPLE     UTERINE     PREGNANCY.  151 

1.  Sound  of  the  Heart. — The  pulsations  of  the  heart  generally  become  per- 
ceptible in  the  course  of  the  fourth  or  fifth  month,  though  more  frequently  during 
the  latter,  and  often  then  at  an  elevated  part  of  the  abdomen  near  the  umbilical 
region ;  in  one  case,  however,  I  thought  I  heard  them  a  little  before  the  fourth 
month,  but,  unfortunately,  I  could  not  re-examine  the  female  until  six  weeks 
afterwards.  jM.  Depaul  declares  that  he  has  heard  them  at  the  end  of  the  third 
month  and  in  the  eleventh  week. 

These  pulsations  are  far  more  frequent  than  those  of  the  mother's  heart; 
ranging,  as  they  do,  from  one  hundred  and  thirty  to  one  hundred  and  sixty  per 
minute ;  and,  moreover,  they  are  very  often  accelerated  or  diminished,  without 
our  being  able  to  detect  the  cause  of  the  changes. 

Like  most  observers,  I  have  several  times  remarked  that,  if  the  foetus  exhibited 
any  violent  movements  during  the  examination,  the  pulsations  increased  and  be- 
came very  difficult  to  count;  but  they  are  not  influenced  by  any  variations  in  the 
mother's  pulse,  whatever  may  be  their  cause. 

The  dorsal  region  of  the  child  seems  to  transmit  the  double  pulsations  most 
easily,  and  consequently  they  are  more  clearly  perceived  at  that  part  of  the 
abdomen  which  corresponds  to  it.  This  circumstance  likewise  explains  why  the 
pulsations  change  position  so  easily  prior  to  the  seventh  month;  in  fact,  it  is  only 
during  the  last  three  months,  that  extensive  movements  ua  the  part  of  the  child 
become  difficult,  and  its  position  nearly  fixed. 

They  may  be  heard  most  frequently  on  the  anterior  inferior  portion  of  the 
abdominal  wall,  just  above  the  iliac  fossa,  or  still  more  rarely  on  the  median  line, 
and  not  merely  at  a  very  limited  spot,  but  over  a  radius  of  two  or  three  inches. 
In  some  cases  they  may  even  be  heard  over  more  than  half  of  the  abdomen ;  but 
it  is  always  easy  to  perceive  that  they  arc  stronger  and  clearer  at  one  point  than 
elsewhere,  and  from  this  point  as  a  centre,  they  become  weaker  and  weaker  as 
the  distance  increases.  The  intensity  of  pulsation  is  of  course  less  marked  as 
the  child  is  younger,  although,  in  some  instances,  they  exhibit  as  much  force  ia 
the  sixth  month  as  at  term,  but  this  is  very  unusual. 

As  regards  the  number  of  pulsations,  the  statement  made  by  many  observers, 
that  it  is  much  more  considerable  at  an  early  period  than  at  term,  is  not  abso- 
lutely true,  for  the  foetal  heart  always  beats  with  the  same  quickness,  saving  some 
accidental  variations,  at  whatever  period  it  may  be  examined.  Labor  produces 
no  modification  of  the  foetal  pulsations  up  to  the  moment  of  rupturing  the  mem- 
branes; but  this  rule  fails  after  the  amniotic  liquid  has  escaj^ed,  because  they  are 
then  generally  louder  and  clearer,  and  may  be  heard  over  a  more  considerable 
extent  of  surface,  which  can  readily  be  explained  by  the  fact  that  the  ear  or  in- 
strument is  then  nearer  the  foetus. 

A\  hen  the  contractions  become  more  energetic,  the  pulsations  are  not  so  reo^u- 
lar,  and  they  are  more  feeble  and  slower  while  the  contraction  lasts. 

In  those  cases  where  the  labor  is  of  moderate  duration,  the  indistinctness  of 

ference  to  this  important  subject;  I  cannot  too  strongly  recommend  all  who  wish  to  make 
themselves  acquainted  with  what  has  been  published  relative  to  it,  to  consult  the  excellent 
monograph  recently  put  forth  by  M.  Depaul.     (Trait^  de  TAuscultation  Obsteiricale,  1S47.) 


152  GENERATION. 

the  sound  of  the  heart  may  be  referred,  I  believe,  to  the  difficulty  of  ausculting 
during  the  pain  ;  but  if  the  foetus  has  been  too  long  subjected  to  uterine  pressure 
— as  where  the  labor  has  been  unusually  prolonged — the  number,  force,  and  regu- 
larity of  the  pulsations  sensibly  decrease. 

Most  observers  have  asserted  that  the  sounds  are  not  always  perceptible,  and 
M.  Stoltz  even  declares  that  they  cannot  be  heard  whenever  the  dorsal  region  is 
directed  backwards,  unless  some  part  of  the  thorax  be  in  contact  with  a  portion 
of  the  uterine  walls  which  may  be  explored.  For  my  own  part,  I  have  not  failed, 
for  several  years  past,  to  hear  them  in  examinations  made  after  the  sixth  month, 
in  all  cases  where  the  children  were  living;  and  as  my  researches  have  now  ex- 
tended to  at  least  seven  or  eight  hundred  women,  I  feel  convinced  that  we  can 
always  distinguish  them  after  that  period,  in  any  position  of  the  foetus  whatever. 

M.  Dubois  was  the  first  to  point  out  the  fact,  that  the  sound  of  the  foetal  heart 
has  sometimes  a  peculiar  resonance,  resembling  the  metallic  tinkling,  a  singu- 
larity which  I  have  twice  had  the  opportunity  of  observing  at  the  Clinique. 
This  remarkable  sonoreity  is  most  frequently  met  with  in  women  in  whom  the 
uterus  is  distended  by  a  great  quantity  of  fluid.  There  are  also  some  circum-  . 
stances  which  render  the  pulsations  a  little  obscure  and  somewhat  difficult  to 
hear ;  thus,  for  instance,  a  lumbo-posterior  position  of  the  foetus,  a  large  quantity 
of  water,  by  which  the  uterine  walls  are  greatly  distended,  and  a  sufficient  de- 
pression of  them  by  the  stethoscope  to  approach  the  child  prevented ;  the  inter- 
position of  several  folds  of  intestines  between  the  abdominal  walls  and  the  uterus, 
and  the  existence  of  borborygmi,  are  all  so  many  circumstances  calculated  to 
render  the  perception  of  the  pulsations  more  difficult,  although  not  absolutely 
impossible. 

The  beatings  of  the  foetal  heart  are  composed  of  two  distinct  sounds,  the  second 
being  stronger  and  more  sonorous  than  the  fir.st;  but,  in  a  great  majority  of 
cases,  both  of  them  may  be  heard  quite  distinctly. 

M.  Ncegele,  however,  appears  to  think  that  only  a  single  sound  is  heard  under 
certain  circumstances,  and  I  have  sometimes  made  the  same  observation ;  but  it 
has  always  seemed  to  me  that  the  perception  of  only  one  sound  might  either  be 
referred  to  bad  manipulation  on  my  part,  or  else  to  some  one  of  those  circum- 
stances just  described  having  prevented  the  application  of  the  stethosc(Jpe  over  a 
point  near  enough  to  the  back  of  the  foetus.  Thus,  though  I  have  frequently 
heard  but  a  single  sound  at  first,  after  changing  the  instrument,  others  became 
clearly  perceptible.  I  am  happy  to  extract  the  following  paragraph  from  the 
thesis  of  M.  Carriere,  a  pupil  of  M.  Stoltz,  which  fully  confirms  my  opinion.  He 
says:  "I  have  remarked  that  the  single  character  of  the  foetal  pulsations  here 
described,  is  most  likely  tu  be  observed  when  the  point  examined  approaches  the 
fundus  of  the  uterus." 

Like  all  useful  discoveries,  obstetrical  auscultation  has  had  its  opponents  as  well 
as  its  partisans;  and  though  the  former  are  daily  diminishing  in  number,  the 
latter  certainly  have  injured  their  cause  by  exaggerating  its  importance ;  we  shall, 
however,  carefully  endeavor  to  ascertain  its  practical  utility. 

a.  It  has  been  stated  that  a  perception  of  the  pulsations  of  the   foetal  heart 


OF    SIMPLE    UTERINE    PREGNANCY.  153 

was  a  certain  sign  of  pregnancy,  as  also  that  the  absence  of  this  sound,  positively 
determined  by  several  examinations  made  after  intervals  of  some  hours,  subse- 
quent to  the  sixth  month,  announces  with  certainty  the  death  of  the  foetus ;  sup- 
posing, of  course,  we  have  a  satisfactory  assurance  of  the  previous  existence  of 
gestation.  There  is,  notwithstanding,  one  circumstance  which  might  lead  to  a 
suspicion  of  pregnancy  even  when  the  uterus  was  really  empty;  it  is  this:  in 
certain  females  the  pulsation  of  the  heart  is  felt  and  heard  as  low  down  as  the 
sub-umbilical  region,  and  we  can  imagine  that  if,  in  such  persons,  under  the 
emotions  naturally  produced  by  an  unjust  suspicion  of  gestation,  or,  from  the 
influence  of  any  febrile  movement,  the  circulatiun  be  accelerated,  the  pulsations, 
from  their  number  and  rapidity,  might  be  mistaken  for  those  of  a  foetus;  but  in 
such  cases,  all  errors  of  diagnosis  may  be  easily  avoided  by  observing  :  1st.  The 
perfect  isochronism  between  the  pulse  at  the  wrist  and  the  abdominal  beatings ; 
and  2d.  That  the  intensity  of  pulsation  constantly  increases  as  the  precordial 
region  is  approached;  which  two  peculiarities  are  never  presented  by  the  sound 
of  the  foetal  heart. 

h.  Can  a  twin  pregnancy  always  be  recognized  by  auscultation  ?  It  is  said 
that,  in  most  cases,  the  existence  of  two  children  in  the  uterine  cavity  may  be 
known  by  the  following  signs  :  1st.  The  sound  of  the  heart  will  be  heard  at  two 
distant  parts  of  the  abdomen ;  and  2d.  The  want  of  isochronism,  which  may 
sometimes  be  detected  between  these  two  series  of  pulsations. 

These  characters  are  advanced  by  some  writers  as  indicating  a  double  preg- 
nancy with  certainty,  but  we  shall  point  out  several  sources  of  error  on  this  point : 
thus,  it  frequently  happens  that  the  pulsations  of  a  single  heart  resound  in  very 
distant  parts.  Now  can  this  be  referred,  as  M.  Dubois  thinks,  to  deficient 
thoracic  development,  to  the  unusual  comparative  size  of  the  heart's  cavities,  to 
the  density  of  the  lungs,  or,  lastly,  to  the  position  of  the  foetus  itself,  the  head 
and  extremities  of  which,  being  applied  against  the  thorax,  and  there  receiving 
the  impulses  from  the  heart's  contractions,  serve  to  transmit  them  to  a  greater 
distance  ?  I  should  be  inclined  to  adopt  this  view ;  for,  whatever  be  the  expla- 
nation, the  fact  is  certain,  and  the  following  appears  to  me  the  best  method  of 
resolving  the  difficulty  :  Whenever  the  pulsations  are  heard  at  two  distant  points, 
the  line  between  these  should  be  carefully  followed  with  the  instrument ;  for  if 
they  are  produced  by  the  presence  of  two  foetuses,  the  pulsations  will  become 
feeble,  or  almost  disappear,  towards  the  centre  of  this  line ;  but  if,  on  the  con- 
trary, they  are  due  to  a  single  child,  they  will  be  just  as  strong  at  its  middle  part 
as  at  either  extremity. 

Again,  the  absence  of  isochronism  in  the  pulsation  does  not  positively  prove 
the  existence  of  two  children ;  for  one  series  may  be  owing  to  the  foetal  heart, 
and  the  other  belong  to  the  same  organ  in  the  mother,  the  resonance  being  trans- 
mitted to  the  abdominal  cavity.  Hence,  it  is  evident  that  the  unusual  distinct- 
ness of  the  mother's  pulsations  coinciding  with  the  presence  of  a  single  foetus 
may  lead  to  the  belief  of  a  double  pregnancy  which  does  not  exist,  and  a  com- 
parative examination  of  the  pulse  then  becomes  necessary. 

A  double  gestation  may  be  easily  recognized,  if  the  precautions  just  indicated 


154  GENERATION. 

are  observed,  because,  the  twins  being  habitually  placed  one  on  the  right  the 
other  at  the  left  part  of  the  abdomen,  distinct  beatings  will  be  clearly  heard,  if 
the  stethoscope  be  successively  applied  to  each  side.  But  this  happy  state  of 
affairs  does  not  always  exist,  for  sometimes  one  foetus  is  situated  directly  before 
the  other ;  and  then  it  is  nearly  impossible,  even  with  the  greatest  attention,  to 
hear  the  heart  of  the  posterior  child ;  and,  consequently,  when  the  other  signs  of 
a  twin  pregnancy  are  present,  the  resvdts  derived  from  auscultation  would  not 
prove  its  non-existence.  Is  it  necessary  to  add,  that  equal  care  should  be  taken 
to  abstain  from  hasty  decisions  in  those  cases  in  which  there  is  reason  to  believe 
that  one  of  the  children  is  dead  ? 

c.  Auscultation  has  also  been  applied  to  the  diagnosis  of  the  foetal  positions, 
but  the  results  derivable  from  this  method  of  exploration  have  certainly  been 
exaggerated.  My  own  experience,  however,  justifies  me  in  regarding  the  follow- 
ing deductions  as  certain  :  1st.  When  the  pulsations  are  heard  low  down,  on  the 
left,  and  in  front,  the  foetus  is  in  the  first  position  of  the  vertex  (left  occipito- 
iliac) ;  if  heard  below,  in  front,  and  to  the  right,  the  foetus  is  in  the  second  posi- 
tion (right  occipito-iliac) ;  but  it  is  often  very  difficult,  not  to  say  impossible,  to 
distinguish  an  occipito-anterior  from  an  occipito-posterior  one,  by  this  method. 
In  general,  however,  I  have  thought  the  pulsations  were  more  sonorous,  and  less 
apparent  in  the  flanks,  in  the  first  case  than  the  second.  2d.  A  presentation  of 
the  breech  may  be  suspected,  when  the  sounds  are  heard  on  a  level  with  or  above 
the  umbilicus,  the  point  where  they  are  most  distinct,  indicating  the  relation  of 
the  posterior  plane  of  the  foetus;  and  our  suspicions  will  almost  amount  to  a  cer- 
tainty when  this  sign  shall  be  further  strengthened  by  those  derived  from  the 
touch. 

As  to  recognizing  a  position  of  the  trunk,  in  the  way  described  by  M.  Depaul, 
it  seems  to  me  to  be  wholly  impossible. ^ 

'  "  Wlien  one  of  the  regions  of  the  trunk  is  presenting,''  says  M.  Depatil,  "  it  is  possil)le, 
provided  the  <lorsal  one  be  in  front,  to  ascertain  in  which  iliac  fossa  the  head  is  situated,  and 
thence  to  announce  which  shoulder  tends  to  engage  in  the  excavation.  The  typical  sound 
will  be  discovered  in  the  left  inferior  quarter,  in  the  left  cephalo-iliac  positions  of  the  right 
or  left  shoulder;  and  it  will  be  found  in  the  right  inferior  quarter,  in  the  right  cephalo-iliac 
positions  of  the  left  or  right  shoulder.  In  some  cases,  hovi'ever,  it  will  be  less  easy  to  deter- 
inine  which  plane  of  the  foetus  corresponds  to  the  anterior  portion  of  the  abdomen ;  though, 
in  reality,  the  precise  information  is  of  Ihtle  importance;  the  knowledge  of  the  relations  of 
the  head  is,  on  the  contrary,  of  the  greatest  interest."  I  have  quoted  this  passage  literally, 
because  it  is  rather  obscure;  though  I  think  we  may  infer  from  it,  that  M.  Depaul  believes 
it  possible  to  discover  the  positions  of  the  trunk  by  auscultation.  I  have  frequently  endea- 
vored to  arrive  at  the  same  results,  but  am,  after  all,  obliged  to  confess  that  it  has  always 
seemed  to  me  to  be  impracticable.   (For  further  details,  see  the  excellent  thesis  of  M.  Depaul  ) 

The  latest  results  obtained  by  M.  Hohl,  tend  to  confirm  the  opinion  which  I  entertain  of 
the  slight  confidence  to  be  reposed  in  auscultation  as  a  means  of  diagnosis  in  trunk  presen- 
tations Thus,  in  seven  first  positions  of  the  right  shoulder,  the  sound  of  the  heart  was  heard 
five  times  a  little  to  the  left,  and  twice  a  little  to  the  right.  In  three  presentations  of  the  left 
shoulder,  the  head  was  once  to  the  left  and  the  back  in  front;  here  the  heart  was  heard  beat- 
ing to  the  left.  In  the  two  other  cases,  the  head  being  to  the  right  and  the  back  in  front,  the 
pulsations  were  heard  in  the  middle. 


OF    SIMPLE     UTERINE    PREGNANCY.  155 

d.  Can  we  appreciate  the  state  of  the  child's  health  or  disease,  of  its  debility 
or  vigor,  during  labor,  by  means  of  auscultation  ? 

This  question,  which  was  brought  before  the  Academy  by  a  memoir  of  M. 
Bodson,  and  which  gave  rise  to  a  remarkable  report  by  M.  P.  Dubois,  is  certainly 
one  of  the  most  curious  and  intei'esting  subjects  of  study;  for  if  we  could  pos- 
sibly judge  from  the  signs  furnished  by  auscultation,  of  the  integrity  of  the  foetal 
life,  no  uncertainty  could  arise  with  regard  to  the  course  to  be  pursued  when  the 
labor  is  too  long  delayed,  after  the  rupture  of  the  membranes ;  for  the  feebleness 
and  relaxation,  or  the  excessive  frequency  of  the  foetal  pulsations;  the  intermis- 
sion and  irregularity  of  their  rhythm ;  the  absence  of  the  second  stroke ;  or  the 
complete  cessation  of  this  phenomenon  during  the  uterine  contraction,  and  the 
slowness  of  its  return  after  the  pain  has  ceased,  would  sufficiently  authorize  a 
prompt  termination;  whilst  the  opposite  phenomena  would  justify  delay. 

These  signs,  and  more  especially  the  irregularity  of  the  pulsations,  which  ap- 
pears the  most  important  of  all,  indicate  in  the  clearest  manner  that  the  foetus  is 
in  a  state  of  suffering;  and  hence  they  should  serve  as  a  formal  indication  to  the 
accoucheur  to  remove  the  infant  promptly  from  the  danger  which  threatens  it, 
by  an  artificial  termination  of  the  labor.  But,  as  M.  Dubois  has  very  judiciously 
remarked,  there  is  not  then  a  sufficient  integrity  of  circulation  to  establish  the 
extra-uterine  life ;  for,  although  the  foetal  pulsations  may  be  still  regular  and 
sonorous  at  the  moment  of  birth,  yet  the  child  has  suffered  so  much  from  the 
long  pressure  of  lab&r,  that  the  respiration  cannot  be  established  ;  and  hence,  in 
this  respect,  the  accoucheur  should  not  rely  upon  auscultation  alone  for  judging 
of  the  opportune  moment  for  the  intervention  of  art,  because  other  considerations 
quite  as  important  should  influence  his  decision;  still,  however,  this  is  a  method 
of  diagnosis  that  is  never  to  be  neglected. 

M.  Nasg^le,  junior,  has  recently  described  a  bellows  murmur,  which  he  attri- 
butes to  the  pulsations  of  the  umbilical  cord,  and  compares  it  with  the  sound 
produced  by  the  beating  of  the  carotids  in  chlorosis,  and  the  murmur  consists, 
he  states,  of  a  simple  pulsation,  which  is  not  synchronous  with  the  one  pre- 
sently to  be  described.  It  is  caused,  as  he  thinks,  by  the  winding  of  the  cord 
around  the  neck  of  the  foetus,  or  by  its  compression  between  the  child's  back  and 
the  uterine  walls;  the  sound  increases  after  the  escape  of  the  liquor  amnii,  and 
its  force  is  greater  in  proportion  as  the  arteries  of  the  cord  are  the  more  deve- 
loped, and  are  more  twisted  on  each  other. 

In  the  positions  of  the  head,  it  is  situated  below  the  umbilicus,  but  higher  up 
in  those  of  the  breech,  and  it  seems  to  descend  during  the  expulsion  of  the  foetus. 
Sometimes  a  bellows  murmur  is  heard  accompanying  the  cardiac  pulsations,  espe- 
cially at  the  first  sound,  but  it  appears  difficult  to  reconcile  this  circumstance 
with  the  interruption  in  the  circulation  caused  by  any  pressure  on  the  cord. 
Since  M.  Naegele,  junior,  pointed  out  this  peculiarity,  several  others  have  noticed 
it,  and  I  also  have  met  with  it  at  different  times,  where  nothing  would  indicate 
even  a  slight  compression  of  the  cord,  or  any  winding  around  the  neck. 

Does  this  belong  to  the  foetal  heart,  as  M.  Dubois  and  M.  Depaul  believe  ? 
Indeed,  the  latter  states  that  he  has  detected  this  sound,  which  he  had  previously 


156  GENERATION, 

heard  during  the  intra-uterine  life,  by  ausculting  the  infant  immediately  after 
birth.  But  nine  other  cases,  he  says,  turned  out  diflFerently,  and  oblige  me  to 
state  the  facts  as  they  occurred.  The  foetal  murmur  occupied  a  part  of  the  uterus 
entirely  removed  from  that  where  the  beating  of  the  heart  was  detected ;  the 
latter  being  pure,  and  unmixed  with  any  murmur.  Five  of  these  children  were 
born  with  one  or  several  turns  of  the  cord  about  the  neck,  whilst  in  the  sixth,  it 
surrounded  the  lower  part  of  the  thorax.  The  remaining  three  were  free  from 
anything  of  the  kind.  All  were  born  living,  and  on  none  of  them  was  it  possible 
to  detect  a  souffle  in  the  cardiac  region  immediately  after  birth. 

The  question  must  therefore  be  decided  by  new  observations;  for,  although 
the  sound  may  be  produced  by  compression  of  the  cord,  the  compression  often 
exists  without  the'  abnormal  murmur. 

Lastly,  M.  Stoltz  has  described  a  rustling  sound,  which  is  only  observed  after 
the  death  of  the  foetus,  and  is  attributed  by  him  to  the  decomposition  of  tlie  am- 
niotic liquid.  "  In  searching  for  the  signs  furnished  by  auscultation,"  he  says, 
"I  have  noticed  a  dull,  irregular  murmuring  like  the  sound  of  fermentation,  in 
many  women  who  were  carrying  dead  children,  which  I  did  not  confound  either 
with  the  buzzing  heard  when  the  ear  is  applied  to  any  body  whatever,  nor  with 
the  rumbling  or  displacements  of  the  intestines,  and  I  therefore  attributed  it  to 
a  decomposition  of  the  liquor  amnii  and  of  the  foetal  fluids. 

This  phenomenon  would  not  therefore  be  constant,  because  the  decomposition 
does  not  always  take  place,  especially  at  the  commencement  of  gestation,  for  the 
silence  of  death  generally  reigns  in  the  womb  at  that  stage.  The  sound  is  syn- 
chronous with  the  pulse  of  the  mother,  and  consequently  varies  in  frequency  like 
it;  it  is  not  accompanied  by  either  impulse  or  blow,  and  seems  as  though  it  took 
place  in  parts  which  were  much  more  sonorous.  I  confess  that  though  I  have 
had  several  opportunities  of  ausculting  females  whose  foetuses  had  ceased  to  exist 
for  eight  to  twelve  days,  or  even  two  weeks,  I  have  never  yet  heard  anything 
resembling  the  sound  described  by  the  learned  Professor  of  Strasbourg. 

2.  Bellows  Murmur. — Numerous  denominations,  each  of  which  is  founded  on 
its  supposed  nature,  have  been  applied  to  this  sound  ;  for  instance,  M.  Korgaradec 
thought  it  was  produced  in  the  utero-placental  circulation,  and  hence  gave  it  the 
name  of  the  placental  murmur ;  on  the  other  hand,  M.  Bouillaud,  and  many 
others,  have  subsequently  assigned  its  seat  (which,  to  say  the  least,  is  very  pro- 
bable) to  the  large  arterial  trunks  placed  on  the  posterior  abdominal  plane,  where 
they  are  subjected  to  considerable  pressure  from  the  developed  uterus,  and  they 
have  denominated  it  on  this  account  the  ahdomlnal  souffle;  and  still  more  re- 
cently, M.  Paul  Dubois  has  endeavored  to  prove  that  it  originates  it  the  vessels 
which  ramify  in  the  substance  of  the  uterine  wall  itself,  whence  he  has  called  it 
the  uterine  souffle.  But  as  we  shall  take  occasion  hereafter  to  discuss  these  three 
opinions,  which  embrace  all  our  present  knowledge  on  the  subject,  we  will  pass 
them  over  here. 

In  general,  the  bruit  de  soufflet  may  be  heard  as  soon  as  the  uterus,  by  rising 
above  the  superior  strait,  becomes  accessible  to  the  stethoscope — that  is,  a  little 
earlier  than  the  sound  of  the  foetal  heart;  in  fact,  M.  Delcns  asserts  he  has  de- 


OF  SIMPLE  UTERINE  PREGNANCY.  157 

tected  it  at  the  third  month,  and  Dr.  Kennedy  towards  the  tenth,  eleventh,  or 
the  twelfth  week.  M.  Depaul  has  also  made  the  game  observation;  but  as  there 
is  a  very  great  difficulty  in  approaching  the  uterus  at  so  early  a  period,  these 
facts  are  certainly  exceptionable. 

The  murmur  undergoes  some  very  singular  modifications  during  the  course  of 
pregnancy ;  thus,  we  do  not  hear  it  in  every  instance ;  again,  it  is  not  at  all  un- 
usual for  it  to  escape  detection  for  a  long  time  after  having  once  been  heard,  and 
then  to  reappear  somewhat  later ;  sometimes  even  we  may  auscult  for  several 
minutes  in  vain,  when  it  suddenly  appears  directly  under  the  ear,  augments, 
becomes  quite  loud  and  distinct,  lasts  for  a  few  moments,  then  diminishes,  and 
finally  ceases  altogether. 

In  other  cases,  two  or  three  pulsations,  attended  by  hloiving,  are  heard  during 
profound  silence,  but  nothing  more  after  that ;  and  on  the  other  hand,  very  fre- 
quent opportunities  are  afforded  us  of  observing  the  promptitude  with  which  the 
sound  changes  its  locality ;  for  it  seems  to  pass  suddenly  from  one  point  to  an 
opposite  one,  being  sometimes  immediately  beneath  the  ear,  at  others  very  dis- 
tant ;  only  covering  a  single  spot  in  the  majority  of  cases,  but  occasionally  extend- 
ing to  two  remote  regions,  and,  what  is  very  remarkable,  with  equal  force  and 
clearness  at  both  those  points;  further,  the  extent  over  which  the  sound  is  heard 
is  usually  quite  limited,  but  in  some  instances  it  becomes  perceptible  over  a  very 
large  surface,  trespassing  upon  nearly  the  whole  anterior  abdominal  region. 

On  several  occasions  my  pupils  have  had  opportunities  of  studying  all  these 
varieties,  which  indeed  are  almost  inexplicable,  whatever  opinion  may  be  adopted 
as  to  the  cause  of  the  sound. 

The  murmur  is  modified  during  labor ;  for  at  the  very  instant  when  Ihe  pains 
begin,  and  even  before  the  patient  herself  is  aware  of  the  latter,  it  becomes  at 
once  louder,  more  sonorous,  and  more  distinct,  and  at  times  exhibits  some  strange 
modifications ;  thus,  at  one  time  the  sound  heard  resembles,  partially  at  least,  the 
tone  of  a  reed,  or  of  a  tense  cord  thrown  into  vibration,  though  as  soon  as  the 
contraction  becomes  stronger  and  more  general,  it  seems  to  grow  weaker,  appear- 
ing at  longer  intervals,  and  finally  becoming  imperceptible ;  but  when  the  pain 
ceases,  the  sound  returns,  at  first  with  the  intensity  it  manifested  at  the  begin- 
ning of  the  contraction,  and  gradually  regains  the  same  sonorousness  it  had  durino- 
the  gestation.  Such  is  the  order  presented  when  the  contractions  are  regular 
and  energetic;  but  if  they  are  false  or  irregular,  the  souflie  is  not  modified,  or  at 
least  is  not  any  stronger,  except  it  be  for  a  few  instants  only. 

It  may  likewise  be  perceived  after  the  expulsion  of  the  foetus,  and  even  of  the 
after-birth ;  for  example,  M.  Carriere  says  he  has  heard  it  twenty-four  hours  sub- 
sequent to  the  delivery  of  the  placenta. 

Generally,  it  extends  towards  the  inferior  lateral  part  of  the  abdomen ;  more 
rarely,  it  is  heard  near  the  fundus  uteri. 

The  following  is  the  result  of  295  observations,  made  by  M.  Depaul,  of  women 
who  had  passed  the  fifth  month  of  gestation ;  it  will  be  seen  that  it  accords  with 
my  own  experience.  It  was  heard  very  distinctly  182  times  on  each  side  of  the 
uterus,  at  a  short  distance  from  the  crural  arch ;  in  27  cases,  it  appeared  on  one 


158  GENERATION. 

side  only;  in  43,  towards  the  fundus  of  the  organ  ;  and  in  18,  it  was  spread  over 
the  entire  surface  of  the  uterus.  Finally,  M.  Depaul  states,  that  in  12  cases,  it 
was  present  in  three  distinct  situations,  namely,  the  fundus  of  the  womb  and  the 
parts  above  the  crural  arches.  During  the  first  half  of  the  pregnancy,  it  was 
oftenest  observed  when  the  stethoscope  was  placed  upon  the  median  line  a  little 
above  the  pubis. 

M.  Hohl  locates  the  murmur  at  a  point  corresponding  to  the  insertion  of  the 
placenta,  and  bases  his  opinion  upon  the  following  reasons :  1.  In  21  cases  in 
which  he  removed  the  placenta  with  his  hand,  he  found  it  adhering  where  the 
souffle  was  fii-st  heard ;  2.  In  15  cases  where  it  was  inserted  upon  the  orifice,  the 
murmur  was  heard  very  low  down ;  3.  In  10  others  the  autopsy  revealed  the 
after-birth  where  the  souffle  had  been  distinguished ;  4.  In  8  cases  of  version,  the 
same  fact  was  discovered  directly;  5.  In  12  cases  of  twin  pregnancy,  one  murmur 
only  was  heard  when  but  a  single  placenta  was  present,  and  two  distinct  ones, 
when  the  after-births  were  separate ;  6.  Lastly,  in  a  great  number  of  cases  the 
intensity  of  the  sound  appeared  to  be  in  direct  relation  with  the  bulk  and  extent 
of  the  placenta. 

I  unite  with  M.  Depaul  in  the  belief,  that  the  place  where  the  murmur  is 
heard,  is  independent  of  the  placental  insertion. 

The  character  of  the  sound  heard  varies  greatly ;  sometimes  it  is  short,  abrupt, 
and  separated  from  the  succeeding  one  by  a  longer  or  shorter  interval  of  com- 
plete silence,  which  is  dependent  upon  the  frequency  of  the  pulse ;  sometimes  it 
is  a  prolonged  roaring,  a  true  "bruit  de  diable,"  which  has  its  period  of  begin- 
nins,  of  increase,  and  termination,  the  latter  blending  with  the  next  in  succession. 
In  short,  it  presents  all  the  variations  of  rhythm  which  have  been  attributed 
to  the  chlorotic  murmurs.  Though  generally  simple  and  intermittent,  it  is  some- 
times continous  and  double  (bruit  de  diable) ;  finally,  it  may  be  both  continuous 
and  simple.  I  have  not  yet  met  with  the  typical,  double  intermittent  sound. 
Like  the  murmur  in  the  carotids,  the  rhythm  may  change  in  a  few  moments  so 
as  to  present  in  a  very  short  time  several  of  the  varieties  just  mentioned. 

The  quality  of  the  sound  also  varies  greatly ;  and  this  not  only  in  different 
women,  but  even  in  the  same  woman,  and  sometimes  whilst  the  exploration  is 
going  on.  Occasionally  it  is  whistling,  and  resembles  much  the  sound  of  the 
wind  blowing  through  a  badly-closed  doorway;  again  it  becomes  roaring,  so  as  to 
imitate  the  vibrations  of  a  bass  cord;  at  other  times  it  is  plaintive,  suggesting 
the  cooings  of  a  turtle-dove. 

The  seat  and  mode  of  production  of  this  sound  is  a  question  that  has  given 
rise  to  much  controversy,  though,  as  the  sound  is  synchronous  with  the  mother's 
pulse,  it  must  evidently  be  connected  with  the  maternal  vascular  system.  Thus 
far  all  agree,  but  diversities  of  opinion  immediately  spring  up  when  a  more  pre- 
cise location  of  it  is  attempted ;  for  the  murmur  is  produced  outside  of  the  uterus, 
exclaims  one  party ;  not  so,  it  is  seated  in  the  uterine  or  the  placental  vessels, 
say  the  others. 

1.  The  Murmur  is  Produced  in  Parts  distinct  from  the  Uterus. — "Whenever 
a  tumor  is  developed  pver  the  course  of  a  large  arterial  trunk,  the  compression 


OF  SIMPLE  UTERINE  PREGNANCY.  159 

exercised  by  it  on  the  vessel  produces  a  souffle,  and  it  is  not  at  all  unusual,  -when- 
ever a  pathological  tumor  is  developed  in  the  abdomen,  to  hear  a  murmur  in  such 
cases,  very  nearly  resembling  that  of  pregnancy ;  now,  the  uterus  developed  by  a 
product  of  conception  constitutes  a  considerable  tumor,  one  which  must  neces- 
sarily compress  the  vessels  and  produce  the  effect  described.  This  view  is  advo- 
cated by  numerous  partisans,  who  contend  that  the  murmur  does  not  begin  to 
appear  until  the  uterus  really  compresses  the  iliac  vessels  by  being  elevated  above 
the  superior  strait ;  that  it  is  usually  heard  at  the  inferior  lateral  part  of  the 
abdomen,  and  more  frequently  on  the  right  side,  because  the  uterus  is  habitually 
inclined  to  the  right ;  and  lastly,  that  if,  according  to  the  plan  of  my  friend,  Dr. 
Jaccjuemier  (which  I  have  since  often  practised  myself),  the  female,  after  having 
been  ausculted  in  the  supine  position,  be  made  to  kneel  down,  with  the  body 
bent  forward  nearly  horizontally,  and  the  elbows  resting  on  the  ground,  in  a  word, 
in  such  a  position  as  to  throw  the  whole  weight  of  the  uterus  upon  the  anterior 
abdominal  wall,  the  murmur  will  no  longer  be  heard,  although  distinctly  audible 
before. 

2.  The  Murmur  is  Prodnced  in  the  Uterus. — Those  who  locate  the  sound  in 
the  uterine  circulation,  diifer  essentially  as  to  its  precise  seat  and  the  mode  of  its 
production.  Thus,  M.  de  Kergaradec  attributes  it  to  the  placental  circulation ; 
whilst  M.  Hohl,  who  also  believes  it  is  perceived  at  the  point  where  the  placenta 
is  inserted,  differs  from  him,  by  supposing  that  the  sound  results  from  the  pas- 
sage of  the  arterial  blood  into  the  venous  sinuses  of  the  placenta ;  but,  to  refute 
this  latter  opinion,  it  is  only  necessary  to  bear  in  mind  the  great  variety  in  the 
seat  of  the  nmrmur  during  pregnancy,  and  that  in  some  cases  it  is  still  percep- 
tible after  the  delivery  of  the  after-birth. 

The  views  of  M.  Dubois  still  claim  a  notice ;  for  whenever,  says  this  Pro- 
fessor, the  disposition  of  the  uterine  apparatus  is  carefully  studied,  the  freest 
communication  will  be  found  to  exist  between  the  arteries  and  veins,  the  uterine 
walls  appearing  to  be  transformed  into  an  erectile  tissue,  or  one  of  varicose  aneu- 
risms ;  and  the  column  of  blood  brought  by  the  arteries  and  divided  through 
their  branches,  mingles,  whilst  passing  directly  into  the  veins,  with  the  slower 
and  less  compressed  columns  contained  in  the  canals  of  the  latter.  This  circum- 
stance is  incontestably  the  cause  of  the  murmur  and  souffle  that  is  so  remarkable 
in  varicose  aneurisms  and  the  accidental  erectile  tissues,  and  it  is  very  likely  that 
the  same  cause  produces  it  in  the  uterine  walls.  Hence  we  can  comprehend  why 
it  is  only  heard  at  that  pei'iod  when  the  vascular  modifications  of  the  organ  are 
the  most  marked;  why  it  is  most  frequently  audible  over  the  spot  corresponding 
to  the  placental  insertion,  because  the  development  of  the  uterine  vascular  system 
is  the  most  considerable  there ;  and  finally,  why  this  sound  may  still  be  heard  in 
some  women  after  delivery,  when  the  retreat  of  the  uterus  is  not  yet  complete, 
and  the  circulation  in  its  walls  has  not  been  reduced  to  its  condition  in  the  non- 
gravid  state. 

No  one,  since  the  researches  of  M.  Dubois,  has  been  able  to  rediscover  the 
large  and  free  communications  between  the  uterine  arteries  and  veins;  it  is  in 
fact  certain,  that  they  communicate  directly  in  no  other  way  than  through  their 


160  GENERATION. 

terminal  and  capillai-y  ramifications.  It  is  plain,  that  when  a  supposed  anato- 
mical foot  is  proved  to  have  no  existence,  the  theory  which  is  founded  upon  it 
can  no  longer  be  maintained. 

There  are  still  some  other  points  concerning  the  uterine  circulation,  which 
have  recently  been  advanced :  thus,  Dr.  Corrigan  thought  the  passage  of  the 
blood  from  the  uterine  arteries  into  the  sinuses,  was  the  cause  of  the  souffle ;  and 
M.  Carriere,  who  admitted  this  opinion,  added,  that  the  circulation  being  much 
more  active  at  the  point  corresponding  to  the  placental  insertion,  the  sound  should 
be  most  audible  on  a  level  with  that  insertion. 

M.  Depaul  has  quite  recently  re-promulgated  the  views  of  Corrigan,  adding 
thereto  the  compressions  produced  both  within  and  without  by  some  portion  of 
the  foetal  ovoid,  and  he  attributes  an  important  influence  to  these  compressions, 
which,  however,  had  previously  been  brought  forward  by  M.  de  Kergaradec,  in 
explanation  of  the  frequent  variations  of  the  souffle  in  its  seat  and  intensity. 

The  cause  of  the  sound,  says  M.  de  la  Harpe  de  Lausanne,  neither  rests  on  a 
particular  condition  of  the  blood,  nor  on  a  modification  of  its  course,  nor  yet  in 
any  peculiar  state  of  the  vessels,  but  simply  on  the  multiplicity  of  the  vessels 
concentrating  at  the  same  point ;  which  multiplicity,  by  increasing  the  currents 
a  hundred  fold,  increases  the  sounds  in  the  same  ratio ;  thus  rendering  those 
audible  by  multiplication,  which,  taken  singly,  were  imperceptible  to  the  human 
ear.  Perhaps  a  comparison  will  serve  to  illustrate  his  idea :  if  a  person  place 
himself,  on  a  mild  day,  under  a  tree  that  has  been  closely  pruned,  deprived  of  its 
leaves,  and  only  having  some  large  branches  left,  he  will  hear  no  sound  or  rust- 
lino-  of  the  air ;  now  let  him  pass  from  this  tree  to  another  one  better  furnished 
with  branches,  though  still  deprived  of  leaves,  and  he  will  perceive,  if  the  same 
air  be  stirring,  a  commencing  sound,  produced  by  the  branches  that  are  agitated 
in  the  wind ;  again,  the  intensity  of  sound  will  become  much  greater,  if  he  once 
more  changes  to  a  fir-tree ;  for  notwithstanding  the  leaves  of  this  latter  are  rigid 
and  immovable,  yet  they  are  innumerable;  and  just  such  is  the  case  with  the 
placental  murmur.  In  fact,  a  liquid  cannot  circulate  in  a  tube  without  producing 
a  certain  amount  of  sound  by  the  friction  of  its  molecules  against  the  walls  of  the 
tube ;  only  the  sound  is  not  detected  by  the  ear  when  the  vascular  canal  is 
isolated,  but  the  contrary  results,  when  thousands  of  little  canals  are  found  at 
the  same  point. 

Which  theory,  therefore,  is  to  be  received  as  the  true  one  ?  To  so  many  con- 
flictino-  views,  shall  I  be  permitted  to  add  another  ?  It  appears  to  me  most  pro- 
bable, that  the  sound  in  question  has  its  origin  in  the  arteries  distributed  in  the 
posterior  plane  of  the  abdomen,  sometimes  in  the  aorta,  but  most  frequently  in 
the  iliac  vessels.  I  think,  however,  that  the  causes  are  numerous,  and  not  due 
simply  to  the  pressure  of  the  uterus  upon  these  large  vessels. 

This  compression  is  doubtless  one  of  the  most  active  causes  of  the  murmur, 
and  the  reasons  why  it  should  be  so,  above  stated,  seem  to  me  convincing ;  the 
contrary  opinions  of  my  colleague,  M.  Depaul,  notwithstanding.  I  am,  however, 
also  convinced  that  the  abdominal  souffle  is,  like  that  of  chlorosis,  partly  due  to 
the  alterations  which  the  blood  undergoes  during  pregnancy.     Whatever  theory 


OF  SIMPLE  UTERINE  PREGNANCY.  161 

be  embraced  respecting  the  mechanism  of  these  abnormal  vascular  sounds  in 
chlorosis,  whether  they  be  attributed  to  the  diminution  of  the  corpuscles,  as  M. 
Andral  supposes,  or  to  hydraemia,  according  to  M.  Beau,  and,  we  may  add  in 
passing,  this  latter  theory  seems  to  me  to  be  the  only  admissible  one,  the  great 
analogy  between  the  blood  of  chlorosis  and  that  of  pregnancy  cannot  be  ignored. 

It  is  equally  dffieult  not  to  recognize  the  entire  resemblance  between  the  souffle 
of  pregnant  women  and  that  of  chlorotic  patients.  They  exhibit  the  same 
varieties  of  rhythm,  as  also  of  tone  and  sonorousness ;  both  are  sometimes  mixed, 
or  composed  simply  of  buzzing,  rasping,  or  whistling  sounds,  which  seem  to  be 
alike  peculiar  to  the  early  stages  of  the  affection.  Both  present,  if  I  may  so  ex- 
press it,  the  same  mobility  of  duration,  rhythm,  and  intensity,  and  appear  to  be 
similarly  affected  by  the  greater  or  less  pressure  of  the  instrument,  as  also  by 
changes  in  the  circulation  of  the  female  as  a  consequence  of  disturbances  of  tem- 
per, violent  movements,  &c. 

Is  it  not,  therefore,  natural  to  conclude,  that  since  pregnancy  and  chlorosis 
produce  the  same  changes  in  the  blood,  the  souffle,  which  is  exactly  alike  in  both 
cases,  is  also  due  to  the  same  cause  ? 

But,  it  will  be  replied,  in  chlorosis  the  murmur  is  heard  more  especially  in  the 
cervical  region ;  why,  therefore,  during  pregnancy  should  it,  if  due  to  the  same 
cause,  fix  itself  particularly  in  the  abdomen  ?  I  would  reply,  in  the  first  place, 
that  in  some  cases  the  cardiac  and  carotid  murmurs  have  been  observed  in  preg- 
nant women  ;  still  I  admit  that,  most  generally,  they  are  not  heard  even  when  the 
abdominal  souffle  is  present.  The  latter  circumstance  can  be  readily  explained, 
for  it  is  in  fact  rarely  that  the  alteration  of  the  blood  is  carried  to  the  same  extent 
as  in  ordinary  chlorosis ;  the  proportion  of  globules  rarely  descends  below  one  hun- 
dred, and  the  amount  of  water  is  far  from  equalling  the  enormous  proportion 
which  it  reaches  in  chlorosis.  Now,  if  it  be  true,  as  M.  Andral  supposes,  that 
the  production  of  abnormal  sounds  is  an  indication  of  a  more  advanced  alteration, 
we  can  comprehend  why  they  should  not  be  perceptible  in  the  carotids,  where 
only  poverty  of  the  blood  could  produce  them. 

The  conditions  are  not  the  same  in  the  abdominal  vessels,  for  there,  to  a  com- 
mencing hydrsemia,  is  superadded  a  considerable  diminution  of  the  calibre  of  the 
vessels,  which  diminution  is  a  result  of  the  compression  of  the  uterine  tumor ; 
and  these  two  circumstances  united,  are  capable  of  producing  a  souffle  which  they 
would  be  unable  to  determine  singly.  The  compression  of  the  arteries  thus  gives 
rise  to  a  sort  of  insufficiency,  which  renders  still  more  sensible  the  slight  increase 
which  the  total  amount  of  the  blood  has  undergone. 

These  two  circumstances  appear  to  me  to  afford  a  sufficient  explanation  of  the 
abdominal  souffle.  Those  accoucheurs  who  have  made  a  special  study  of  this 
question,  committed  an  error,  in  which  I  myself  shared  for  a  long  time,  in  not 
having  reflected  sufficiently  upon  the  physiological  conditions  of  pregnancy, 
which,  indeed,  were  badly  understood,  until,  at  least,  within  a  few  years  past. 
In  endeavoring  to  discover  the  cause  of  these  abnormal  sounds  in  a  special  ar- 
rangement of  the  vascular  apparatus  of  the  uterus,  they  wandered  farther  and 
farther  from  the  truth.     In  order  to  render  their  theory  more  acceptable,  they 

11 


162  GENERATIOX. 

made  distinctions  between  the  abdominal  souffle  and  the  carotid  murmur,  wbieli 
have  no  real  existence.  Thus,  say  they,  the  latter  is  accompanied  by  a  sensation 
as  of  a  blow,  and  of  pulsation,  which  is  always  wanting  in  the  former.  But  it  is 
now  satisfactorily  proved  that  the  sound  of  a  blow,  analogous  to  those  of  the 
healthy  heart,  is  ordinarily  nothing  but  the  simple  I'everberation  of  the  first  sound 
of  the  heart,  whieh  is  capable  of  extending  into  the  arteries  situated  near  that 
organ,  but  which  is  very  rarely  propagated  into  the  abdominal  aorta,  and  the 
iliac  and  femoral  arteries.  These  arterial  trunks,  says  M.  Beau,  present  only  a 
considerable  pulsation,  or  elevation,  whieh  is  very  rarely  accompanied  by  a  true 
murmur.  It  should  also  be  observed,  that  the  souffle  in  the  cervical  region  is 
itself  frequently  independent  of  anything  like  the  sound  of  a  blow. 

It  has  been  stated  that  we  have  several  times  known  the  sound  to  disappear 
when  the  woman  was  placed  on  all  fours,  but  that  in  other  instances  it  still  re- 
mained. M.  Depaul  recollects  having  repeated  this  experiment,  with  the  effect 
of  continuing  to  hear  the  uterine  murmur,  without  the  slightest  variation.  This 
last  remark,  made  by  such  observers  as  MM.  Depaul  and  Carriere,  deserves  fur- 
ther attention  on  our  part.  As  M.  Beau  has  pointed  out,  it  is  much  more  diffi- 
cult than  would  be  supposed,  and  sometimes  even  impossible,  to  cause  the  woman 
to  assume  such  a  position  that  the  large  arteries  shall  escape  all  compression  by 
the  uterus.  The  abdominal  walls  of  young  primiparous  women  are  too  resisting 
to  yield  under  the  momentary  weight  of  the  uterus,  and  whatever  position  be 
assumed,  they  retain  the  organ  strongly  applied  against  the  posterior  plane  of  the 
abdomen. 

M.  Beau  has  also  proved  that  this  persistence  of  the  abdominal  souffle  is  not 
peculiar  to  pregnancy,  but  that  in  the  case  of  a  woman  aflFected  with  a  cyst  of  the 
ovary,  shown  to  be  such  at  the  autopsy,  it  was  impossible  to  give  the  tumor  any 
position  in  which  it  ceased  to  compress  the  arteries  of  the  pelvis,  and  conse- 
quently to  put  an  end  to  the  murmur. . 

I  would  add,  that  whilst  admitting,  as  I  endeavor  to  prove,  that  compression 
is  not  the  sole  cause  of  the  murmur,  but  that  the  serous  plethora  of  pregnancy 
also  contributes  to  its  production,  it  might  readily  be  supposed  that  if  the  latter 
reach  a  certain  degree,  it  might  of  itself  give  rise  to  the  abnormal  .sound,  even 
should  the  position  of  the  female  entirely  relieve  the  abdominal  vessels  from 
pressure. 

The  same  remarks  will  apply  to  the  variable  results  which  are  sometimes  ob- 
tained, when,  after  having  heard  the  sounds  on  one  side  of  the  abdomen,  the 
woman  is  made  to  reverse  her  position.  Sometimes,  we  have  said,  it  ceases  to 
be  heard ;  at  others  it  persists,  although  the  inclination  of  the  uterus  had  re- 
moved the  pressure  from  the  vessels  on  the  point  opposite  the  side  upon  which 
the  woman  lies.  In  the  first  case,  the  plethora  was  too  slight  to  maintain  a 
sound,  the  production  of  which  was  partly  due  to  the  compression  of  the  vascular 
tube ;  in  the  second,  either  the  inclination  of  the  uterus  had  not  removed  the 
pressure,  or  else  the  alteration  of  the  blood  was  alone  sufficient  to  produce  the 
abnormal  sound. 

Although  MM.  Barth  and  Boger  are  disposed  to  attribute  the  abdominal 


OF     SIMPLE     UTERINE     PREGNANCY.  163 

murmur  to  pressure,  they  nevertheless  find  some  objections  which  prevent  their 
adopting  the  opinion  in  its  full  extent.  Why,  say  they,  is  not  the  sound  in- 
creased when  the  uterus  is  pressed  upon  with  the  stethoscope,  and  why  does  it 
sometimes  disappear  when  the  pressure  is  made  rather  stronger  ?  It  is,  replies 
M.  Beau,  because  the  murmurs  are  the  result  of  a  certain  degree  of  pressure, 
which  if  increased  or  diminished,  the  sounds  are  altered  or  lessened.  The  effect 
is  the  same  as  that  which  is  frequently  observed  in  the  carotid  murmurs,  which 
do  not  increase,  and  which  even  disappear,  when  a  little  too  much  pressure  is 
made  upon  the  artery ;  and  as  these  latter  sounds  are  sometimes  found  to  have 
their  intensity  somewhat  increased  by  a  slight  pressure,  so  the  abdominal  mur- 
murs are  occasionally  notably  increased  when  the  uterus  is  a  little  pressed  upon. 

Finally,  how  happens  it,  say  MM.  Earth  and  Roger,  that  in  certain  cases  in 
which  no  souffle  was  heard  upon  auscultation  of  the  abdomen,  it  could,  through 
the  assistance  of  the  metroscope  of  M.  Nauche,  be  perceived  upon  the  neck  of 
the  uterus,  which  is  situated  in  the  centre  of  the  pelvic  cavity,  and  therefore  re- 
moved from  the  vessels? 

We  may  suppose,  again  replies  M.  Beau,  that  in  the  cases  in  question  the 
murmur  had  its  origin  in  the  hypogastric  arteries.  Now  the  neck  of  the  uterus 
is  nearer  these  arteries,  than  that  part  of  the  body  of  the  organ  which  is  in  rela- 
tion with  the  abdominal  parietes.  Besides,  is  it  not  possible  that  certain  organs 
which  are  poor  conductors  of  sound,  such  as  a  mass  of  intestine  or  of  omentum, 
might  have  been  interposed  between  the  surface  of  the  uterus  and  the  walls  of 
the  abdomen,  and  thus  have  prevented  the  transmission  of  the  vibrations  to  the 
ear? 

In  short,  I  agree  with  M.  Bouillaud,  and  with  the  views  advocated  by  M. 
Beau,  in  his  excellent  memoir  upon  arterial  murmurs,  in  regarding  the  abdo- 
minal souffle  of  pregnancy  as  due,  in  part,  to  the  compression  of  the  vessels 
situated  on  the  posterior  wall  of  the  abdomen ;  but  I  also  think  that  the  altered 
state  of  the  blood  assists,  as  it  does  in  chlorosis,  in  the  production  of  the  pheno- 
menon. 

Since  the  researches  of  Hope  and  of  M.  Aran,  some  physicians  have  regarded 
the  veins  as  the  seat  of  the  continuous  souffle,  which  is  sometimes  heard  in  the 
cervical  region  of  chlorotic  patients.  For  a  long  time,  I  entertained  this  opinion 
myself,  but  it  was  so  thoroughly  shaken  by  the  experiments  of  M.  Beau,  that  I 
now  regard  the  arterial  system  as  the  seat  of  all  the  abnormal  sounds.  I  should, 
however,  remark,  for  the  benefit  of  those  who  still  hold  to  the  theory  of  Hope, 
that  this  does  not  invalidate  the  explanation  which  I  suggest  of  the  nature  and 
point  of  departure  of  the  abdominal  souffle,  for  beside  the  iliac  veins,  there  arc 
large  venous  trunks  destitute  of  valves  proceeding  from  the  uterus,  which  are 
equal  to  the  production  of  certain  sounds  which  are  sometimes  heard  during 
pregnancy. 

The  abdominal  souffle  is  not  of  great  practical  importance ;  its  value,  as  a  sign, 
is  limited  to  rendering  the  existence  of  pregnancy  probable.  It  may  exist  inde- 
pendently of  pregnancy,  and  does  not  always  accompany  it ;  it  is  not  influenced 
by  the  life  or  death  of  the  fatus,  nor  is  it  modified  in  any  degree  by  a  state  of 


164  GENERATION. 

suffering  of  the  child;  it  cannot,  in  any  case,  enable  us  to  determine  certainly 
either  the  place  of  insertion  of  the  placenta,  nor  its  form,  size,  nor  the  changes 
which  it  may  undergo.  The  observations  of  MM.  Depaul  and  Nsegele,  jun., 
prove,  in  opposition  to  the  conclusions  of  Hohl,  that  the  diagnosis  of  double  or 
triple  pregnancies,  is  incapable  of  assistance  from  the  souffle,  presenting  as  it 
does  in  these  cases  no  modifications  which  are  not  also  observed  in  simple  preg- 
nancies. 

Summary. — It  is  now  well  understood  that,  in  ausculting  the  abdomen  of  a 
pregnant  woman,  we  may  hear  both  the  pulsations  of  the  foetal  heart  and  the 
bruit  de  souffle.  The  first  is  a  certain  sign  of  pregnancy;  but  the  second,  being 
also  produced  by  other  causes,  only  becomes  of  importance  when  we  have  pre- 
viously ascertained  that  the  female  has  no  other  disease. 

The  sound  of  the  heart  may  aid  in  ascertaining  the  position  of  the  foetus;  the 
souffle  can  communicate  no  information  as  to  the  place  of  insertion  of  the  placenta, 
and  indicates  nothing  as  regards  the  child's  position ;  while  any  feebleness,  and 
more  especially  any  irregularity  or  intermittence  of  the  heart's  pulsations,  furnish 
strong  presumptive  reasons  for  believing  that  the  foetus  is  suffering,  and  that  its 
life  is  compromised. 

When  desirable  to  auscult  a  female  who  is  supposed  to  be  pregnant,  we  must 
request  her  to  lie  down  on  her  back ;  at  the  commencement  of  gestation  this 
precaution  is  indispensable ;  but  towards  the  last  it  becomes  less  so,  and  she  may 
then  be  examined  standing.  In  fact,  whatever  be  her  position  in  the  latter 
months,  this  exploration  is  quite  easy,  on  account  of  the  dimensions  of  the  uterus 
and  the  volume  of  the  foetus,  but  at  first  it  is  nearly  always  necessary  to  flex  the 
thighs  upon  the  belly,  so  as  to  completely  relax  the  abdominal  muscles,  and  of 
course  this  could  only  be  done  in  the  horizontal  position.  The  dorsal  or  lateral 
decubitus  is  requisite  to  explore  thoroughly  the  fundus  or  sides  of  the  womb,  and 
also  to  cause  the  foetus  to  fall  from  either  side ;  the  thighs  should  also  be  flexed, 
or  extended,  according  to  the  region  examined.  The  unaided  ear  will  answer, 
but  the  stethoscope  should  generally  be  employed ;  for,  by  using  it,  the  sounds 
detected  can  be  more  readily  limited,  and  the  abdominal  parietes  more  easily 
depressed  so  as  to  approach  nearer  to  the  foetus;  besides,  many  females  object  to 
the  accoucheur  thus  applying  his  head  flat  on  the  abdomen.  Experience  has 
likewise  convinced  me  that,  when  the  unassisted  ear  is  used,  the  clearness  of  the 
sensations  is  singularly  diminished  by  the  frictions  which  the  respiratory  move- 
ments of  the  abdomen  make  against  the  ear.  When  used,  the  enlarged  extre- 
mity of  the  instrument  should  be  deprived  of  its  mouth-piece,  and  its  whole  cir- 
cumference be  exactly  placed  over  the  region  to  be  ausculted. 

It  is  also  advisable  that  the  woman  lie  on  a  bed  of  a  sufficient  height,  other- 
wise the  accoucheur  is  obliged  to  stoop  too  much,  and  this  inconvenient  position 
is  attended  by  such  a  degree  of  congestion  as  to  render  it  impossible  to  hear 
anything.  And  further,  to  avoid  all  unnecessary  searching,  it  is  best  to  place 
the  stethoscope  at  first  directly  over  the  part  where  the  pulsations  of  the  heart 
are  most  commonly  heard,  that  is,  in  front,  below,  and  a  little  to  the  left  side. 

It  is  equally  desirable  to  ascertain  from  the  female  where  she  generally  per- 


OF  SIMPLE  UTERINE  PREGNANCY. 


165 


ceives  the  foetal  movements,  for  most  frequently  the  pulsations  of  the  heart  will 
be  found  on  the  opposite  side,  because  the  superior  and  inferior  extremities  being 
always  folded  on  the  abdominal  plane,  the  back,  in  other  words,  the  part  of  the 
foetus  which  most  easily  transmits  the  sounds,  will  evidently  be  turned  towards 
the  left,  if  the  right  side  is  the  habitual  seat  of  the  active  motions. 

Before  the  fifth  month,  the  pulsations  are  usually  perceived  in  the  lower  part 
of  the  abdomen  on  the  median  line,  about  half  way  between  the  pubis  and  um- 
bilicus ;  consequently,  the  instrument  should  be  first  applied  there. 

The  instrument  proposed  by  Nauche,  under  the  name  of  metroscope,  the  ex- 
tremity of  which  is  intended  to  be  introduced  into  the  vagina  and  applied  to  the 
neck  or  inferior  part  of  the  womb,  ought  not  to  be  used. 


A  Table  exhibiting  the  Signs  of  Pregnancy  at  various  Periods. 

EATIONAL    SIGNS.  SENSIBLE    SIGNS. 

First  and  Second  Months. 
1.  Suppression  of  the  menses  (numerous  ex-     1.   Augmentation  in  the  size  and  weight  of 


ceptions). 

2.  Nausea — vomitinp;s. 

3.  Slight  flatness  of  tlie  hypogastric  region. 

4.  Depression  of  the  umbilical  ring. 


the  uterus. 
2.  Descent  of  the  organ. 
3    The  womb  is  less  movable. 
4.  Its  walls   have   the  consistence  of  caout- 
chouc. 
5.  Tumefaction  of  the  breasts,  accompanied     5.  The  neck  is  directed  downward,  forwards, 
with  sensations  of  pricking  and  tenderness.         and  to  the  left. 

6.  The  orifice  of  the  os  tincse  is  rounded  in 
primiparoe,  but  more  patulous  in  others 
who  have  had  children. 

7.  A  slight  softening  in  the  mucous  mem- 
brane covering  the  lips,  and  this  mem- 
brane appears  cedematous. 


1.  Suppression  of  the  menses  (a  few  excep 
tions). 


2.  Frequently,  the  appearance  or  the  continu- 
ance of  the  vomitings. 

3.  A  small  protuberance  in  the  hypogastric 
region. 

4.  Less  depression  of  the  umbilical  cicatrix. 


5.  Augmented  swelling  of  the  breasts,  pro- 
minence of  the  nipple,  and  slight  discolo- 
ration in  the  areola. 


Third  and  Fourth  Months. 

1.  The  fundus  uteri  rises  to  the  level  of  the 
superior  strait  towards  the  end  of  the  third 
month,  and  is  perceived  at  the  close  of  the 
fourth  about  the  middle  of  the  space  be- 
tween the  umbilicus  and  pubis. 

2.  A  perceptible  flatness  on  percussion  in  the 
hypogastric  region. 

3.  A  rounded  tumor,  as  large  as  a  child's 
head  of  a  year  old,  may  be  detected  by  the 
abdominal  palpation. 

4.  By  resorting  to  this  process  and  the  vaginal 
touch  jointly,  the  displacement  en  masse, 
and  the  volume  of  the  uterus  may  be  easily 
ascertained. 

5.  The  neck  has  the  same  situation  and  di- 
rection during  the  third  month  as  in  the 
preceding  ones;  at  the  fourth  it  is  elevated 
and  directed  backwards  and  to  the  left 
side. 


166 


GENERATION. 


RATIONAL    SIGNS.  .    SENSIBLE    SIGNS. 

6.  Kyesteine  in  tlie  urine.  6.  The  softening  of  the  periphery  of  the  ori- 

fice is  much  better  marked.  The  latter  is 
more  open  in  multipara,  even  admitting 
the  extremity  of  the  finger;  but  it  is  closed 
and  always  rounded  in  primiparte. 

Fifth  and  Sixth  Months. 

1.  Suppression  of  the  menses  (some  rare  ex-     1.  The   fundus  uteri  is  one  finger's  breadth 
ceptions).  below  the  umbilicus  at  the  end  of  the  fifth 

month  ;  and  the  same  distance  above  it  at 
the  expiration  of  the  sixth. 

2.  The  disturbances  in  the  digestive  organs     2.  Fcetal    irregularities,    and    active    move- 
generally  disappear.  ments,  which  are  very  perceptible. 

o.  Considerable  development   of  the  whole  3.  The   sound   of  the  heart   and  abdominal 
sub-umbilical  region.  souffle  are  now  perceptible. 

4.  A  convex,  fluctuating,  roimded  abdominal  4.  Ballottement. 
tumor,  salient,  particularly  on  the   middle 

line,  and  sometimes   exhibiting   the  fcetal 
inequalities. 

5.  The  umbilical  depression  is  almost  com-     5.  A   tumor  is  felt  at   the  anterior  superior 
pletely  efl^aced.  part  of  the  vagina,  which  is  sometimes  soft 

and  fluctuating,  at  others  rounded,  hard, 
and  resisting. 

6.  The  inferior  half  of  the  intra-vaginal  por- 
tion of  the  cervix  uteri  is  softened. 

7.  The  whole  ungual  part  of  the  first  pha- 
langeal bone  can  penetrate  the  cavity  of 
the  neck  in  multiparce.  The  latter  is  soft- 
ened to  the  same  extent  in  primipara?,  but 
the  orifice  is  closed. 


6.  The  discoloration  in  the  areola  is  deeper; 
glandiform  tubercles;  areola  spotted. 

7.  Kyesteine  in  the  urine. 


Seventh  and  Eighth  Months. 

1.  Suppression  of  the  menses  (the  exceptions     1.  Increased  size  of  the  abdomen, 
are  very  rare). 

2.  Disorders  of  the  stomach  (rather  rare).  2.  The   fundus  uteri  is  four  fingers' breadth 

above  the  umbilicus  at  the  seventh  month, 
and  five  or  six  at  the  eighth. 

3.  The  abdominal  tumor  has  the  same  cha-     3.  The  organ  is  nearly  always  inclined  to  the 
racters,  except  that  it  is  more  voluminous.  right. 

4.  A  complete  effaccment  of  the    umbilical     4.  More    violent   active    movements   of  the 
depression,  the  dilation   of  the    ring,  and         fcetus. 

sometimes  a  pouting  of  the  navel. 

5.  Numerous  discolorations  on  the  skin  of  the     5.  Sounds  of  the  heart  and  abdominal  souffle, 
abdomen. 

0.  Sometimes  a  varicose  and  (Edematous  con-     6.  Ballottement   is   very  evident  during   the 
dition  of  the  vulva  and  inferior  extremities.         seventh  month,  but  more  obscure  in   the 

eighth. 
7.  Vaginal    granulations  —  abundant    leucor-     7.  The    softening    extends    along    the    neck, 
rhceal  discharge.  above  the  vaginal  insertion.    In  primipara-, 

the  cervix  is  ovoid,  and  seems  to  have  di- 
minished in  length;  in  others  it  isconoidal, 
the  base  being  below,  and  sufficiently  palu- 


OF     SIMPLE     UTERINE     PREGNANCY. 


leT 


RATIONAL   SIGNS. 


8.  Deeper  discoloration  of  the  central  areola, 
and  an  extension  of  the  spotted  areola. 
Sometimes  there  are  numerons  stains  on 
the  breasts :  flow  of  milk ;  complete  deve- 
lopment of  the  glandiform  tubercles. 

9.  Persistence  of  kyesteiiie  in  the  urine. 

First  Fortnight  of 
1.  The  vomitings  frequently  reappear. 


2.  The  abdominal  tumor  has  increased ;  the 
skin  is  much  stretched,  and  very  tense. 

3.  Difficulty  of  respiration. 


4.  All   the  other  symptoms  persist,  and  are 
increased  in  intensity. 


SENSIBLE    SIGNS. 

lous  to  admit  all  the  first  phalanx.  The 
neck  at  its  superior  fourth  is  still  hard  and 
shut  up. 


the  Ninth  Month. 

1.  The  fundus  uteri  reaches  the  epigastric 
region,  and  gains  the  border  of  the  false 
ribs  on  the  right  side. 

2.  Active  movements.  Sounds  of  the  heart 
and  abdominal  souffle. 

3.  Often  there  is  no  proper  ballottement,  but 
merely  a  kind  of  rising  of  the  tumor  formed 
by  the  head. 

4.  The  neck  is  softened  throughout  its  whole 
length,  excepting  the  circuml'erence  of  the 
internal  orifice,  which  still  remains  closed 
and  resisting.  In  women  who  have  pre- 
viously borne  children,  the  finger  may  be 
introduced  into  the  cervix  to  the  extent  of 
a  phalanx  and  a  half,  and  in  fact  is  only 
arrested  by  the  internal  orifice,  which  is 
closed  and  wrinkled,  though,  in  some  cases, 
already  beginning  to  open.  In  primiparte, 
the  softening  is  equally  extensive,  and  the 
neck  is  swollen  in  the  middle  in  an  ovoidal 
form,  but  the  external  orifice,  although  par- 
tially opened,  does  not  permit  the  introduc- 
tion of  a  finger. 


Last  Fortnight  of  the  Ninth  Month. 
1.  The  vomitings  often  cease.  1.  The  fundus  uteri  has  sunk  lower  than  in 

the  first  fortnight. 
Q.  The  abdomen  is  fallen.  2.  Active  movements;  bruits  du  ca'urand  de 

sonfRe. 
^.  The  respiration  less  oppressed.  3.  Ballottement  often  imperceptible. 

4.  More  difficulty  in  walking.  4.  The  head  more  or  less  engaged  in  the  ex- 

cavation. 

5.  Frequent  and  ineflfectual  desires  to  urinate.     5.  In   multiparce,  the  internal  orifice  softens 

and  dilates;  the  finger  can  then  penetrate 
through  a  cylinder,  as  it  were,  an  inch  and 
a  half  in  length,  and  come  into  contact  with 
the  naked  membranes  ]n  primiparce,  the 
internal  orifice  experiences  the  same  modi- 
fication, but  the  external  remains  closed. 
During  the  last  week,  in  consequence  of 
the   spreading  out   at  the  internal   orifice 


168  GENERATION. 

RATIONAL    SIGNS.  8EN81BLB    SIGNS. 

the  whole  cavity  of  the  neck  becomes  con- 
founded with  that  of  the  body,  and  the 
finger,  in  reaching  the  membranes,  only 
traverses  a  thin  orifice  in  primiparoe,  but  a 
rounded  collar  in  the  others  of  a  variable 
thickness. 

6.  Hemorrhoids  ;  augmentation  of  the  csdeiiia 
and  varicose  state  of  the  lower  extremities. 

7.  Pains  in  the  loins,  and  colics. 


BOOK  III. 

OF  THE  HUMAN  OVUM  AFTER  FECUNDATION. 

The  human  ovule,  prior  to  fecundation,  and  at  iis  full  maturity,  is  composed, 
as  previously  stated  (page  70),  1st.  Of  the  vitelline  membrane,  or  the  envelope. 
2d.  Of  a  granular  liquid  contained  in  this  membrane,  and  called  the  vitellus 
(yolk).  3d.  Of  a  little  vesicle  enclosed  in  the  first,  and  situated  in  the  midst  of 
the  granular  liquid.  This  is  the  germinal  vesicle,  originally  discovered  by  Pur- 
kinje,  in  the  eggs  of  birds,  and  subsequently  proved  by  M.  Coste  to  exist  in  those 
of  mammiferae.  4th,  and  lastly.  Of  the  germinal,  or  proligerous  spot  (niacula 
germinafiva),  which  is  detached  from  the  clear  contents  of  the  germinal  vesicle, 
and  is  held  in  suspension  in  the  fluid  which  the  latter  contains. 

If  the  ovule  be  examined  several  weeks  after  the  fecundation  has  taken  place, 
it  will  be  found  to  have  undergone  some  very  remarkable  transformations ;  for  it 
is  then  composed  of  such  difl'erent  parts,  that  if  comparative  anatomy  had  not 
furnished  us  opportunities  of  observing,  step  by  step,  and  hour  by  hour,  the 
divers  modifications  it  passes  through  before  the  organization  is  fully  completed, 
we  could  not  believe  it  to  be  one  and  the  same  product.  Thus,  at  the  end  of  the 
second  or  third  week  after  fecundation,  it  exhibits  some  very  different  elements 
to  the  observer;  for  example,  we  encounter,  in  passing  from  without  inwards, 
1st.  The  chorion,  a  thick  exterior  membrane,  studded  with  numerous  villosities. 
2d.  A  much  thinner  membrane,  situated  more  internally,  and  designated  as  the 
amnios.  3d.  A  more  or  less  considerable  space  between  these  two  envelopes,  that 
is  filled  by  an  albuminous  liquid,  in  the  midst  of  which  a  little  vesicle  (the  um- 
bilical vesicle)  is  situated.  And  4th.  A  liquid  fills  the  cavity  of  the  amnios,  the 
quantity  varying  with  the  period  of  pregnancy,  and  in  this  fluid  is  the  embr)-o. 

Finally,  let  us  add  that  the  ovule  is  enveloped  nearly  throughout  by  a  double 
membrane,  which  at  first  is  entirely  foreign  to,  but  subsequently  contracts  inti- 
mate relations  with  it ;  this  is  the  deciduous  membrane.  But  before  studying  the 
constituent  parts  of  the  ovum  at  an  advanced  period  of  its  development,  let  us 
see  what  is  their  proper  commencement,  and  how  they  can  arise  out  of  the  simple 
elements  that  form  the  ovule  prior  to  conception. 


DEVELOPMENT    OF    THE    HUMAN    OVUM. 


CHAPTER  I. 

DEVELOPMENT    OF   THE    HUMAN    OVUM. 

When  the  ovule  has  attained  its  full  maturity,  the  vesicle  in  which  it  is  en- 
closed becomes  the  seat  of  an  excitation  which  determines  there  a  considerable 
afflux  of  fluid,  and  causes  its  progressive  distension.  This  hypertrophy  may,  as 
we  have  seen,  be  either  spontaneous,  or  produced  by  coition  or  other  venereal 
excitement.  As  a  consequence  of  the  distension,  the  vessels  on  that  portion  of 
the  vesicle  which  projects  the  furthest  from  the  surface  of  the  ovary  become 
atrophied,  their  walls  grow  thinner,  and  soon  give  way,  thereby  permitting  the 
ovule  to  escape,  which,  in  passing  out,  draws  along  with  it  a  part  of  its  granular 
cumulus.  The  ovum  then  engages  in  the  tube,  whose  enlarged  extremity  had 
been  applied  to  the  ovary.  It  must  not  be  supposed  that  the  period  for  the 
ovule's  arrival  in  the  tube  is  invariable  in  the  same  species  of  animals,  and  it 
probably  varies  in  the  human  race  also,  though  nothing  positive  is  known  on  that 
point.  Pending  its  stay  in  the  ovary,  the  ovum  underwent  no  appreciable  modi- 
fication ;  but  as  soon  as  it  enters  the  oviduct,  the  beginning  of  those  changes  it 
must  necessarily  pass  through,  in  order  to  give  birth  to  a  new  being,  is  observed; 
and  hence,  to  study  these  modifications  in  due  course,  we  must  first  examine  those 
manifested  in  the  tube,  and  then  such  as  do  not  appear  until  after  its  arrival  in 
the  uterine  cavity. 


ARTICLE  I. 

CHANGES   OF   THE   OVUM   IN    THE   TUBE.' 

After  the  ovum  is  once  deposited  in  the  oviduct,  it  is  no  longer  possible  to 
find  either  the  vesicle  or  the  germinal  spot ;  and  this  disappearance  of  the  vesicle, 
and  of  the  accumulation  of  granules  at  its  centre,  constitute  the  first  modification 
which  the  ovum  undergoes  subsequent  to  its  departure  from  the  ovary. 

In  the  first  half  of  the  tubal  canal  the  ovum  is  environed  by  a  layer  of  granu- 
lations, of  variable  thickness,  which  constituted  the  proligerous  disc  while  it  re- 
mained in  the  ovary.  The  vitelline  membrane  is  somewhat  thickened,  but  it  is 
still  the  only  one  that  can  be  observed  around  the  vitellus ;  when  the  ovum 

'  It  has  horetofore  been  always  impossible  to  study  these  changes  in  the  human  egg,  and 
the  description  we  are  about  to  give  is  the  result  of  observations  made  on  the  eggs  of  mam- 
miferte,  especially  of  the  dog  and  rabbit;  but  analogy  favors  the  belief  diat  similar  pheno- 
mena take  place  in  the  human  species  ;  indeed,  the  strongest  resemblance  exists  between 
the  ovum  of  the  latter  and  the  unfecundated  egg  of  a  bitch;  besides,  the  youngest  ova  that 
have  been  studied  in  the  female,  exactly  resemble  those  wliich  have  arrived  at  a  certain 
degree  of  development  in  animals.  It  is,  therefore,  extremely  probable  that  if  they  are  en- 
dowed with  the  same  organization  before  conception,  and  still  exhibit  a  perfect  resemblance 
after  the  fecundation,  they  must  have  passed  through  similar  successive  transformations. 


170 


GENERATION. 


reaches  the  second  half  of  the  tube,  it  is  no  longer  imbedded  in  the  granulations 
of  the  disc,  since  they  have  disappeared,  though  a  layer  of  a  perfectly  transparent 
gelatinous  substance  may  be  distinguished  ai'ound  the  vitelline  membrane. 

During  the  first  part  of  this  course  the  yolk  has  its  consistence  increased  (Bis- 
choflP),  and  forms  a  more  compact  mass ;  it  therefore  does  not  exactly  fill  up  the 
vitelline  membrane,  a  small  quantity  of  clear,  transparent  liquid  being  interposed 
between  the  internal  face  of  the  latter  and  its  own  proper  surface.  This  conden- 
sation of  the  yolk  is  sufficiently  marked,  even  after  the  envelope  has  been  incised, 
to  constitute  a  solid  body,  which  may  be  separated  by  a  very  fine  needle  into  two, 
four,  or  six  parts. 

In  the  second  half  and  inferior  third  of  the  tube,  the  surrounding  layer  of 
albumen  augments,  as  well  as  the  thickness  of  the  vitelline  membrane.     But, 

FiR.36. 


A.  The  layer  of  albumen,    v.  The  vitelline  membrane. 


^X 


37. 


_/-^:>-^- 


V 


according  to  the  statement  of  Barry  and  Bischoff,  the  yolk  undergoes  the  most 

remarkable  changes  of  all,  for,  instead  of  form- 
ing, as  hitherto,  a  compact,  homogeneous  mass, 
it  is  divided  first  into  two  rounded  portions 
(Fig.  35),  the  number  doubling  successively,  ia 
proportion  as  the  ovum  approaches  the  womb — 
their  diameter  of  course  diminishing  at  the 
same  time  ;  consequently,  in  tracing  the  vitellus 
along  the  duct,  the  whole  yolk  will  be  observed 
to  divide  in  two  regular  rounded  halves,  then 
into  four  (Fig.  36),  afterwards  into  eight  little 
spheres,  and  finally,  each  of  the  last  subdivides 
again  J  so  that,  by  reason  of  these  successive 
subdivisions,  the  vitelline  spheres  become  smaller 
and  smaller,  and  ultimately  terminate  by  causing 
the  whole  mass  of  the  yolk  to  resemble  a  mul- 
berry in  appearance.  The  yolk  is  in  course  of 
dissolution  at  the  period  when  the  ovum  arrives 
in  the  womb. 
The  time  necessary  for  the  ovum  to  traverse  this  passage  is  very  variable  in 

different  animals,  and  even  sometimes  in  the  same  species;  thus,  according  to 


The  Fecundated  Ovum  at  a  more 

advanced  stage. 
A.  The  albuminous  layer  surroundini? 
the  vitelline  membrane  v,  which  is 
seen  to  be  thickened,  and  to  contain 
within  its  cavity  the  mulberry-like 
mass. 


DEVELOPMENT    OF    THE    HUMAN    OVUM.  17f 

^I.  Coste,  the  ovum  of  rabbits  does  not  react  the  uterus  before  the  third  or  the 
fourth  day,  whilst  in  the  bitch,  it  has  been  found  in  the  tubes  as  late  as  the  tenth, 
twelfth,  or  even  fifteenth  day ;  and  we  have  formerly  stated  that,  in  the  human 
species,  no  one  case  has  ever  proved  its  existence  in  the  womb  prior  to  the  twelfth 
day.  However,  it  is  well  to  remark,  that  as  a  general  rule,  the  passage  is  very 
rapid  through  the  external  half  of  the  tube,  whilst  its  progress  through  the 
second  half  and  especially  through  the  last  third  is  exceedingly  slow,  in  conse- 
quence perhaps  of  the  extreme  narrowness  of  this  portion  of  it. 

Finally,  the  ovum  augments  somewhat  in  volume  during  its  course,  being  pro- 
bably nourished  at  first  at  the  expense  of  the  granulations  which  accompany  it, 
and  subsequently  by  absorbing  the  albuminous  liquid  secreted  in  the  oviduct 
itself.^ 

ARTICLE   II. 

MODIFICATIONS   OF   THE    OVULE   FROM   ITS   FIRST   ARRIVAL   IN    THE   WOMB 
UNTIL    AFTER    THE    DEVELOPMENT    OF    THE    ALLANTOIS. 

When  the  ovum  approaches  the  uterine  cavity,  it  consists  of  the  vitellus,  to- 
gether with  any  granulations  that  may  remain  from  the  decomposition  of  the 
mulberry-like  body,  of  the  thickened  vitelline  membrane,  and  a  very  thin  layer 
of  albumen  that  surrounds  it.  Shortly  after,  the  vitelline  granulations  wholly 
disappear,  and  they  are  replaced  by  a  perfectly  limpid  and  transparent  liquid. 
These  granulations  seem  to  be  condensed  on  the  internal  wall  of  the  vesicle,  and, 
by  their  adherence  to  each  other,  to  constitute  thei'e  a  second  vesicle,  enclosed  by 
and  lining  the  first.  This  second  membrane  is  not  easily  recognized;  but,  if  the 
example  of  M.  Coste  be  followed,  and  the  ovule  be  placed  in  water,  it  will  be- 
come quite  apparent.  In  fact,  a  very  curious  endosmotic  phenomenon  then  takes 
place;  the  water  passing  through  the  vitelline  membrane  detaches  the  second 
vesicle  in  such  a  manner  that  the  latter,  being  completely  isolated,  as  also  puck- 
ered and  corrugated  in  every  direction,  floats  or  hangs  suspended  in  the  new 
liquid  which  distends  the  vitelline  membrane ;  and  to  this  M.  Coste  has  given 
the  title  of  the  hlaatodermic  membrane.  But  while  this  blastodermic  vesicle,  or 
membrane,  is  being  developed,  the  layer  of  albumen  which  surrounded  the  ovum 
on  its  first  arrival  in  the  uterus,  disappeai's,  and  consequently  the  vitelline  vesicle 
loses  much  of  its  thickness. 

Hitherto,  the  ovum  still  remained  free  and  without  any  adhesion  to  the  uterine 
walls;  but  it  commences  about  this  period  to  contract  more  intimate  relations 
with  the  latter,  and  hence  can  no  longer  be  displaced  by  blowing  upon  it.  To- 
wai'ds  the  sixteenth  or  seventeenth  day  after  the  fecundation,  a  rounded,  whitish 
spot  begins  to  appear  on  some  point  of  the  blastodermic  vesicle,  which  seems  to 
be  detached,  or  to  stand  in  relief;  this  has  been  called  the  taclie  emhryonnaire 

'  This  layer  of  albumen  which  surrounds  the  ovum  of  the  rabl:)it  ami  of  the  roebuck  wliilst 
it  remains  in  the  tube,  does  not  exist  around  the  ovum  of  the  bitch  and  of  the  sow.  On  ac- 
count of  these  differences,  it  will  remain  xtncertain  whether  it  envelopes  the  human  ovum 
until  observations  which,  as  yet,  it  has  been  impossible  to  make,  shall  settle  the  question. 


172 


GENERATION. 


38. 


(the  embryonic  spot),  by  M.  Coste,  and  it,  like  the  blastodermic  vesicle,  is  com- 
posed of  cellular  granulations,  excepting  that  these  latter  are  more  contracted, 

and  are  aggregated  in  a  larger  quantity  at  this  point. 
(Figs.  39  and  40.)  At  the  same  time,  a  minute 
examination  is  all  that  is  necessary  to  convince  us 
that  the  vesicle,  as  also  the  embryonic  spot,  is  com- 
posed of  two  laminae,  lying  in  contact  with  each 
other,  but  which  may  be  separated  by  a  couple  of 
fine  needles.  To  render  this  doubling  of  the  blas- 
toderm more  evident,  we  present  two  theoretical 
figures,  exhibiting  it  at  the  same  stage  of  develop- 
ment. In  the  first,  which  is  a  front  view  of  the 
ovuin,  the  blastoderm  with  the  rounded  embryonic 
spot  is  seen.  The  same  figure,  in  profile,  shows  the 
two  blastodermic  laminae,  both  presenting  a  swelling 
near  the  embryonic  spot.  One  has  been  called  the 
external,  or  serous  layer,  and  the  other  is  denominated  the  internal,  imicous,  or 
the  vegetative  one.     Shortly  after  this  period,  the  embryonic  spot  enlarges  by  the 


The  ovule  shortly  after  its  arri- 
val in  the  womb.  a.  The  dimi- 
nished albuminous  layer,  v.  The 
vitelline  membrane.  B.  The  blas- 
todermic membrane. 


Fig.  39. 


Fis.  40. 


Fig.  39.  The  blastoderm,  with  the  embryonic  spot  seen  in  front,  v.  The  vitelline  membrane,  e.  The 
external  layer  of  the  blastoderm,    p.  The  embryonic  spot. 

Fig.  40.  The  same  figure  in  profile,  to  show  the  two  layers  of  the  blastoderm,  v.  The  vitelline  mem- 
brane.   E.  The  external;  and  I,  the  internal  or  intestinal  layer  of  the  blastoderm. 

fui*ther  addition  of  granules,  but  more  in  one  of  its  diameters  than  in  the  others, 
so  as  to  exchange  its  rounded  for  an  elongated  form. 

A  considerable  projection  above  the  external  face  of  the  blastoderm  may  be 
simultaneously  noticed,  which  exhibits  a  convexity  towards  the  vitelline  mem- 
brane, and  a  concavity  looking  to  the  central  part  of  the  ovum  (Fig.  41) ;  and 
thenceforth  the  cavity  of  the  blastodermic  vesicle  is  divided  into  two  distinct 
portions,  the  one  embryonic,  the  other  forming  the  umbilical  vesicle. 

A  line  of  greater  obscurity  may  soon  be  recognized  at  the  centre  of  this  spot, 
being  the  first  trace  of  the  embryo.  The  margins  of  this  spot  fold  inwards,  as  do 
also  the  extremities,  thereby  giving  rise  to  an  elongated  body,  with  the  ends 
swollen,  in  consequence  of  their  doubling  up,  and  a  cavity  of  some  depth  at  its 
centre.  The  body  of  the  embryo  is  then  readily  distinguished,  and  resembles 
tolerably  well  in  shape  the  body  of  a  guitar. 

The  extremity  that  is  most  swollen  is  called  the  cephalic,  and  the  other,  or  less 


DEVELOPMENT    OF    THE    HUMAN    0  V  U  JI. 


173 


Fig.  41. 


A  section  of  a  more  deve- 
loped oviinj,  in  vvliich  ihe  two 
portions,  the  embryonic  and 
the  utnliilical  vesicle,  befiin 
to  appear,  o.  The  umhilical 
vesicle,  i.  The  internal  layer 
of  the  lilastoderm.  e.  The 
external  layer,  v.  The  vitel- 
line membrane. 


Fig.  42. 


voluminous  one,  the  caudal  extremity ;  about  that  time  the  serous  lamina  of  the 
blastoderm  can  be  traced  as  continuous  with  the  most 
external  layers  of  the  embryonic  body,  whilst  the  mucous 
one  forms  its  internal  plane.  In  proportion  as  the  em- 
bryonic spot  loses  its  distinctive  characters,  numerous 
little  elevations,  irregularly  scattered  over  the  external 
surface  of  the  ovum,  are  seen  to  develop  themselves, 
being,  in  fact,  the  commencement  of  those  villosities 
which  subsequently  stud  the  exterior  surface  of  the 
chorion. 

During  the  progress  of  these  phenomena,  the  exter- 
nal, or  serous  layer  of  the  blastoderm  (Fig.  42)  is  raised 
in  folds  around  its  central  portion,  which  has  been  de- 
veloped into  the  embryo,  and  more  especially  so  at  the 
caudal  and  cephalic  extremities.  The  fold  gradually 
enlarges  above,  below,  and  on  the  sides,  in  such  a  man- 
ner as  to  form  a  true  hood  over  the  head  and  caudal 
termination ;  hence  named  from  this  resemblance  the 

cephalic  and  caudal  hoods.  These  folds  elongate  rapidly,  passing  along  the  dorsal 
regions  of  the  embryo,  and  ultimately  come  into  contact  with  each  other  on  the 
median  line.  (Fig.  43.)  The  internal  lamina  of 
this  fold  is  continuous  with  the  embryo,  along  the 
whole  circumference  of  its  large  ventral  opening ; 
and  hence  this  first  lamina,  which  is  originally  ap- 
plied almost  directly  to  the  embryo,  but  soon  after 
is  separated  from  it  by  a  certain  quantity  of  liquid, 
thus  becomes  its  immediate  envelope,  and  has  re- 
ceived the  name  of  the  amnion,  and  the  interposed 
fluid,  that  of  the  aviniotic  liquor. 

As  to  the  external  layer  of  the  fold,  it  is  mani- 
festly continuous  with  the  serous  lamina  of  the 
blastoderm,  and  although  primarily  applied  to  the 
preceding,  it  is  speedily  separated  therefrom  by  the 
interposition  of  a  liquid  which  removes  them  fur- 
ther and  further  from  each  other,  until  at  last,  its 
exterior  face  is  brought  into  contact  with  the  vitel- 
line vesicle.  According  to  some  authors,  these 
two  become  confounded,  and  by  uniting  form  the  outer  membrane  of  the  ovum ; 
but  others  teach  that  the  vitelline  vesicle  will  be  gradually  absorbed  (as  we  have 
endeavored  to  represent  in  the  plates  Figs.  44,  45,  and  46),  while  the  external 
lamina  of  the  blastoderm  is  being  developed,  and  the  latter  alone  will  then  con- 
stitute the  enveloping  membrane.  We  embrace  the  former  opinion  the  more 
willingly,  because  we  have  a  proof  that  the  exochorion  is  the  primary  membrane 
of  the  ovum,  from  its  exhibiting  some  small  irregular  elevations  on  its  exterior 
surface,  prior  to  the  formation  of  the  amnios,  which  are  the  rudiments  of  the 
chorial  villosities. 


A  section,  showing  the  origin  and 
first  traces  of  the  amnios,  o.  The 
umbilical  vesicle,  i.  The  intestinal ; 
and  E,  the  external  layer  of  the  blas- 
toderm. V.  The  vitelline  membrane, 
c  c.  Origin  of  the  cephalic  and  cau- 
dal amniotic  hoods. 


174 


GENERATION. 


Fig.  43. 


The  amniotic  hoods  more  developed. 
o.  The  umbilical  vesicle.  I.  The  inter- 
nal or  iiiteslinal;  and  e,  the  external 
liiyer  of  the  blastoderm.  ¥.'.  A  portion 
of  the  external  layer  converted  into  the 
amnios,  f.".  The  embryo,  c.  The  limit 
of  the  amniotic  lioods.  v.  The  vitelline 
membrane. 


At  the  puint  of  junction,  the  cephalic  and  caudal  hoods  constitute,  by  their 

union,  a  kind  of  membranous  bridge,  which 
there  joins  the  amnios  to  the  chorion.  This 
bridge  is  gradually  absorbed,  and  the  two  mem- 
branes become  completely  isolated.  (See  Figs. 
45  and  46.) 

Such  is  the  view  most  generally  received  oa 
the  mode  of  formation  of  the  amnios.  We  must 
mention,  however,  one  other,  which,  without 
being  new,  has  latterly  acquired  considerable 
importance  by  the  discussions  which  it  has 
created  at  the  Academy  of  Sciences. 

We  have  just  seen  that  the  amnios  is  directly 
continuous  at  the  umbilicus  with  the  abdominal 
walls  of  the  embryo,  which  is  in  fact  so  mani- 
fest, that  no  just  ground  of  belief  is  afforded 
that  the  latter  was  ever  independent  of  the 
amnios,  as  some  have  recently  supposed.  Messrs. 
Oken,  Pockels,  Serres,  and  Breschet  have  en- 
deavored, notwithstanding,  to  prove  that  the  amnios  once  existed  as  an  indepen- 
dent vesicle,  distended  by  a  fluid ;  and  that  afterwards  the  foetus,  by  coming  into 
contact  with  it,  caused  its  depression,  and  became  enveloped  by  it,  like  a  double 
night-cap,  but  having  no  other  relation  with  it  than  that  of  simple  apposition ; 

or,  in  other  words,  that  the  amnios  had  the 
same  connection  with  the  embryo  as  the  serous 
membranes  with  the  viscera  they  cover. 

Messrs.  Coste,  Velpeau,  and  Bischoff  have 
combated  this  view  successfully,  in  my  esti- 
mation, by  contending  for  the  existence,  at  all 
periods,  of  the  continuity  we  have  just  de- 
scribed, and  they  cannot  possibly  admit  an 
opinion  which  is  founded  solely  on  pathologi- 
cal altemtions.  For  my  own  part,  after  exa- 
mining the  preparations  of  M.  Coste,  I  can 
have  no  doubt  as  to  the  little  value  of  such 
assertions. 

Immediately  after  the  amnios  is  formed, 
the  margins  of  the  embryonic  spot,  and  espe- 
cially its  two  extremities,  become  more  and 
more  turned  inwards,  thereby  augmenting  the 
concavity  which  it  previously  exhibited ;  and, 
at  the  bottom  of  the  groove  thus  constituted, 
the  mucous  lamina  of  the  blastoderm  is  ob- 
served to  concur  in  forming  the  intestinal  canal,  which  is  represented  at  this 
early  period  by  an  elongated  gutter,  communicating  freely  with  the  interior  cavity 


Fi".  44. 


This  fitrnre  shows  the  amnios  almost 
completed,  and  likewise  the  orii,'in  of  the 
allantois.  o.  The  umbilical  vesicle,  i.  The 
intestines,  e.  The  amnios,  e'.  The  ex- 
ternal layer  of  the  blastoderm,  or  the 
non-vascular  chorion,  v.  Tho  vitelline 
membrane,  c.  The  amniotic  hoods  ready 
to  close  up.    A.  Tlie  allantois. 


DEVELOPMENT    OF    THE    HUMAN     OVUM. 


175 


Fig.  45. 


of  the  blastoderm.  But,  in  proportion  as  this  constantly  increasing  inversion  of 
the  lateral  walls,  and  of  the  extremities  of  the  embryo  progresses,  this  communi- 
cation becomes  more  and  more  contracted,  so  that  in  a  short  time  the  intestinal 
cavity  only  connects  with  the  blastodermic  vesicle  by  a  contracted  pedicle;  and 
thenceforth,  this  latter  receives  the  name  of  the  umbilical  vesicle,  and  the  vessels 
which  are  distributed  tg  its  vascular  layer,  consisting  of  two  veins  that  enter,  and 
an  artery  that  emerges  from  the  embryo,  are  called  the  omjyJialo-niesenteric  vessels. 
(Fig.  44.) 

As  the  contraction  of  the  ventral  opening  in  the  embryo,  and  the  circumscrip- 
tion of  the  umbilical  vesicle  goes  on,  we  may  observe  at  the  inferior  part  of  the 
intestinal  canal,  just  in  the  region  where  the  bladder  and  rectum,  during  the 
earlier  days  of  embryonic  life,  are  confounded  under  the  name  of  cloaca;  we 
observe,  I  repeat,  the  intestinal  parietes  to  form  there  a  slight  elevation.  Now, 
this  little  tumor  (Fig.  44)  gradually  elon- 
gates, so  as  to  constitute  a  minute  vesicle, 
which  communicates  by  its  narrow  pe- 
dicle with  the  intestinal  cavity ;  this  is 
the  allantois,  which  has  been  known  for 
a  long  time  to  exist  in  mammiferas,  but 
which  M.  Coste  was  one  of  the  first  to 
detect  in  the  human  ovum.  The  allan- 
tois is  scarcely  formed  before  it  is  pro- 
vided both  with  venous  and  arterial 
vessels,  consisting  of  the  two  umbilical 
arteries  and  one  umbilical  vein ;  the 
former  arising  from  the  primitive  iliacs, 
the  latter  going  to  the  liver,  as  may  be 
seen  somewhat  later. 

This  little  vesicle  passes  through  the 
umbilicus  at  first  alongside  of  the  pedicle 
belonging  to  the  umbilical  vesicle,  and 
soon  undergoes  a  rapid  development. 
The  growth  of  the  allantois  and  its  ves- 
sels is  so  rapid  that  it  soon  comes  into 
contact  with  the  external  membrane  of 
the  ovum.  In  some  animals,  the  allan- 
tois comes  into  juxtaposition  by  its  base 
with  only  one  point  of  the  chorion,  and 

becomes  attached  there ;  and  then  the  terminal  extremities  of  the  umbilical  ves- 
sels not  only  reach  this  membrane,  but  even  extend  for  the  most  part  to  the  vil- 
losities  developed  on  its  external  surface,  and  acquire  there  a  considerable  growth. 

In  others  (see  Figs.  45  and  46),  the  allantois  spreads  out  like  an  umbrella 
around  the  embryo  and  umbilical  vesicle,  and  applies  itself  to  the  whole  external 
face  of  the  amnios,  as  well  as  to  the  internal  one  of  the  chorion,  then  the  two 
laminae  are  fused  into  each  other  in  such  a  way  as  to  leave  no  trace  of  the  allan- 


Tliis  figure  shows  the  rapid  progress  of  tlie 
allantois,  and  how  it  spreads  over  the  fcelus,  the 
umbilical  vesicle,  and  the  amnios.  This  latter 
begins  to  enshenth  Ihe  pedicle  of  the  umbilical 
vesicle,  and  that  of  Ihe  allantois  in  such  a  way 
as  to  form  a  commencement  of  the  cord.  Ac- 
cording to  some  writers,  the  vitelline  membrane 
disappears  more  and  more.  o.  The  umbilical 
vesicle.  e'.  The  amnios,  e".  The  external 
layer  of  the  blastoderm,  c.  The  point  where 
the  two  hoods  come  into  contact,  v.  The  vitel- 
lina  membrane  almost  entirely  atrophied,  a.  The 
allantois. 


176 


GENERATION. 


tois  (Fig-  46)  ;  though,  when  this  view  is  more  critically  examined,  it  cannot  be 

regarded  as  altogether  exact,  says  Bis- 
choff,  as  regards  the  human  species, 
for:  1.  No  one  has  ever  observed  the 
least  trace  of  the  allantois,  either  on  the 
internal  face  of  the  chorion,  nor  on  the 
external  one  of  the  amnios ;  and  as  both 
these  are  perfectly  simple  membranes, 
surely  some  ovum  would  have  been 
found  in  which  the  fusion  had  not  be- 
come so  perfect.  2.  The  amnios  never 
has  vessels,  and  the  chorion  is  equally 
devoid  of  them,  except  at  the  point 
where  the  allantois  is  attached,  and  the 
contrary  should  exist,  as  in  the  rumi- 
nantia  and  carnivora,  if  the  allantois  of 
women  observed  the  same  law  as  it  does 
in  those  animals;  it  is  therefore  pro- 

amiiios,  and  that  part  of  the  external  layer  of  the  bable  that  itS  base  Only  is  brought  intO 
blastoderm  which  formed  the  non-vascular  chorion;  .       ,       ^,^  •  •it  ,•  p 

contact  witn  a  circumscribed  portion  ot 
the  chorion. 

It  is  very  difficult  to  decide  upon  this 
question ;  but  the  cases  in  which  the 
point  of  insertion  of  the  placenta  is  very 
distant  from  that  at  which  the  cord  is 
attached  to  the  chorion,  would  seem  to  prove,  that  in  some  cases  at  least,  the 
allantois  spreads  around  the  entire  circumference  of  the  ovum.  Whichever 
opinion  we  adopt,  the  views  relative  to  the  vascular  relations  which  become 
established  between  the  chorion  and  the  allantois,  remain  unchanged. 

The  development  of  the  allantois  completes  the  essential  parts  of  the  ovum, 
although  by  reference  to  Fig.  55,  Plate  III,  it  will  now  be  found  to  consist :  1,  of 
the  embryo;  2,  of  a  variable  quantity  of  liquid  in  which  it  swims;  3,  of  the 
amnios,  already  considerably  distended,  and  forming  a  sheath  to  the  parts  that 
pass  through  the  ventral  aperture ;  4,  of  the  umbilical  vesicle  situated  between 
the  amnios  and  chorion,  whose  delicate  pedicle,  with  the  omphalo-mesenteric 
vessels  appertaining  to  it,  however,  still  communicate  with  the  intestinal  cavity ; 

5,  the  pedicle  of  the  allantois  vesicle  still  charged  with  the  umbilical  vessels ; 

6,  the  space  between  the  amnios  and  chorion,  partly  occupied  by  the  umbilical 
vesicle,  but  principally  filled  with  a  liquid  called  by  M.  Velpeau  the  reticulated 
or  the  vitriform  hody,  according  to  the  degree  of  its  consistence;  and  7,  of  the 
outer  envelope,  or  the  chorion. 

The  phenomena  yet  to  be  studied,  have  special  reference  to  the  enlargement 
of  the  ovum,  and  the  development  of  the  embryo;  but  before  engaging  with 
them,  it  is  indispensably  necessary  to  detail  the  changes  that  occur  during  the 
first  fortnight  of  gestation  on  the  internal  surface  of  the  womb. 


In  this  fitrure,  the  allantois  has  spread  over  the 
whole  internal  surface  of  the  ovum,  and  but  very 
slight  traces  are  left  of  the  continuity  betvveen  the 


the  latter  has  a  tendency  to  be  confounded  with  the 
chorion,  and  the  amnios  encloses  tlie  umbilical  cord 
more  and  more.  o.  The  umbilical  vesicle,  e'.  The 
amnios,  c.  The  point  where  the  two  hoods  are  fused 
into  each  other,  and  form  but  a  single  membrane. 
e".  The  external  layer  of  the  blastoderm,  a.  The 
allantois.    v.  The  vitelline  membrane. 


OF    THE     DECIDUA.  177 

CHAPTER   II. 

OF    THE    DECIDUA. 

In  the  second  edition  of  this  work,  after  having  stated  the  opinions  which  have 
been  successively  advanced,  respecting  the  origin,  nature,  and  mode  of  develop- 
ment of  the  decidua,  I  said,  "  I  have  examined,  with  M.  Coste,  several  of  the  pre- 
parations on  which  he  relies  for  the  support  of  his  view,  that  the  decidua  is 
nothing  else  than  the  uterine  mucous  membrane  itself,  which  is  hypertrophied 
by  the  progress  of  gestation :  unfortunately,  the  ovum  in  all  of  them  had  advanced 
to  the  third  mdnth  at  least,  and  it  seems  to  me  that  the  question  can  only  be 
determined  when  an  opportunity  shall  be  afforded  of  examining  an  ovum  of  not 
more  than  five  or  six  weeks.  I  am,  therefore,  far  from  having  a  settled  convic- 
tion, though  I  am  willing  to  confess  that  the  last  uterus  examined  by  us  together, 
has  singularly  shaken  my  belief  on  this  point  of  ovology  ;  and  this,  conjoined  with 
the  descriptions  given  by  Weber  and  Sharpey,  restrains  me  from  speaking  with 
the  same  degree  of  confidence  as  formerly.  I  therefore  think  it  a  question  re- 
quiring further  examination."     (Page  176,  trans,  of  2d  edition.) 

My  desires  expressed  in  1844  have  been  realized  j  and,  thanks  to  the  kindness 
of  M.  Coste,  I  have  had  the  opportunity  of  examining  an  admirable  collection  of 
specimens  of  all  ages,  which,  I  take  the  opportunity  of  acknowledging,  have  not 
left  the  remotest  doubt  in  my  mind,  at  least  as  regards  the  principal  fact.  I 
therefore  reject  the  more  or  less  ingenious  hypotheses  proposed  hitherto, — hypo- 
theses which,  it  is  true,  were  rendered  very  probable  by  the  examination  of  a  large 
number  of  ova  expelled  by  abortion, — and  with  the  sincerest  conviction  of  its 
truth  adopt  the  opinion,  that  the  decidua  is  nothing  else  than  the  hypertrophied 
mucous  membrane.  For  the  benefit  of  those  who  may  not  have  the  good  fortune 
to  see  the  beautiful  preparations  of  the  learned  Professor  of  the  College  of  France, 
I  think  it  proper  to  give  further  on  the  description  and  the  figure  borrowed  from 
the  magnificent  atlas  which  he  is  publishing. 

But,  before  stating  what  I  believe  to  be  proved  in  reference  to  this  interesting 
point,  it  will  be  necessary  to  give  a  brief  exposition  of  the  theory  which  has  been 
generally  received  until  of  latter  time,  as  also  to  endeavor  to  discover  the  cause 
of  the  error  of  almost  all  whx)  have  investigated  this  subject. 

If  an  ovum  which  has  been  expelled  intact,  in  consequence  of  an  abortion 
within  the  first  two  months,  be  examined,  there  will  be  found  to  exist,  outside  of 
the  chorion,  a  sort  of  pouch  with  which  the  ovum  lies  in  contact  by  nearly  four- 
fifths  of  its  external  surface,  whilst  the  villi  of  the  chorion  are  free  and  floatinjr 
in  the  other  fifth. 

This  pouch,  which  is  pyriforra  in  shape,  like  the  uterine  cavity  upon  which  it 
seems  to  be  moulded,  generally  presents  but  a  single  opening,  situated  at  the 
apex  of  the  cone,  which  it  represents,  and  evidently  corresponding  to  the  orifice 
of  the  neck  of  the  uterus;  sometimes,  however,  I  have  found  it  perforated  on  at 
least  one  side  at  the  point  corresponding  to  the  opening  of  the  Fallopian  tubes. 

12 


178 


GENERATION. 


FiK.  47. 


B^S 


The  walls  of  this  pouch  are  formed  by  a  membrane  known  to  embryologists  as 
the  decidua.  It  has  two  surfaces,  one  external  and  the  other  internal.  The 
internal  surface  is  smooth,  covered  with  epithelium,  and  when  examined  with  a 
lens,  presents  small  elevations,  in  form  not  unlike  the  circumvolutions  of  the 
cerebrum,  and  each  furnished  with  several  oval  openings.  The  cavity  limited  by 
this  surface  sometimes  contains  a  muco-albuminous  fluid,  and  in  certain  patholo- 
gical cases,  fluid  or  coagulated  blood,  though  ordinarily  they  do  not  exist  in  it. 

The  external  surface  of  the  decidua  may  be  divided  into  two  portions,  the 
smaller  of  which  is  in  contact  with  the  ovum,  and  surrounds  the  greater  part  of 
its  external  surface ;  the  other,  and  by  far  the  largest  portion,  is  entirely  free, 
and  must,  when  the  ovum  was  still  within  the  uterus,  have  been  applied  to  the 
internal  surface  of  the  womb.  This  external  surface  is  very  irregular,  and  thickly 
studded  with  small  and  slender  filaments. 

The  portion  of  this  membrane  in  contact  with  the  ovum,  was  at  first  termed 
the  ovular  decidua,  and  afterwards,  as  suggestive  of  the  way  in  which  it  was 
supposed  to  be  formed,  the  decidua  reflejca  ;  the  other  was 
called  the  uterine  or  parietal  decidua,  on  account  of  its 
relation  with  the  wall  of  the  uterus. 

Now,  what  is  the  nature  of  this  membrane  ?  What  is 
the  mode  of  its  formation  ?  At  what  period  is  it  deve- 
loped ?  To  furnish  replies  to  these  questions  the  following 
theory  was  imagined,  which  theoretically  furnishes  quite  a 
good  solution  of  all  the  difficulties  of  the  case. 

As  previously  stated,  the  uterus,  like  all  the  other  geni- 
tal organs,  becomes  the  seat  of  a  more  active  vitality  imme- 
diately after  a  fruitful  coition ;  in  consequence  of  which 
the  blood  flows  there  in  increased  quantity,  occasioning  a 
congestion  and  turgescence  of  tissue,  not  far  removed  froui 
inflammation.  This  abnormal  excitement  is  always  accom- 
panied by  the  secretion  of  coagulable  lymph,  a  sero-albu- 
minous  fluid,  which  soon  fills  up  the  uterine  cavity.  In  the  course  of  a  few  days 
the  fluid  thickens,  and  its  exterior  particles,  by  becoming  more  consistent,  form 
a  soft  pulpy  membrane,  which  lines  the  whole  internal  surface  of  the  womb ; 
thereby  constituting  a  true  sac,  that  is  in  contact  externally  with  the  mucous 
membrane  throughout,  and  is  filled  by  the  uncoagulated  portion  of  the  fluid. 
From  its  position,  this  pouch  must  evidently  assume  the  shape  of  the  uterine 
cavity  upon  which  indeed  it  seems  to  be  moulded  (Fig.  47). 

The  fecundated  ovule  does  not  reach  the  cavity  of  the  womb  until  after  the 
lapse  of  eight,  ten,  «r  even  twelve  days,  from  the  time  of  fecundation,  but  the 
membrane  just  spoken  of  begins  to  form  much  earlier.  The  consequence  is, 
that  after  the  ovule  has  traversed  the  tube,  it  finds  the  internal  orifice  closed  by 
the  decidua,  and  evidently  can  only  pass  between  it  and  the  uterus  by  pushing 
the  membrane  before  it.  From  this  time,  the  decidua  presents  two  distinct 
layers,  the  most  extensive  of  which  lines  the  internal  surface  of  the  uteras,  except 
at  the  point  occupied  by  the  ovum;  it  is  called  the  external  or  uterine  decidua. 


A  section  of  ihe  womb, 
exhibiting  the  decidua  in 
situ,  before  the  arrival  of 
the  ovum.  a.  The  cavity 
of  the  neck,  b  b.  Orifices 
of  the  Fallopian  tubes,  c. 
The  decidua.  d.  The  ca- 
vity of  the  deciduous  mem- 
brane. 


OF     THE     DECIDUA. 


179 


Fig.  48. 


The  decidua  after  the  arrival  of 
the  ovum.  c.  The  external,  or  ute- 
rine decidua.  K  E.  The  internal 
or  reflected  layer,  d.  The  cavity  of 
the  decidua.  p.  The  chorion,  g. 
The  amnion.  The  other  references 
the  same  as  in  the  preceding  figure. 


The  other,  which  is  pressed  inward  by  the  ovule,  and  is  therefore  in  contact  with 
a  greater  or  less  extent  of  its  external  surface,  is  termed  the  internal  or  reflexed 
decidua,  the  ovular  decidua,  and  the  epichorion  of  Chaussicr. 

These  two  layers  are  at  first  widely  separated  from  each  ether ;  but  as  the 
ovum  increases  in  size,  the  extent  of  the  reflected  decidua  is  necessarily  augmented 
and  the  cavity  diminished,  so  that  by  the  fourth 
month  the  latter  has  disappeared,  and  the  parietal 
and  ovular  layers  come  in  contact. 

The  ovum  is  in  immediate  contact  with  the 
uterine  mucous  membrane  by  a  small  part  of  its 
chorial  villosities  only ;  all  the  rest  of  its  external 
surface  being  separated  from  it  by  the  reflexed 
layer,  the  cavity,  and  the  parietal  layer  of  the 
decidua.  All  the  villi  of  the  chorion  which  are 
covered  by  the  decidua,  after  a  time  become  atro- 
phied and  disappear;  but  those  which  are  in 
immediate  contact  with  the  mucous  membrane 
become  greatly  developed,  and  contract  more  or 
less  intimate  connections  with  the  vascular  villi 
belonging  to  the  latter  membrane,  at  the  point 
where  subsequently  the  placenta  will  be  developed. 

We  see  that  thus  far  this  hypothesis  coincides 
very  ingeniously  with  the  appearances  presented  by  ova  which  have  been  expelled 
uninjured  by  abortion.  It  enables  us  to  understand  perfectly  how  that,  notwith- 
standing the  complete  integrity  of  the  decidua,  the  ovum  is  yet  covered  by  it  in 
but  a  part  of  its  extent. 

Subsequently,  however,  at  the  autopsies  of  women  who  died  in  the  third  or 
fourth  months  of  gestation,  a  membrane  was  discovered  upon  the  external  sur- 
face of  the  placenta,  resembling  precisely  the  parietal  decidua,  and  continuous 
with  it,  without  there  being  any  discoverable  line  of  demarcation  between  it  and 
this  inter-utero-placental  membrane;  so  that  this  uterine  decidua,  which  in 
aborted  ova  was  in  contact  with  but  a  portion  of  the  surface  of  the  ovum,  was 
found  to  surround  it  completely,  as  the  shell  encloses  the  egg  of  a  bird,  when 
opportunity  ofi'ered  for  examining  it  in  situ  in  the  uterus.'  This  apparent  con- 
tradiction with  the  theory  was  accounted  for  by  the  following  hypothesis. 

The  arrival  of  the  ovule  does  not  at  once  suspend  the  former  secretion  in  the 
uterus;  and  it  continues  to  go  on,  more  particularly  from  the  surface  that  is 
directly  in  relation  with  the  ovum,  in  consequence  of  the  greater  vitality  which 
the  latter  maintains;  and  the  secreted  matter,  being  precisely  similar  to  that 

'  In  1851, 1  exhibited  to  the  Academy  of  Medicine,  and  afterwards  presented  to  M.  Coste, 
who  has  had  it  engraved  in  his  great  Atlas,  an  aborted  ovum,  presenting  a  perfect  decidua, 
surrounding  the  ovum  as  the  shell  surrounds  the  egg  of  a  bird.  The  examination  of  this 
ovum  revealed  an  arrangement  entirely  similar  to  what  will  be  described  hereafter  from 
specimens  observed  in  the  uterus.  This  is,  I  believe,  the  first  perfect  aborted  o\'um  which 
has  ever  been  studied. 


180  GENERATION. 

which  formed  the  primitive  decidua,  thickens  in  turn,  thereby  constituting  a  layer 
of  phistic  material,  precisely  like  the  first,  between  the  ovum  and  womb,  which 
bathes  both  the  chorial  and  the  uterine  villosities ;  and  when  this  deposit  finally 
coagulates,  it  contributes  to  the  formation  of  the  placental  mass,  the  external 
surface  of  which  is  in  this  manner  necessarily  covered  by  an  albuminous  layer. 
This  lamina  has  been  called  the  secondary,  or  the  inter-utero-placental  decidua 
(jlecidua  scrotimi).  Although  limited  at  first  to  the  external  surface  of  the 
placenta,  it  soon  unites  so  intimately  with  the  uterine  layer  of  the  primitive 
decidua,  that  their  separation  becomes  quite  difficult  at  a  more  advanced  period. 

Aecording  to  this  view,  the  decidua  serotina  and  the  pi'imitive  decidua,  have 
a  common  origin  and  texture,  and  only  difter  as  regards  the  time  of  their  for- 
mation. 

In  adding,  finally,  that  the  decidua  was  by  some  supposed  to  be  destitute  of 
vessels  (anhistous  membrane  of  Velpeau),  whilst  others  considered  it  to  be  per- 
forated and  traversed  by  arteries  and  veins  in  considerable  number,  we  shall 
have  briefly  reviewed  the  most  generally-received  opinions  upon  the  subject. 

With  the  exception  of  some  disagreement  in  regard  to  unimportant  details,  all 
authors  were  unanimous  as  respects  this  capital  fact,  namely,  that  the  decidua  is 
a  newly-formed  membrane  superadded  to  the  uterine  mucous  membrane,  from 
which,  however,  it  is  entirely  distinct.  So  evident,  indeed,  did  this  fact  appear, 
that  for  the  past  ten  years,  no  one,  notwithstanding  the  old  assertions  of  Sabatier, 
Mayer,  Seller,  and  Weber,  could  bring  himself  to  admit  that  the  decidua  was 
only  a  development  of  the  lining  membrane  of  the  uterus.  And  even  at  the  pre- 
sent time,  notwithstanding  the  numerous  preparations  of  M.  Coste  (1842),  who 
was  the  first  to  sustain  the  truth  of  this  proposition  in  France,  many  honest  minds 
still  hold  to  the  theory  of  Hunter,  which  I  myself  supported  so  long.  The 
evidence  of  anatomical  demonstration  is  not,  however,  to  be  resisted,  and  I  doubt 
not  that  all  who,  like  myself,  shall  have  studied  the  beautiful  preparations  at  the 
College  of  France,  will  be  convinced  of  the  error  of  their  views. 

Theory  of  the  Decidua. — The  history  of  the  decidua  is,  at  the  present  time, 
merely  a  continuation  of  the  account  of  those  modifications  of  the  uterine  mucous 
membrane,  the  study  of  which  was  begun  whilst  treating  of  menstruation.  They 
are,  in  fact,  so  intimately  connected,  that  in  order  to  understand  what  remains  to 
be  said  on  the  subject,  it  is  necessary  to  recall  the  condition  of  the  mucous  mem- 
brane of  the  uterus  at  the  menstrual  period. 

Whilst  the  evolution  of  the  ovarian  vesicle  is  going  on  in  the  ovary,  the  vascu- 
larity of  the  uterine  mucous  membrane  is,  as  we  have  stated  (p.  75),  greatly  in- 
creased, and  the  highly-congested  vessels  are  discoverable  beneath  the  epithelium. 
The  utricular  glands  also  become  visibly  enlarged.  By  this  development  of  its 
principal  elements,  the  mucous  membrane  is  so  thickened,  that  in  consequence  of 
its  restriction  to  the  small  cavity  of  the  uterus,  it  is  thrown  into  folds  and  cir- 
cumvolutions of  variable  depth,  which  are  especially  well  marked  at  the  angles, 
and  give  forth  secondary  ramifications  from  the  sides,  so  as  to  occasion  some 
uniformity  of  appearance.  This  state  of  turgescence,  and  the  violet  hue  which 
often  accompanies  it,  is  maintained  in  a  greater  or  less  degree,  until  the  ovule  is 


OF    THE    DECIDUA.  181 

discharged ;  it  diminishes  during  the  last  days  of  the  menstrual  epoch,  and  dis- 
appears almost  entirely  some  time  after  the  catamenia  have  ceased. 

But,  if  the  ovule,  before  leaving  the  ovarian  vesicle,  or  during  its  passage 
through  the  tube  towards  the  cavity  of  the  womb,  receive  the  vivifying  influence 
of  the  spermatic  fluid,  the  fecundation  will  maintain  and  increase  the  abnormal 
excitement  of  the  genital  organs,  produced  by  the  simple  development  of  the 
Graafian  vesicle.  Then,  instead  of  subsiding,  the  uterine  mucous  membrane 
becomes  still  more  turgescent,  and  of  a  deeper  violet  color,  and  the  folds  and 
wrinkles  increase  so  as  to  more  than  fill  the  cavity  of  the  organ.  Its  vessels  are 
engorged  and  distended  to  such  a  degree  as  to  cause  small  efi"usions,  which  are 
perceptible  beneath  the  epithelium,  and  also  to  produce  ecchymoses,  which  give 
to  the  internal  surface  of  the  uterus  a  striking  marbled  appearance. 

Notwithstanding  this  great  turgescence,  the  internal  surface  of  the  mucous 
membrane  is  smooth  and  polished,  and  never  presents  the  villous  projections 
described  by  Baer,  neither  is  there  any  fluid  secreted,  nor  any  trace  of  a  newly- 
formed  false  membrane.  The  orifices  of  the  glandular  tubes,  which  are  much 
more  visible  than  in  the  unimpregnated  condition,  are  alone  seen  upon  the  surface. 

For  a  short  time  after  it  has  entered  the  womb,  the  ovule  is  free  from  all  ad- 
hesions, but  soon  becomes  permanently  fixed  at  the  point  where  it  was  arrested 
at  the  outset.  Before  studying  the  means  by  which  at  a  later  period  it  becomes 
adherent  to  a  circumscribed  portion  of  the  uterine  parietes,  let  us  examine  the 
facts,  and  see  what  can  be  learned  respecting  the  youngest  ovules  which  it  has 
been  possible  to  observe  up  to  the  present  moment. 

In  the  beautiful  Atlas  of  M.  Coste,  is  figured  and  described  the  uterus  of  a 
young  primiparous  woman,  who  committed  suicide  about  the  twentieth  or  twenty- 
first  day  of  her  pregnancy,  and  whose  body  was  opened  at  the  3Iorgue  of  Paris. 
The  size  of  the  organ  was  nearly  double  that  of  the  normal  condition.  A  longi- 
tudinal incision  was  made  thi'ough  its  posterior  wall,  after  which  it  was  opened 
and  spread  out,  so  as  to  exhibit  the  whole  extent  of  the  cavity.  The  latter  was 
free  as  in  the  unimpregnated  condition,  and  contained  no  fluid.  The  mucous 
membrane  was,  however,  much  thickened  and  tumefied,  presented  numerous  irre- 
gular folds,  and  was  furnished  throughout  with  a  rich  network  of  vessels.  Not- 
withstanding the  general  hypertrophy  of  the  mucous  membrane,  a  sort  of  soft 
tumor  was  discoverable,  situated  on  the  anterior  surface  of  the  uterus  between 
the  two  Fallopian  tubes,  as  though  the  membrane  were  thicker  there  than  else- 
where. (See  Plate  II,  Fig.  47.)  Upon  incising  this  elevated  portion,  the  ovum 
was  recognized  by  the  villi  of  its  chorion.  The  internal  orifices  of  the  tubes  and 
of  the  neck  were  free  and  permeable  as  usual. 

Another  woman  was  examined  at  the  Morgue,  who  had  committed  suicide 
about  the  fortieth  day  of  her  pregnancy.  The  uterus,  which  was  much  larger 
than  in  the  preceding  case,  was  incised  longitudinally  on  its  anterior  surface,  and 
so  disposed  as  to  exhibit  the  greatest  possible  extent  of  the  internal  surface. 

As  in  the  foregoing  specimen,  the  mucous  membrane,  which  was  very  vascular 
throughout  and  greatly  hypertrophied,  was  in  some  points  still  more  pufi'ed  up, 
and  furrowed  with  folds  and  wrinkles. 


182  GENERATION. 

The  upper  two-thirds  of  the  cavity  were  occupied  by  a  soft,  fluctuating  tumor, 
situated  upon  the  posterior  surface  between  the  two  Fallopian  tubes.  Exter- 
nally, this  tumor  presented  altogether  the  appearance  and  organization  of  the 
mucous  membrane  lining  the  remainder  of  the  womb.  The  lower  third  of  the 
cavity  was  free,  so  that  the  cavity  of  the  neck  could  be  entered  without  any  ob- 
stacle presenting.  The  openings  of  the  tubes  were  also  permeable.  An  incision 
upon  the  most  prominent  part  of  the  tumor  revealed  a  cavity  enclosing  an  ovum. 

The  most  superficial  examination  of  these  two  pieces  convinced  us  :  1.  That 
the  internal  surface  of  the  uterus  is  lined  by  a  thick,  soft  membrane,  which  pre- 
sents numerous  wrinkles  and  folds  at  several  points.  2.  That  the  ovum  was 
situated  in  the  upper  part  of  the  womb,  and  apparently  lodged  in  a  cavity  per- 
fectly distinct  from  that  of  the  remainder  of  the  organ. 

Now,  in  order  to  solve  the  problem  which  we  are  investigating,  we  shall  have 
to  ascertain  first,  the  nature  of  the  membrane  which  lines  the  cavity  of  the  uterus, 
as  also  of  those  forming  the  walls  of  the  pouch  which  encloses  the  ovule. 

1.  The  Membrane  lining  the  Uterus  is  simply  the  Mucous  Membrane  in  a  state 
of  Eijpertro'phy. — When  these  uteri  are  compared  with  the  description  given 
(page  95)  of  the  changes  which  the  organ  undergoes  at  the  menstrual  period,  it 
will  be  readily  perceived  that  the  internal  layers  of  the  uterus  present  in  both 
cases  the  same  physical  properties,  the  former  being,  however,  more  tumefied, 
vascular,  and  folded.  It  will  also  be  seen,  especially  after  the  uterus  has  been 
immersed  in  spirits  and  water,  that  the  numerous  small  openings  are  merely  the 
glandular  apertures  enlarged,  which  are  observable  upon  the  mucous  membrane 
in  the  unimpregnated  condition.  (Page  Gl).  Finally,  the  demonstration  is  com- 
pleted by  the  researches  of  M.  Robin,  showing  that  this  membrane,  like  that  of 
the  unimpregnated  uterus,  is  composed  of  the  same  anatomical  elements,  that  is 
to  say:  1,  of  fibro-plastic  elements  j  2,  of  cellular  tissue  fibres;  3,  of  nucleated 
fibres  in  small  proportion ;  4,  of  an  amorphous  matter  sei'ving  as  a  connecting 
medium;  5,  of  tubular  glands;  6,  of  capillary  vessels;  7,  that  it  is  covered  with 
the  same  kind  of  cylinder-epithelium.  Therefore,  it  can  be  none  other  than  the 
same  membrane  in  a  hypertrophied  condition. 

2.  The  ovum  is  enclosed  in  a  distinct  cavity,  separated  from  that  of  the  uterus 
by  a  membranous  partition,  which  has  to  be  incised  in  order  to  expose  it.  This 
is  the  membrane  hitherto  described  as  the  decidua  reflexa ;  now  what  is  it?  It 
presents,  throughout,  the  characters  of  the  uterine  mucous  membrane ;  it  has 
the  same  physiognomy,  the  same  arrangement,  the  same  vascularity,  and  the  same 
glandular  orifices ;  only  there  is  upon  its  most  prominent  portion  a  small  circular 
space,  around  which  the  vessels  disappear.  This  space,  which  is  whiter,  or  of  a 
lighter  rose  color  than  the  remainder,  is  the  largest  in  the  most  advanced  ovum. 
The  membrane  is  distinctly  continuous  with  the  uterine  mucous  membrane  at  its 
base,  and  the  vessels  traversing  it  are  absolutely  the  same  with  those  which 
ramify  in  the  latter.  Finally,  microscopic  investigations  leave  no  doubt  that  the 
structure  of  the  two  membranes  is  identical.  With  the  same  physical  qualities, 
continuity  of  tissue,  and  identity  of  structure,  the  membrane  surrounding  the 
ovum,  the  decidua  reflexa  of  authors,  can  be  nothing  else  than  a  portion  of  the 
mucous  membrane  of  the  uterus. 


OF    THE     DECIDUA.  183 

If  the  ovum  be  removed  from  the  cavity  which  enclosed  it,  the  bottom  of  the 
latter  is  found  to  be  lined  by  a  membrane  which  is  thickly  sown  with  anfractuosi- 
ties  or  irregular  lacunae  of  various  sizes,  in  which  those  villi  of  the  chorion  were 
engaged  which  subsequently  form  the  placenta.  It  is  the  portion  of  the  mucous 
membrane  to  which  the  fecundated  ovule  adhered  at  the  outset,  and  is  conse- 
quently continuous  with  that  covering  the  parietes. 

Therefore,  the  ovule,  which  upon  entering  the  womb  lies  free  in  the  cavity, 
becomes,  after  the  lapse  of  a  period  as  yet  unascertained,  enveloped  by  and 
lodged  in  a  sort  of  fold  of  the  mucous  membrane. 

The  manner  in  which  this  inclusion  of  the  ovule  is  effected  is  a  subject  of 
hypothesis;  for,  although  the  ovule  has  been  observed  when  free,  at  the  outset, 
as  also  when  completely  enveloped  after  the  third  week  of  gestation,  observations 
are  wanting  for  the  iiitei-mediate  period.  Therefore,  in  the  absence  of  direct  in- 
formation, we  give  the  explanation  proposed  by  M.  Coste,  and,  indeed,  it  is  diffi- 
cult to  conceive  how  the  phenomenon  could  take  place  otherwise. 

After  traversing  the  Fallopian  tube,  the  ovum  escapes  from  its  internal  orifice, 
and  falls  into  the  cavity  of  the  uterus.  On  account  of  the  swelling  of  the  mucous 
membrane,  this  cavity  is  almost  obliterated,  and  the  ovule  is  consequently  sup- 
ported between  two  opposite  points  of  the  hypertrophied  and  softened  membrane. 
Therefore,  it  rarely  progresses  very  fur,  and  usually  becomes  fixed  upon  the  fundus 
near  the  middle  of  the  interval  between  the  orifices  of  the  two  tubes. 

Now,  notwithstanding  its  minuteness,  it  is  impossible  that  the  ovum  should  not 
depress  the  softened  tissues  with  which  it  is  in  contact,  and  it  soon  excavates,  so 
to  speak,  a  cell  in  their  substance. 

As  the  ovule  increases  in  size,  the  swelling  of  the  mucous  membrane  also  pro- 
gresses, especially  at  the  point  where  the  former  is  arrested.  As  a  consequence 
of  this  simultaneous  development,  the  depression  produced  by  the  ovule  in  the 
substance  of  the  mucous  membrane  becomes  deeper,  and  it  is*  gradually  buried, 
first  one  quarter  of  it,  then  one-half,  until  at  last  it  is  almost  completely  hidden 
and  enclosed.  (Richard,  Extract  from  the  Lessons  of  M.  Coste.)  In  proportion 
as  it  becomes  more  deeply  buried,  the  edges  of  the  cavity  excavated  by  it  seem 
to  grow  up  around  it,  at  first  to  the  level  of  the  most  projecting  portion,  and  then 
approach  each  other,  so  as  gradually  to  contract  the  opening  by  which  a  com- 
munication is  maintained  with  the  remainder  of  the  uterine  cavity.  The  borders 
of  the  opening  draw  still  nearer,  and  finally  circumscribe  a  minute  orifice,  the 
trace  of  which  remains  for  a  short  time  only,  in  the  form  of  a  central  depression 
or  nmhilicus.  The  umbilicus  itself  at  last  disappears,  and  from  this  time  the 
ovum  is  completely  imprisoned  in  a  sort  of  cyst,  whose  walls  are  composed  exclu- 
sively of  the  mucous  membrane. 

Whatever  may  be  thought  of  this  theory,  we  find  in  the  uterus,  five  or  sis 
weeks  after  conception,  an  entirely  free  space,  the  ovum  occupying  but  a  portion 
of  the  cavity,  and  a  greatly  hypertrophied  mucous  membrane,  which  at  the  point 
where  the  ovum  is  fixed,  seems  to  fold  upon  itself  in  order  to  embrace  the  latter. 
We  have  now  to  ascertain  what  becomes  of  the  uterine  mucous  membrane  during 
gestation,  as  also  of  the  two  layers  produced  by  its  folding. 


184  GENERATION. 

One  of  these  layers  is  situated  between  the  ovum  and  the  uterus,  at  the  point 
where  the  placenta  will  subsequently  be  developed ;  the  other  covers  the  entire 
non-adherent  portion  of  the  ovum.  The  first,  the  intermediate  or  utero-epichorial 
memhraiic,  replaces  the  decidua  serotina  or  secondary  decidua,  the  inter-utero- 
placental  tissue  of  authors;  the  other,  or  epichorial  membrane,  was  called,  accord- 
ing to  the  old  theory,  the  decidua  rejiexa  or  ovular  decidua.^ 


EXPLANATION  OF  PLATE  IL 

Fig.  49.  Uterus  at  the  twentieth  or  twenty-fifth  day  of  gestation.  Half  the  natural  size. 

c,  c.  Mucous  membrane  of  the  uterus,  with  its  rich  vascularization. 

c^.  The  portion  of  mucous  membrane  which  covers  the  ovum. 

a;.  The  small  circular  space  around  which  the  vessels  disappear,  and  whose  centre 
presents  the  appearance  of  a  recently-closed  umbilicus. 

u,  u.  Muscular  structure  of  the  uterus,  exhibiting  upon  the  cut  surface,  a  multitude 
of  venous  sinuses  in  various  degrees  of  development. 

m,  m.  Muscular  portion  of  the  neck,  distinguished  from  that  of  the  body  by  the  ab- 
sence of  venous  sinuses. 

I.  Vaginal  portion  of  the  neck. 

V.  A  gland  of  Naboth,  greatly  distended. 

5,  g.  The  ovaries.  On  the  one  to  the  right  is  a  highly-developed  corpus  luteum,  ^r; 
its  surface  is  very  vascular,  and  on  its  apex  is  perceived  </',  the  cicatrix  of  the  opening 
through  which  the  ovule  escaped. 

t,  t.  Fallopian  tubes. 

p,  p.  Fimbriated  extremities  of  the  tubes. 

Fig.  50.  Is  the  same  specimen  as  the  preceding,  except  that  a  circular  incision  has 
been  made  in  the  portion  of  mucous  membrane  upon  which  the  ovum  is  situated,  and 
the  flap  turned  back,  so  as  to  exhibit  its  deep  or  ovular  surface. 

h.  Section  of  the  mucous  membrane  covering  the  ovum,  exhibiting  its  thickness  rela- 
tively to  that  which  lines  the  remaining  portion  of  the  womb. 

c'^.  Internal  surface  of  the  flap  of  the  uterine  mucous  membrane  (decidua  reflexa) 
which  covered  the  ovum.  < 

ce.  The  ovum,  with  its  surface  thickly  set  with  short  but  considerably-branched  villi, 
which  come  into  direct  contact  with  the  maternal  blood. 

Fig.  5L  The  uterine  mucous  membrane  of  the  specimen  represented  by  Fig.  49, 
divided  on  a  level  with  the  neck,  and  seen  separately.  The  blood  which  distended  its 
vessels  having  escaped,  in  consequence  of  its  immersion  in  spirits  and  water,  the  vas- 
cular network  which  it  exhibited  has  disappeared,  and  permits  us  to  see  that  its  entire 
surface  is  perforated  with  minute  openings,  which  are  the  glandular  apparatus,  observ- 
able upon  the  mucous  memln-ane  of  the  uterus  in  the  unimpregnated  condition.  The 
portion  of  mucous  membrane  beneath  which  the  ovum  was  situated,  is  incised  as  in  the 
preceding  figure,  but  the  ovum  is  here  removed,  so  as  to  exhibit  completely  the  walls  of 
the  cavity  which  contained  it. 

'  Examine  Plate  II,  engraved  upon  copper,  for  the  details  to  follow.  The  fineness  of  the 
parts  to  be  represented  would  be  very  imperfectly  figured  by  plates  or  wood-cuts,  distributed 
in  the  text.  The  three  engravings  are  borrowed  from  the  splendid  Atlas  accompanying  JM. 
Coste's  History  of  the  Development  of  Organized  Bodies. 


Pin 


v-^vyv^. 


H  50. 


lii  51. 


A  h-aj.Uei. 


.jmctajra  lUi  Pbl"- 


i 


OF    THE    DECIDUA.  185 

f.  The  cell  or  cavity  which  contained  the  ovum,  strewn  with  anfractuosities  and  irre- 
gular lacunae,  in  which  the  villi  of  the  chorion  were  inserted. 

c.^\  Internal  surface  of  the  flap  of  mucous  membrane  which  covered  the  ovum.  The 
same  lacunaj  are  observable  in  it  as  ou  tlie  opposite  surface /J  but'  they  are  smaller,  less 
numerous,  and  less  pronounced. 

s.  Sections  of  the  venous  sinuses  of  the  mucous  membrane  of  the  uterus. 

/',  V .  Internal  orifice  of  the  Fallopian  tubes,  rendered  visible  in  the  preparation  by  the 
greater  unfolding  of  the  mucous  membrane.  There  is  no  indication  of  their  ever  having 
been  obliterated. 

A.  Tlie  Intermediate  or  Titer o-ejyichorial  Membrane. — If,  after  the  removal  of 
the  ovum,  the  cavity  which  it  occupied  be  examined  during  the  first  month,  or 
the  first  half  of  the  second,  a  multitude  of  irregular  grooves  or  lacunas,  of  variable 
size  and  depth,  in  which  the  villi  of  the  chorion  were  engaged  (see  PI.  II,  Fig. 
51),  will  be  perceived  upon  the  mucous  membrane  which  forms  its  bottom. 
These  lacunae,  into  which  smaller  ones  enter,  and  which  are  so  numerous  as  to 
give  to  this  portion  of  the  membrane  the  appearance  of  an  areolar,  erectile  tissue, 
are  supposed  by  M.  Coste  to  be  produced  by  the  wearing  away,  or  con-osion  of  the 
vessels,  which  are  more  hypertrophied  at  this  point  than  elsewhere,  by  the  in- 
vading growth  of  the  chorion ;  so  that  the  lacunae,  by  communicating  directly  in 

.  this  way  with  the  subjacent  uterine  sinuses,  permit  the  maternal  blood  to  flow 
into  the  cavity  occupied  by  the  ovum,  and  come  into  direct  contact  with  the  villi 
of  the  chorion.* 

The  presence  of  the  ovum,  determines  at  this  point  a  considerable  hypertrophy 
of  all  the  elements  of  the  mucous  membrane.  The  corresponding  villi  of  the 
chorion  also  become  greatly  developed,  and  all  together  constitute  at  a  rather 
later  period  the  mass  of  the  placenta.     (See  Placenta.) 

B.  The  epichorial  memhrane  presents  very  difiierent  appearances  according  to 
the  period  at  which  it  is  examined.  Shortly  after  its  formation  is  completed, 
that  is  to  say,  after  the  umbilicus  is  obliterated,  it  differs  in  no  respect  from  the 
parietal  mucous  membrane  :  its  uterine  surface  has  the  same  color,  the  same 
thickness,  the  same-  profuse  supply  of  vessels,  and  is  perforated  in  like  manner 
with  numerous  glandular  orifices.     Its  ovular  surface  presents  at  the  same  period 

'  M.  Coste  has  several  times  witnessed  the  ovum  swimming,  as  it  were,  in  a  pool  of  fluid 
blood.  New  researches  are  needed  to  show  whether  this  be  a  normal  condition,  or  the  result 
of  an  accidental  hemorrhage. 

When  we  consider  that  the  entire  ovular  surface  of  the  epichorion  presented  the  same  irre- 
gular lacunae,  they  may  be  supposed  to  have  been  produced  by  the  development  of  the  villi 
of  the  chorion,  which  penetrate  the  substance  of  the  mucous  membrane,  as  do  the  roots  of  a 
tree  into  the  earth,  and  leave  the  place  which  they  occupied  empty,  after  the  ovum  is  ex- 
tracted. That  this  areolar  appearance  is  better  marked  upon  the  inter-utero-placental  mucous 
membrane,  is  due  to  the  much  greater  development  of  the  villous  tufts  of  the  chorion  there 
than  elsewhere,  and  which  occupy  a  larger  space  in  consequence. 

There  would  be,  therefore,  no  eroded  maternal  vessels  ;  as  regards  the  blood  surrounding 
the  ovum,  I  am  better  satisfied  with  supposing  that,  if  the  condition  be  a  normal  one,  the 
congested  state  of  the  uterine  vessels  is  greatest  at  the  point  of  attachment  of  the  ovule,  and 
may  be  carried  to  the  extent  of  producing  an  exhalation  of  blood,  which  does  not  take  place 
from  the  remainder  of  the  parietal  mucous  membrane. 


186  GENERATION. 

irregular  cavities  or  lacunas  of  variable  depth,  resemblina;  precisely  those  dei^cribed 
as  belonging  to  the  inter-utero-placental  layer,  and  which  are  penetrated  in  like 
manner  by  the  villi  of  the  portion  of  the  chorion  covering  the  ovum.  (See  PI.  II, 
Figs.  51  and  52.)  But,  as  the  ovum  enlarges,  it  elevates  and  extends  it,  until 
about  the  end  of  the  first  month,  when  commencing  atrophy  is  observed  at  its 
centre,  in  consequence  of  which  its  vessels  and  glands  disappear,  and  the  whole  of 
th,is  portion  of  the  membrane  gradually  loses  its  thickness.  (See  PI.  II,  Fig.  49.) 
The  result  is,  that  either  in  consequence  of  the  distension  which  it  undergoes,  or 
of  the  pressure  exerted  upon  its  most  prominent  portion  through  the  growth  of 
the  ovum,  a  small  but  gradually-enlarging  circular  space,  deprived  of  vessels, 
appears  in  its  centre,  whilst  the  remainder  of  the  surface  presents  the  same  vas- 
cularity as  the  parietal  mucous  membrane.  This  central  portion  becomes  very 
thin,  even  at  periods  when  the  circumference  of  the  membrane  preserves  a  con- 
siderable thickness. 

The  obliteration  of  the  vessels  and  the  atrophy  of  the  glandules  progresses 
from  the  centre  towards  the  circumference,  so  that  by  the  third  month,  the  epi- 
chorial  membrane  differs  so  materially  from  the  parietal  mucous  membrane  that, 
except  at  the  parts  adjacent  to  the  points  where  the  two  become  continuous,  the 
glandular  orifices  and  vessels  are  no  longer  discoverable. 

The  lacunae  described  as  existing  upon  the  ovular  surface,  are  still  further 
effaced  by  the  atrophy,  and  as  the  villi  of  the  chorion,  which  were  inserted  into 
them,  can  no  longer  derive  thence  the  means  of  nutrition,  they  become  useless 
and  atrophied  in  like  manner. 

As  the  development  of  the  ovum  progresses,  it  tends  naturally  to  encroach  upon 
the  cavity  of  the  womb,  and  consequently  to  bring  the  epichorion  and  the  uterine 
mucous  membrane  nearer  togethei",  until,  at  the  end  of  the  third  month,  the  two 
are  in  contact.  At  a  rather  later  period,  they  become  so  adherent  as  to  be  sepa- 
rated with  difiiculty. 

It  is  hardly  necessary  to  state,  that  when  thus  deprived  of  its  vascular  elements, 
the  ovular  portion  of  the  membrane  can  no  longer  accommodate  itself  to  the  dis- 
tension produced  by  the  ovum,  otherwise  than  by  a  progressive  thinning  of  the 
membrane,  and  that  its  extreme  delicacy  in  advanced  ovums,  or  at  maturity,  is 
to  be  thus  accounted  for.  It  is  found,  however,  even  after  labor,  adhering  either 
to  the  chorion  or  to  the  parietal  mucous  membrane. 

C.  The  uterine  mucous  membrane  retains  the  characters  already  described 
until  towards  the  end  of  the  second  month ;  but  from  this  time  it  begins  to  grow 
thinner,  and  its  numerous  and  deep  folds  are  gradually  effjiced.  This  first  period 
of  degeneration  progresses,  however,  very  slowly,  for  at  the  third  month,  the 
state  of  the  membrane  is  very  nearly  the  same  as  at  the  menstrual  periods. 
(Richard.  Thesis.) 

From  the  fourth  month,  it  begins  to  lose  the  marks  of  energetic  vitality  which 
had  characterized  it  hitherto,  and  its  external  appearance  (perforation  and  vas- 
cularity) is  altered ;  it  becomes  atrophied  to  such  an  extent,  as  to  be  reduced  by 
the  seventh  month  to  the  one-twenty-fifth  of  an  inch  in  thickness,  and  is  still 
thinner  at  the  termination  of  pregnancy.     Though  inseparable  at  the  outset  from 


OF    THE    DECIDUA.  187 

the  subjacent  tissue,  it  is  now,  in  a  measure,  an  independent  membrane,  and  may 
be  isolated  and  detached  in  strips  of  considerable  size.  This  ready  separation  is 
due,  according  to  M.  Robin,  to  the  commencing  development  between  it  and  the 
muscular  tissue  of  a  new  membrane,  which  is  at  first  soft,  downy,  and  homo- 
geneous, the  first  trace,  in  fact,  of  the  mucous  membrane  which  is  to  replace  the 
decidua  that  falls  after  labor.  It  thickens  gradually  during  the  latter  half  of 
gestation,  and  lines  the  internal  surface  of  the  uterus,  whose  muscular  fibres  are 
not  therefore  left  exposed  by  the  complete  decollation  and  expulsion  of  the  uterine 
decidua,  which  takes  place  after  labor.  New  researches  are  required  to  substan- 
tiate this  opinion  of  M.  Robin. 

After  the  birth  of  the  child,  the  decidua  which  is  thrown  oflP  in  connection 
with  the  chorion  may  still  be  divided  into  two  layers  (uterine  decidua  and  decidua 
reflexa).  It  has  a  reddish-gray  and  areolar  appearance,  and  an  irregular  surface: 
it  is,  besides,  quite  soft  and  easily  torn,  and  although  the  vessels  which  traversed 
it  whilst  attached  to  the  uterus  are  for  the  most  part  obliterated  and  atrophied, 
some  of  them  are  occasionally  found  still  filled  with  blood.  The  villi  of  the 
chorion  become  fibrous  and  non-vascular,  are  found  inserted  in  its  tissue,  being 
especially  numerous  in  the  vicinity  of  the  placenta. 

The  inter-utero-placental  mucous  membrane  is  detached  and  expelled  with  the 
placenta,  of  which  it  forms  a  part  (maternal  placenta).  It  is  about  one-eighth  of 
an  inch  thick  on  the  external  surface  of  the  cotyledons,  though  the  prolongations 
which  it  seeds  in  between  them  are  much  thinner.  At  the  circumference  of 
the  placenta,  it  is  evidently  continuous  with  the  ovular  and  uterine  deciduas. 

This  sort  of  maternal  placenta  is  traversed  by  numerous  vessels,  which  accom- 
pany the  prolongations  sent  in  by  it  between  the  cotyledons  (remains  of  the 
utero-placental  vessels.)     (See  Placenta.^ 

From  the  details  into  which  we  have  entered,  it  is  evident, 

1.  That  excepting  the  membranes  proper  of  the  ovum,  the  amnion  and  cJiorion, 
the  uterus  contains  none  other  than  its  own  mucous  membrane ; 

2.  That  at  the  moment  when  the  ovule  enters  the  cavity  of  the  uterus,  this 
membrane  has  tlxroughout  a  thickness  equal  to,  if  not  greater  than  that  which  it 
possesses  at  the  menstrual  period ; 

3.  Th;it  this  abnormal  thickness  is  wholly  due  to  the  hypertrophy  of  its  con- 
stituent elements,  and  especially  of  the  fibro-plastic  element,  as  proved  by  M. 
Robin ; 

4.  That  immediately  after  the  arrival  of  the  ovule,  the  vitality  of  the  uterus 
seems  to  be  concentrated,  in  a  great  measure,  at  that  point  of  the  mucous  mem- 
brane where  the  ovule  is  arrested  ; 

5.  That  as  a  consequence  of  this  concentration  of  the  vital  forces,  the  point 
mentioned  of  the  mucous  membrane  becomes  thickened,  grows  up  around  the 
ovule,  investing  it  with  a  circular  ring,  which  soon  encloses  it  completely ; 

6.  That  from  this  moment  the  ovule  is  separated  from  the  uterine  tissue  by 
the  utero-epichorial  mucous  membrane,  and  from  the  remainder  of  the  uterine 
cavity  by  the  epichorial  mucous  membrane ; 

7.  That,  after  the  first  month,  the  epichorial  mucous  membrane  becomes  atro- 


188  GENERATION. 

phied  from  the  centre  towards  the  circumference,  loses  its  vascularity  and  glan- 
dular openings,  and  then  alone  merits  the  title  of  anTiistous  membrane,  given  by 
M.  Velpeau  to  the  entire  decidua ; 

8.  That  this  atrophy  involves  that  of  the  corresponding  villi  of  the  chorion, 
whilst  those  which  are  in,  relation  with  the  utero-epichorial  mucous  membrane 
become,  like  the  latter,  considerably  developed,  and  subsequently  form  the 
placenta ; 

9.  That,  from  the  fourth  month,  the  parietal  mucous  membrane  begins  to 
degenerate,  growing  gradually  thinner,  in  consequence  of  the  diminution  of  the 
fibro-plastic  tissue,  and  of  the  obliteration  by  atrophy  of  its  vessels  and  glands ; 

10.  Finally,  that  a  new  mucous  membrane  is  formed,  by  which  the  old  one  is 
removed  farther  and  farther  from  the  muscular  tissue  to  which  it  adhered  so 
closely  at  the  outset,  and  that  after  labor  it  is  completely  detached  and  expelled 
with  the  ovum. 

This  exfoliation  of  the  mucous  membrane  of  the  uterus  after  parturition  is 
explained,  to  a  certain  extent,  by  the  formation  of  a  new  mucous  membrane ;  but 
it  is  much  more  difficult  to  understand  how  it  should  occur  in  abortions  during 
the  early  months,  when  the  adhesion  between  the  mucous  and  muscular  tissues 
is  so  very  firm.  It  is  true,  that  the  exfoliated  decidua  is  much  thinner  than  that 
which  may  be  observed  still  adhering  to  the  uterus  at  the  same  period,  and  that 
we  may  suppose  a  part  only  of  the  parietal  membrane  to  have  been  detached. 
But  does  this  supposition  render  the  fact  any  more  intelligible  ?  especially,  does 
it  explain  why  the  utero-epichorial  mucous  membrane,  with  which  the  villi  of  the 
chorion  have  already  contracted  such  intimate  connections,  is  almost  never  thrown 
off  with  the  ovum  in  abortions  ?  These  difficult  points  evidently  require  that 
new  researches  should  be  instituted  for  their  elucidation. 


CHAPTER  III. 

MODIFICATIONS    OF   THE    HUMAN   OVUM. 

(from  the  DEVELOPMEXT  of  the  ALLAXTOIS  until  the  EXD  of  GESTATION".) 

By  the  details  already  given,  we  have  shown  that  the  human  ovum,  after  the 
allantois  has  been  developed,  consists  of  the  embryo,  the  two  vesicles  which 
emanate  from  it,  and  the  enveloping  membranes,  that  are  destined  to  protect  it, 
and  to  establish  with  the  mother  the  relations  necessary  to  its  existence.  The 
modifications  these  different  parts  undergo,  from  the  early  weeks  of  intra-uterine 
life  down  to  the  end  of  gestation,  still  claim  our  attention  ;  and  we  shall  commence 
the  description  by  examining  the  appendages  of  the  foetus. 


MODIFICATIONS     OF    THE    nUMAN     OVUM.  189 

ARTICLE   I. 

OF   THE    FCETAL   APPENDAGES. 

These  comprise  the  allantois,  the  umbilical  vesicle,  the  amnion,  and  the 
chorion. 

§  1.  Of  the  Allantoid  Vesicle. 

The  little  pyriform  vesicle  we  have  denominated  the  allantois,  is  observed, 
about  the  tenth  day,  to  spring  from  the  inferior  part  of  the  intestinal  canal,  and 
taking  on  a  rapid  growth  it  soon  becomes  applied  by  its  base  to  the  internal  sur- 
face of  the  chorion.  The  terminal  branches  of  the  two  umbilical  arteries  and 
vein,  as  previously  stated,  ramify  on  the  walls  of  this  vesicle ;  and  hence  the 
urachus,  which  is  nothing  else  than  the  pedicle  of  the  allantois,  is  accompanied  in 
its  course  by  three  bloodvessels  (see  Fig.  59,  PI.  Ill),  two  of  which  (i  t)  are 
arterial,  coming  from  the  iliacs,  and  called  the  umbilical  arteries.  They  run  to 
the  chorion,  where  they  ramify,  and  ultimately  reach  the  villi  that  form  the  foetal 
placenta.     The  third  trunk  is  venous,  and  is  known  as  the  umbilical  vein. 

The  umbilical  vein  j  leaves  the  right  auricle  of  the  heart  at  the  point  f,  and 
soon  after  receives  the  contents  of  the  vena  cava  inferior  k ;  it  then  traverses  the 
under  surface  of  the  liver  m,  to  which  it  sends  a  copious  vascular  supply,  and, 
before  passing  this  organ,  receives  the  omphalo-mesenteric  vein  at  the  point  o ; 
then,  after  leaving  the  liver,  it  gains  the  left  side  of  the  abdomen  between  the 
walls  of  this  cavity  and  the  intestinal  fold  E ;  next,  by  turning  abruptly  towards 
the  umbilical  cord,  it  gets  to  the  left  side  of  the  urachus,  and  accompanies  the 
latter  to  the  chorion,  where  it  follows  the  umbilical  arteries  into  the  villosities. 

After  the  earliest  periods  of  development  are  over,  there  is  but  a  single  umbi- 
lical vein  left,  although,  during  the  first  part  of  the  embryonic  existence  two  are 
met  with,  one  upon  each  side  of  the  urachus  (and  consequently  one  for  each 
umbilical  artery).  That  on  the  right  side  becomes  effaced,  but  its  traces  may 
still  be  found  at  the  thirtieth  or  even  the  fortieth  day;  indeed,  some  such  existed 
and  were  perceptible  on  the  embryo  I  am  now  describing. 

When  the  umbilical  vein  has  actually  passed  the  liver,  it  gives  off  no  branches 
whatever,  in  its  course  along  the  urachus,  nor  does  it  divide  and  subdivide  until 
it  reaches  the  chorion.  But,  in  the  earlier  periods  of  gestation,  when  the  two 
exist,  they  are  observed  to  spread  over  the  walls  of  the  chest  and  abdomen  in 
the  form  of  a  large  vascular  plexus,  extending  as  far  as  the  vertebral  column ; 
however,  this  new  apparatus  soon  vanishes  and  leaves  no  vestige  of  its  former 
existence. 

The  body  of  the  allantoid  vesicle  disappears  very  rapidly,  and  scarcely  a  trace 
of  it  can  possibly  be  found  after  the  lapse  of  a  few  days  from  its  first  appearance. 
In  fact,  nothing  more  is  seen  than  a  cord  of  variable  length,  extending  from  the 
embryo  to  the  chorion,  and  having  the  umbilical  vessels  enclosed  within  it.  This 
likewise  becomes  gradually  atrophied  in  such  a  way  as  to  disappear  altogether  in 


190  GENERATION. 

tlie  substance  of  the  umbilical  cord  j  nevertheless,  a  portion  of  it  still  persists  in 
the  abdominal  cavity  of  the  embryo,  forming  there  the  cord  subsequently  known 
as  the  urachus;  and  just  as  this  latter  terminates  in  the  rectum,  it  exhibits  a 
small  swelling  which  is  afterwards  converted  into  the  urinary  bladder.  We  may 
remark,  in  anticipation,  that  this  rudimentary  bladder  communicates  with  the 
rectum,  and  constitutes  there  that  transitory  cloaca,  whose  existence  in  the 
human  species  may  be  positively  verified  by  direct  observation.  It  is  this  early 
disappearance  of  the  allantois  which  has  induced  some  ovologists  to  doubt  its 
existence  in  the  human  race.  It  is  exclusively  destined  to  bring  the  embryonic 
vessels  into  contact  with  the  external  membrane  of  the  ovum,  whence  they  are 
soon  placed  in  their  proper  relation  with  the  internal  surface  of  the  womb. 

§  2.  Of  the  Umbilical  Vesicle. 

This  vesicle  is  formed  exclusively  by  the  internal  or  mucous  layer  of  the  blasto- 
derm ;  at  first,  it  is  very  voluminous,  occupying  nearly  the  whole  cavity  of  the 
ovum,  and  communicating  so  freely  with  the  intestinal  cavity  as  to  form  with  it 
apparently  but  a  single  vesicle.  But  the  gradual  contraction  of  the  ventral 
opening  serves  to  separate  the  two,  as  we  have  already  demonstrated,  leaving 
only  a  pedicle  of  variable  thickness,  according  to  the  size  of  this  aperture. 

The  umbilical  vesicle  contains  a  yellowish-white  liquid,  in  which  numerous 
granules  and  some  few  globules  are  seen  floating.  It  seems  to  be  formed  of  two 
laminae,  one  being  an  external  or  vascular,  and  the  other  an  internal  or  mucous 
layer.  As  the  amnion  becomes  developed,  the  vesicle  is  crowded  by  this  mem- 
brane, and  is  then  found  placed  between  the  external  face  of  the  latter  and  the 
internal  surface  of  the  chorion. 

In  consequence  of  the  development  of  the  allantois,  the  umbilical  vesicle  loses 
much  of  its  importance  in  the  human  species,  as  it  so  soon  becomes  an  organ  of 
little  value  either  to  the  growth  of  the  ovum  or  the  embryo  :  and  furthermore,  it 
dwindles  away  speedily ;  thus,  during  the  first  three  weeks,  it  is  as  large  as  an 
ordinary  pea,  but  after  the  fourth,  it  begins  to  collapse  and  diminish  in  size,  and 
at  six  weeks  subsequent  to  the  conception,  it  does  not  exceed  a  coriander  seed  in 
bulk ;  then  it  remains  stationary  for  a  time,  not  disappearing  altogether  until 
towards  the  fourth  month.  I  have  observed  it  several  times  of  latter  years  on 
ova  of  three  to  three  and  a  half  months,  in  which  it  generally  still  retained  the 
volume  and  shape  of  a  small  lentil,  being  of  a  yellowish  color,  and  having  its  sur- 
face wrinkled.  However,  I  may  remark,  that  its  size  appeared  very  variable  in 
several  ova  of  the  same  age. 

In  proportion  as  the  umbilical  vesicle  becomes  atrophied,  it  is  removed  further 
and  further  from  the  trunk  of  the  embryo,  in  consequence  of  the  development  of 
the  amnion,  and  its  pedicle  is  also  elongated  in  a  marked  manner ;  thus,  the  latter 
is  from  two  to  six  lines  in  length,  being  continuous  at  one  end  with  the  intestine, 
and  at  the  other  with  the  vesicle  by  a  kind  of  an  infundibuliform  expansion. 
The  pedicle  is  apparently  separated  into  two  portions  by  the  amnios,  before  the 
abdominal  walls  are  completely  closed  up;  one  part  lying  between  the  spine,  or 
rather  the  intestine,  and  the  spot  afterwards  occupied  by  the  umbilicus,  while  the 


MODIFICATIONS    OF    THE    HUMAN    OVUM.  191 

other  remains  exterior  to  the  abdomen.  This  pedicle  is  traversed  by  a  small 
canal  for  the  first  five  or  six  weeks  of  its  existence,  and  through  it  the  fluid  in 
the  vesicle  may  be  pressed  back  into  the  intestine,  but  it  is  obliterated  after  that 
period.  About  the  same  time,  also,  it  becomes  more  and  more  delicate,  and  often 
ruptures  from  its  great  elongation ;  and  its  umbilical  portion  being  lost  in  the 
cord,  can  no  longer  be  traced  into  the  abdomen.  When  broken,  the  vesicle  may 
be  found  more  or  less  removed  from  the  root  of  the  cord,  and  lying  between  the 
chorion  and  amnion. 

The  umbilical  vesicle  has  a  rich  vascular  apparatus,  the  blood  of  which  is 
carried  to  and  from  the  embryo  by  the  intervention  of  two  trunks,  one  venous, 
the  other  arterial ;  both,  however,  accompany  the  pedicle,  and  form  a  constituent 
part  of  it.  The  first,  N  (see  Fig.  59,  PI.  Ill),  called  the  omphalo-mesenteric 
vein,  enters  the  abdomen,  winds  around  the  duodenum,  and  then  opens  into  the 
umbilical  vein  at  the  point  o,  just  as  the  latter  is  emerging  from  the  liver.  As 
it  passes  the  duodenum,  branches  are  given  ofi"  to  the  stomach  and  intestines, 
and  when  it  discharges  into  the  umbilical  vein,  it  sends  a  voluminous  trunk  to 
the  liver.  That  portion  which  furnishes  the  branches  just  described,  persists  in 
the  adult  under  the  name  of  the  ventral,  or  hepatic-portal  vein,  whilst  all  the 
rest  will  disappear  with  the  umbilical  vesicle  and  its  pedicle. 

The  arterial  trunk  P,  accompanying  the  pedicle,  has  been  designated  as  the 
omphalo-mesenteric  artery.  Arising  from  the  aorta,  it  gains  the  summit  of  the 
intestinal  convolution,  and  gives  off  branches  to  the  mesentery  and  to  the  intes- 
tine itself;  then  it  reaches  the  pedicle,  and  follows  the  latter  to  the  umbilical 
vesicle,  upon  which  it  ultimately  ramifies.  The  part  that  supplies  the  mesentery 
is  converted  in  the  adult  into  a  mesenteric  artery,  all  the  rest  being  effaced. 
From  all  which,  it  appears  that  the  vascular  system  of  the  umbilical  vesicle  re- 
presents the  primitive  circulation  in  the  embryo,  corresponding  in  it  to  the  san- 
guiferous apparatus  of  the  yolk  of  fowls.  Of  course,  these  vessels  will  become 
atrophied  with  the  organ  to  which  they  belong. 

The  umbilical  vesicle  seems  to  be  intended  to  serve  as  a  reservoir  for  the  fluid 
designed  to  nourish  the  foetus  during  the  first  weeks  of  intra-uterine  existence. 

§  3.  Of  the  Amnion. 

The  most  internal  membrane  of  the  ovum,  or  the  amnion,  is  formed  by  the 
inner  lamina  of  the  fold,  or  the  cephalic  and  caudal  hoods  which  constituted  the 
external  serous  layer  of  the  blastoderm  surrounding  the  embryo.  Being  con- 
tinuous, as  we  have  shown,  with  the  margins  of  the  ventral  opening,  it  seems  at 
first  to  be  attached  by  its  middle  part  to  the  skin  on  the  dorsal  region. 

The  internal  amniotic  surface  subsequently  exhales  a  liquid  into  its  cavity,  in 
which  the  embryo  swims  freely;  hence  the  amnios  constitutes  a  little  sac  around 
the  foetus,  having  smooth  and  transparent  walls.  Its  inner  surface  is  bathed  by 
the  liquid  enclosed  in  the  cavity,  whilst  its  external  one  is  separated  from  the 
chorion  by  a  space  of  variable  size,  which  is  likewise  filled  with  a  fluid. 

Originally,  this  membrane  was  not  concentric  with  the  chorion ;  but  in  pro- 


192  GENERATION. 

portion  as  the  development  advances  it  presses  back  the  exterior  liquid  more  and 
more,  thereby  condensing  it,  and  finally  comes  in  contact  with  the  external  enve- 
lope of  the  ovum.  Now,  since  it  adheres  to  the  periphery  of  the  umbilical  open- 
ing, it  must  furnish,  by  such  an  extension,  a  sort  of  membranous  sheath  to  the 
pedicles  of  the  allantoid  and  the  umbilical  vesicles,  as  well  as  to  their  accom- 
panying vessels,  surrounding  them  throughout  their  course  from  the  umbilicus 
to  the  chorion ;  and  all  the  parts  thus  enclosed  constitute  what  is  called  the 
umhiUcal  cord  ;  whence  it  follows  that  the  abdominal  cavity  itself  must  be  in 
connection  with  the  canal  represented  by  this  cord,  and  consequently  that  the 
foetal  appendages  may  communicate  with  it  through  the  route  thus  opened  to 
them.  It  is  thus  that  the  pedicle  of  the  umbilical  vesicle  becomes  united  to  the 
ileo-coecal  fold  of  intestine,  whilst  the  allantois  connects  with  the  rectum  by  the 
intervention  of  the  urachus. 

As  we  have  just  stated,  the  amnios  is  separated  from  the  chorion  during  the 
earlier  weeks  by  a  space  filled  with  fluid,  which  space  is  larger  in  proportion  as 
the  ovum  is  the  more  recent.  This  extra-amniotic  liquid  forms  a  gelatinous  or 
albuminous  mass,  of  a  weblike  arrangement,  and  having  the  umbilical  vesicle  in 
its  midst.  The  mass  becomes  more  and  more  compact  by  pressure  of  the  amnion, 
which  has  a  constant  tendency  to  approach  the  chorion,  thus  acquiring  the  aspect 
of  a  membrane  (the  memhrana  media  of  BischoflF),  which  is  situated  between 
the  chorion  and  the  amnion,  where,  says  this  author,  it  may  be  readily  distin- 
guished towards  the  end  of  pregnancy,  as  a  gelatinous,  though  continuous  mem- 
brane. Wagner,  on  the  other  hand,  describes  this  mass  as  resembling  the  inter- 
muscular cellular  tissue ;  and  M.  Velpeau  has  given  it  the  name  of  the  vifri/orm 
or  reticulated  body ;  but  he  is  certainly  wrong  in  considering  it  as  analogous  with 
the  allantois. 

The  amnion  undergoes  no  important  change  during  the  ulterior  development 
of  the  ovum,  nor  does  its  texture.  Of  course,  it  would  be  more  firm  and  con- 
sistent, acquiring  by  time  a  greater  resemblance  to  the  serous  membranes, 
although  it  neither  encloses  nor  possesses  vessels  at  any  period.  Nevertheless, 
says  Duges,  it  probably  has  some  openings,  which  permit  the  waters^  exhaled  by 
the  uterine  capillaries,  and  received  by  the  vessels  of  the  decidua  and  the  villi 
of  the  chorion,  to  be  diffused  around  the  foetus ;  but  this  perspiration  of  the 
liquids  secreted  by  the  internal  uterine  surface,  may  very  possibly  be  a  simple 
phenomenon  of  endosmosis. 

§  4.  Waters  of  the  Amnion. 

The  amniotic  cavity  is  filled  with  a  liquid,  in  which  the  foetus  is  immersed. 
At  the  commencement  of  pregnancy,  this  fluid  is  of  slight  density,  and  more  or 
less  transparent  and  limpid,  but  towards  term  it  becomes  viscid,  unctuous,  and 
more  consistent  than  pure  water;  sometimes  it  is  as  clear  as  serum;  at  others,  is 
of  a  light  yellow  or  greenish  color.  It  frequently  becomes  lactescent,  turbid,  and 
interspersed  with  yellowish-gray,  or  even  black  albuminous  flakes;  again,  in  cer- 
tain cases,  it  is  strongly  tinged  with  yellow,  when  the  membranes  are  ruptured, 
from  the  admixture  of  a  quantity  of  meconium ;  it  exhales  a  disagreeable  odor, 
analogous  to  that  of  the  spermatic  fluid,  and  its  taste  is  slightly  saline. 


MODIFICATIONS     OF    THE    HUMAN    OVUM.  193 

The  quantity  of  the  amniotic  fluid  varies  greatly  j  thus,  in  the  early  months, 
it  is,  relatively  to  the  foetus,  more  abundant  in  proportion  as  the  embryo  is 
younger.  Kiolan  found  four  ounces  in  an  ovum  containing  a  foetus  of  the  size 
of  an  ant.  The  weight  of  the  foetus  and  that  of  the  fluid  at  the  middle  of  ges- 
tation, are  very  nearly  equal.  Again,  dating  from  this  period,  the  difi"erence  is 
generally  in  favor  of  the  foetus,  and  the  weight  of  the  latter  at  term  is  four  or 
five  times  greater  than  the  waters,  which  seldom  exceed  a  pound  or  a  pound  and 
a  quarter ;  consequently,  if  the  assertion  is  true,  that  the  waters  augment  in  their 
absolute  quantity  until  term,  it  is  equally  so  to  say  they  increase  relatively  to  the 
foetus  in  the  first,  and  diminish  in  the  second  half  of  pregnancy.  In  fact,  the 
variations  in  this  respect  are  infinite,  even  at  the  time  of  the  accouchement. 

According  to  the  analysis  of  Vauquelin,  100  parts  of  amniotic  liquor  consist: 
of  water,  98-8;  of  albumen,  hydrochlorate  of  soda,  phosphate  of  lime,  and  lime, 
1-2.  The  interesting  question  now  arises.  What  is  the  source  of  the  amniotic 
fluid?  Some  assert  that  it  comes  from  the  mother;  others,  that  it  is  produced 
by  the  foetus.  Chaussier,  Meckel,  and  Beclard,  adopting  an  intermediate  opinion, 
suppose  that  its  secretion  takes  place  simultaneously  from  the  female  and  her 
product. 

Everything  proves,  says  M.  Velpeau,  that  the  liquor  amnii  is  the  result  of  a 
transudation  or  of  a  simple  exhalation,  like  the  serum  of  the  pleura,  pericardium, 
&c.,  and  that  this  process  requires  no  particular  canals  for  its  accomplishment, 
being  a  phenomenon  of  pure  vital  imbibition. 

According  to  Burdach,  the  amniotic  waters  cannot  be  secreted  by  the  foetus, 
because  they  exist  prior  to  its  formation,'  and  therefore  they  must  be  exclusively 
furnished  by  the  internal  uterine  surface,  and  reach  the  cavity  of  the  amnios  by 
traversing  its  walls.  We  also  believe,  that  the  greater  part  of  this  liquid  comes 
from  the  mother's  organs ;  yet  we  must  add  that  it  also  contains  certain  products, 
secreted  by  the  foetus;  for  instance,  it  is  frequently  colored  by  some  meconium, 
and  besides,  it  is  almost  certain  that  the  urine  may  be  discharged  into  the  amniotic 
cavity  during  the  latter  months  of  pregnancy.  A  few  incontestable  facts  prove 
that  such  an  evacuation  is  necessary  to  the  maintenance  of  foetal  life;  thus,  Bil- 
lard  and  T.  W.  King  record  having  seen  cases  of  ruptured  bladder,  resulting 
from  iraperforation  of  the  urethra;  and  further,  Desorraeaux  and  P.  Dubois  have 
observed  an  obliteration  of  this  canal  in  two  stillborn  children,  which  had  given 
rise  to  an  enormous  distension  of  the  bladder,  ureters,  and  both  kidneys ;  indeed, 
the  latter  were  found  transformed  into  two  multilocular  cysts.  Similar  facts  have 
been  presented  before  the  Academy  of  Medicine  by  MM.  Depaul  and  Moreau. 

According  to  some  authors,  the  principal  use  of  these  waters  is  to  contribute 
to  the  nutrition  of  the  foetus,  during,  at  least,  a  great  part  of  gestation.  (See 
Nutrition  of  the  Foetus.)  However  this  may  be,  the  waters  of  the  amnios  serve 
during  pregnancy  to  maintain  the  insulation  of  the  external  foetal  parts  before  the 
skin  becomes  covered  with  the  sebaceous  coat  hereafter  to  be  described ;  to  pro- 

'  It  is  only  necessary  to  recall  our  remarks  on  the  development  of  the  amnios  to  refute 
this  opinion. 

13 


194  GENERATION. 

mote  the  active  movements  of  the  fcetus  and  its  development,  both  of  which 
would  have  been  greatly  incommoded  without  this  intervention,  by  the  pressure 
of  the  uterine  walls ;  to  protect  the  fcietus  from  all  external  violence,  and  to  afford 
it  the  means  of  conforming  to  the  laws  of  gravity.  They  likewise  favor  a  uniform 
expansion  of  the  womb,  and  remove  all  pressure  from  the  umbilical  cord,  thus 
assuring  the  integrity  of  the  foeto-placental  circulation  both  during  pregnancy 
and  labor.  In  the  latter,  they  seem  destined  to  guard  the  child  from  the  vio- 
lence of  the  uterine  contractions,  which,  without  them,  would  certainly  compro- 
mise its  existence ;  to  aid  in  forming  the  amniotic  bag,  the  engagement  of  which 
renders  the  dilatation  of  the  neck  more  uniform  and  easy;  to  lubricate  the  pelvic 
canal,  and  thus  facilitate  the  descent  of  the  foetus ;  and  lastly,  they  render  mani- 
pulations of  every  kind  less  difficult  than  they  otherwise  would  be. 

§  5.  Of  the  Chorion. 

The  chorion  is  the  most  external  envelope  of  the  ovum.  Writers  are  by  no 
means  unanimous  in  their  views  as  to  the  elements  of  which  it  is  composed. 
Thus,  some  of  them,  as  we  have  had  occasion  to  state,  suppose  that  it  is  formed 
by  the  vitelline  membrane,  the  external  lamina  of  the  blastoderm,  and  the  allan- 
toid  vesicle,  uniting  to  constitute  a  single  layer.  According  to  others,  on  the 
contrary,  the  vitelline  membrane  will  disappear  soon  after  the  doubling  of  the 
blastodermic  vesicle,  and  the  external  lamina  of  the  latter,  conjoined  with  the 
allantois,  will  then  form  the  chorion.  As  to  ourselves,  the  reasons  have  hitherto 
been  given  that  induce  us  to  adopt  the  former  opinion. 

But  be  that  as  it  may,  the  chorion  certainly  does  not  exhibit  the  same  aspect 
at  the  advanced  stages  of  pregnancy ;  for  during  early  embryonic  existence  the 
external  membrane  of  the  ovum  is  thin,  transparent,  and  perfectly  smooth  on  its 
outer  surface,  whilst  about  the  second  week  this  surface  presents  some  minute 
granular  elevations,  which  increase  in  length  very  rapidly,  and  the  chorion  soon 
becomes  studded  with  numerous  villi.  But  at  that  time  neither  the  chorion  nor 
the  villi  have  a  proper  vascular  apparatus,  since  it  is  not  until  after  the  allantois, 
tosether  with  the  umbilical  vessels,  has  become  applied  to  the  chorion,  that  any 
vessels  can  be  detected  going  from  this  membrane,  either  to  penetrate  into  all 
the  villi,  or  only,  perhaps,  into  a  portion  of  them. 

The  chorion  is  enveloped  in  a  great  measure  by  the  reflexed  or  epichorial  deci- 
dua,  which  separates  it  from  the  parietal  decidua ;  and  is  in  contact  by  a  restricted 
svirface,  with  the  portion  of  the  mucous  membrane  which  constitutes  the  utero- 
epichorial  or  inter-utero-placental  decidua.  There  is  at  the  outset  a  considerable 
space  between  its  external  surface  and  the  internal  one  of  the  pouch  containing 
it,  which  space  is  occupied  by  its  villi,  and  may  become,  as  we  have  already 
stated,  the  seat  of  a  considerable  effusion  of  blood. 

Those  villi  which  are  in  contact  with  the  reflected  decidua,  penetrate  at  first, 
as  they  increase  in  size,  into  the  substance  of  that  membrane ;  they  soon,  how- 
ever, become  atrophied,  and  dwindle  away  almost  completely,  the  interval  dis- 
appears, and  the  two  membranes  come  into  immediate  contact. 


MODIFICATIONS    OF    THE    HUMAN     OVUM.  195 

As  regards  the  villi  of  the  chorion,  not  covered  by  the  reflected  decidua,  so 
far  fi-om  being  atrophied,  they  speedily  undergo  a  considerable  development, 
penetrate,  as  do  the  roots  of  a  tree  the  earth,  into  the  thickened  and  softened 
uterine  mucous  membrane  (utero-epichorial  decidua),  and,  intercrossing  with  the 
numerous  vessels  developed  in  its  substance,  contribute  to  the  formation  of  that 
essentially  vascular  mass  we  are  about  to  describe  under  the  name  o^  placenta. 

The  chorion  is  in  apposition  by  its  internal  face  with  the  amnios  at  an  advanced 
period  of  pregnancy ;  but,  as  previously  noticed,  these  two  membranes  are  not 
concentric  in  the  earlier  months,  being  then  separated  by  a  considerable  space 
that  is  occupied  by  the  umbilical  vesicle  and  an  albuminous  liquid,  which  is  the 
more  abundant  and  limpid  as  the  gestation  is  less  advanced. 

After  the  development  of  the  placenta,  the  chorion  is  a  thin,  transparent, 
colorless  membrane,  united  outwardly  to  the  decidua  by  some  short,  delicate  fila- 
ments, the  remnants  of  the  atrophied  villi,  and  inwardly  to  the  amnios  by  an 
albuminous  layer  (^tunica  media).  The  part  corresponding  to  the  placenta  is  no 
longer  in  immediate  contact  with  the  decidua ;  it  is  thicker,  and  adherent  to  the 
foetal  surface  of  that  vascular  body,  and  the  attachment  is  more  intimate  near 
the  root  of  the  cord.  After  what  has  already  been  stated,  it  were  idle  to  discuss 
the  vascularity  of  the  chorion,  for  it  evidently  has  no  vessels  until  after  the  allan- 
tois  has  been  developed;  but  from  that  period  it  consists  of  two  laminae,  the 
external  or  primitive  of  which,  also  called  the  exochorion,  is  wholly  destitute  of 
vessels,  whilst  the  internal  or  allantoid  is  essentially  vascular,  and  has  been 
denominated  the  endochorion. 


ARTICLE  II. 

OF    THE   ORGANS   OF   CONNECTION. 

§  1.  The  Placenta.     {After-hirth,  Secimdines.) 

The  placenta  is  a  soft,  spongy  mass,  constituting  the  principal  connection  be- 
tween the  ovum  and  utenis,  being  destined  to  the  hematosis,  and  perhaps  also  to 
the  nourishment  of  the  foetus. 

It  is  a  flattened  body,  about  three-quarters  of  an  inch  in  thickness  at  the 
centre ;  but  tapering  oif  towards  the  circumference,  which  does  not  often  exceed 
two  or  three  lines ;  in  some  cases  it  is  very  thin,  but  then  is  very  large,  and  fur- 
ther, its  figure  and  dimensions  are  exceedingly  variable ;  thus,  the  ordinary  dia- 
meter of  the  placenta  varies  from  six  to  eight  and  a  half  inches,  at  times  one 
diameter  is  longer  than  the  others,  and  the  shape,  therefore,  is  circular,  oval,  &c., 
according  to  circumstances.  The  term  battledoor-placenta,  has  been  applied  to 
that  variety  in  which  the  cord  is  inserted  on  the  border.  As  a  general  rule,  only 
one  placenta  exists  in  simple  pregnancies.  However,  a  very  curious  exception 
was  observed  quite  recently  at  the  Clinique  of  the  Berlin  Hospital,  namely, 
a  double  placenta  for  a  single  child.  Dr.  Ebert  furnishes  the  following  descrip- 
tion of  this  anomaly :  When  displayed  on  a  table,  it  was  found  to  be  divided  into 


196 


GENERATION. 


two  exactly  equal  rounded  parts,  which  were  entirely  distinct,  having  no  connec- 
tion whatever  with  each  other,  excepting  through  the  intervention  of  the  cord 
and  membranes;, an  interval  of  about  three  inches  separated  the  two  portions. 
The  cord  was  twenty-one  inches  long,  containing,  as  in  the  normal  state,  the 
three  vessels  spirally  arranged,  but  this  spiral  form  ceased  nearly  two  inches  from 
the  bifurcation  of  the  umbilical  vein ;  at  this  point  the  two  arteries  were  placed, 
one  on  each  side  of  the  vein,  and  only  communicated  by  a  trifling  anastomosis. 

The  vein  bifurcated  about  four  inches  from  the  placenta;  the  two  resulting 
branches  were  of  unequal  length,  and  the  longest  sent  a  branch  to  the  opposite 
placenta.  The  arteries  had  a  similar  arrangement,  one  being  sent  to  each  after- 
birth. The  one  corresponding  with  the  longest  vein  likewise  sent  a  branch  to 
the  other  placenta,  but  the  interior  subdivisions  of  the  vessels  offered  no  further 
anomaly. 

The  membranes  formed  a  single  cavity  for  the  foetus  and  amniotic  waters ;  they 
invested  the  two  portions  of  the  cord,  the  foetal  face  of  both  placentas,  and  passed 

from    one   organ   to   the    other,  thus 
FitT.  50,  establishing  a  kind   of  membranous 

bridge  between  them,  which,  with  the 
cord,  was  the  sole  point  of  communi- 
cation between  these  two  masses. 
(Arch.  Gen.,  1842,  t.  xiv.) 

A  similar  case  has  recently  occur- 
red at  the  Clinique  d' accouchement  de 
Paris,  a  drawing  of  which  has  been 
prepared  by  M.  P.  Dubois. 

A  placenta  presenting  the  same 
anomaly,  was  recently  exhibited  by 
me  to  the  Biological  Society.  This 
specimen  derived  additional  interest 
from  the  fact,  that  it  was  the  product 
of  a  double  pregnancy,  the  other  ovum 
having  a  distinct  and  regularly-formed 
placenta. 

A  much  more  singular  case  hag 
been  obligingly  communicated  to  me  by  Dr.  Blot.  In  this  instance,  the  placental 
mass  presented  nearly  the  usual  appearance,  but  around  it  were  distributed  several 
entirely  distinct  cotyledons,  which  were  connected  with  it  only  by  the  vessels 
proceeding  from  them  to  join  the  ramifications  of  the  cord.  (Fig.  52.) 

The  after-birth  presents  a  foetal,  or  internal,  and  an  external,  or  uterine  sur- 
face ;  also  a  circumference,  or  border.  The  internal  surface  is  covered  both  by 
the  chorion  and  amnion,  and  exhibits  numerous  ramifications  of  the  umbilical 
arteries  and  vein,  which  generally  converge  about  the  centre  of  this  body  to  form 
the  umbilical  cord.  The  uterine  surface  is  much  less  smooth,  polished,  and 
uniform  than  the  preceding,  and  is  slightly  convex,  whilst  the  former  is  a  little 
concave.     It  is  subdivided  into  a  variable  number  of  lobes,  or  irregularly-rounded 


Placenta,  with  five  separate  Cotyledons. 
Chorion,    b.  Amnion,    c.  The    cord,     b.  Sepa- 
rate cotyledons. 


MODIFICATIONS     OF    THE    HUMAN     OVUM. 


197 


cotyledons,  held  together  by  a  soft,  lamellated,  albuminous  tissue,  which  is  so 
easily  lacerated,  that  a  rupture  may  occur  during  the  separation  of  the  placenta, 


Fig.  53. 


Fig.  54. 


Fig.  53.    The  internal,  or  fcetal  surface  of  the  placenta. 
Fig.  54.    The  external,  or  uterine  surface  of  the  placenta. 


SO  that  after  its  expulsion,  the  cotyledons  appear  to  be  separated  from  each  other 
by  deep  furrows  or  fissures. 

The  external  surface  of  the  placenta  is  covered  by  the  decidua,  or  inter-utero- 
plaeental  mucous  membrane ;  a  true  maternal  placenta,  which  is  thrown  off  in 
connection  with  the  foetal  placenta  (see  Structure  of  the  Placenta^,  and  which 
covers  the  convex  surface  of  the  cotyledons  to  the  depth  of  about  one-eighth  of 
an  inch.  This  maternal  placenta  is  traversed  by  numerous  vessels,  the  open 
orifices  of  which  are  seen  upon  the  external  surface  of  the  after-birth  (utero- 
placental vessels). 

The  placental  circumference  is  thin  and  irregular,  and  its  extent,  although 
very  variable,  is  generally  about  twenty-five  inches.  The  margin,  according  to 
M.  Velpeau,  is  continuous  without  a  well-marked  line  of  demarcation  with  the 
double  lamina  formed  by  the  folding  of  the  deciduous  membrane.  But  in  the 
opinion  of  other  anatomists,  the  periphery  of  this  vascular  mass  is  continuous 
with  the  chorion,  and  only  contiguous  to  the  double  fold  of  the  decidua,  which  is 
there  thicker  and  more  dense,  and  presents  a  kind  of  triangular  sinus  for  the 
reception  of  the  placental  border. 

Our  future  remarks  upon  the  structure  of  the  placenta,  will  serve  to  show  that 
its  circumference  is  continuous  with  both  the  chorion  and  the  decidua;  with  the 
chorion  by  its  foetal  portion,  which,  after  all,  is  formed  by  the  hypertrophied  villi 
of  the  chorion ;  and  with  the  decidua  or  parietal  mucous  membrane  by  its  ma- 
ternal portion,  which  is  but  a  thickened  part  of  this  same  uterine  mucous  mem- 
brane. 

Structure. — The  placenta  is  an  essentially  vascular  organ.  The  vessels  enter- 
ing into  its  composition  are  dependencies  of  the  vascular  systems,  both  of  the 
mother  and  of  the  child. 

Their  ramifications  within  the  villi  of  the  chorion  adhere  to  each  other,  though 


198  GENERATION. 

not  by  means  of  a  structure  analogous  to  cellular  tissue,  as  some  authors  would 
have  it,  nor  by  a  plastic  matter,  as  is  thought  by  M.  Velpeau ;  but  simply,  as  the 
investigations  of  M.  Robin  prove,  by  a  limited  amount  of  an  amorphous  substance, 
which  is  somewhat  fibroid  where  most  abundant,  but  without  a  trace  of  cellular 
or  any  other  kind  of  tissue. 

The  structure  of  the  after-birth  has  been  a  theme  of  numerous  discussions 
among  embryologists ;  but  the  researches  of  MM.  Blandin,  Jacquemier,  Flourens, 
and  Bonami,  in  our  own  times,  and  even  yet  more  recently  those  of  Reid,  Weber, 
Coste,  Eschricht,  and  Robin,  have  thrown  much  light  on  this  subject. 

We  have  sought  laboriously  for  the  truth  amongst  these  diflferent  opinions ;  and 
in  believing  that  we  have  found  it  in  the  facts  established  by  MM.  Coste  and 
Robin,  we  are  no  less  convinced  that  their  task  has  been  greatly  facilitated  by 
the  researches  of  their  predecessors.  In  order  to  render  justice  to  all,  we  con- 
sider it  our  duty  to  give  an  analysis  of  the  principal  investigations  which  have 
been  made  in  reference  to  this  interesting  point  of  ovology. 

If,  while  the  placenta  is  still  adherent  to  the  uterine  wall,  a  careful  eflFort  be 
made  to  detach  it,  we  can  easily  see  that  this  detachment  takes  place  at  the  ex- 
pense of  a  particular  tissue,  which  at  once  separates  and  holds  the  two  surfaces 
in  contact.  Now,  this  utero-placental  substance  is  of  an  albuminous,  or  rather  of 
a  laminated  character,  consisting  of  numerous  lamellae  which  interlace  in  all 
directions,  and  adhere  to  each  other  at  certain  points  only  of  their  surface ;  and, 
as  a  necessary  consequence  of  such  an  interlacement,  this  tissue  pi'esents  multi- 
tudes of  cells  or  areola,  which  become  more  apparent  by  making  a  slight  traction 
on  the  placenta  and  uterus,  or  by  introducing  a  current  of  air  under  the  contiguous 
parts.  This  membranous  layer  (that  has  also  been  accurately  described  by  M, 
Jacquemier)  is  moulded,  as  it  were,  on  the  irregular  surface  of  the  placenta,  to 
which  the  adhesion  is  more  perfect  than  to  the  corresponding  part  of  the  womb ; 
it  dips  into  the  fissures  that  separate  the  cotyledons,  unless  these  should  happen 
to  be  very  deep,  in  which  case,  it  merely  passes  from  one  lobe  to  another,  thereby 
forming  a  species  of  membranous  bridge ;  but  a  cellulo-mucous  partition  much 
thicker  than  the  preceding  penetrates  deeply  between  the  lobes.  At  term,  this 
membrane  is  very  thin ;  a  delicate,  soft,  gelatinous  layer  remaining  adherent  to 
the  corresponding  portion  of  the  uterus.  The  lamina  clothing  the  external  sur- 
face of  the  placenta  is  continuous  with  the  decidua,  without  exhibiting  any  other 
difference,  says  the  same  author,  than  a  considerable  augmentation  of  thickness; 
a  disposition  that  is  apparently  mechanical,  being  due  to  the  relief  made  by  the 
projecting  circumference  of  the  after-birth,  and  which  thus  determines  around 
that  organ  a  gi-eater  accumulation  of  plastic  material.  According  to  that  able 
anatomist,  this  membrane  offers  all  the  physical  characters  of  the  decidua;  and 
he  seems  quite  disposed  to  consider  them  both  as  being  one  and  the  same. 

This  inter-utero-placental  tissue  is  traversed  by  a  great  number  of  venous  and 
arterial  vessels,  which  pass  from  the  internal  surface  of  the  uterus  to  the  placenta 
(utero-placental  vessels) ;  but  it  does  not  appear  to  be  the  ultimate  termination  of 
a  single  bloodvessel,  since  the  cells  it  forms  do  not  communicate,  as  has  been 


MODIFICATIONS    OF    THE    HUMAN     OVUM.  199 

stated,  with  the  uterine  veins.  No  trace  of  the  injection  remained,  in  this  tissue, 
in  the  preparations  just  alluded  to,  made  by  M.  Bonami. 

Let  us  proceed,  however,  to  the  vascular  structure  of  the  placenta,  properly  so 
called;  and,  as  I  have  witnessed  the  injections  of  M.  Bonami,  I  cannot  do  better 
than  transcribe  here  the  following-  parts  of  his  thesis  :  "  An  injection,  composed 
of  spirit  varnish,  colored  with  red  lead,  was  first  thrown  into  the  venous  system 
of  the  uterus  through  the  primitive  iliac  and  one  of  the  ovarian  veins.  A  second, 
consisting  of  spirits  of  turpentine  and  indigo,  was  then  made  of  the  uterine  arte- 
ries through  the  inferior  extremity  of  the  aorta,  ligatures  being  previously  placed 
on  all  the  vessels  capable  of  transmitting  the  injected  fluids  to  the  inferior  extre- 
mities. 

"  The  uterine  cavity  having  been  opened  at  some  distance  from  the  placental 
insertion,  and  the  fcjetus  stripped  of  its  membranes,  a  blackish  liquid,  which  was 
nothing  but  the  blood,  was  next  squeezed  from  the  vessels  of  the  cord ;  then 
injections,  having  linseed  oil  colored  with  white  lead  and  yellow  ochre  as  their 
base,  were  thrown  into  the  umbilical  vein,  and  into  one  of  the  arteries." 

These  injections  were  made  with  the  greatest  possible  precaution,  and  the  fol- 
lowing results  were  afterwards  obtained  from  a  careful  dissection.  "  At  first,  the 
red  liquid  injected  into  the  uterine  veins  could  be  distinctly  perceived  on  the 
foetal  surface  of  the  placenta.  But,  by  what  canals  could  the  injection  have 
penetrated  so  far  as  this  ?  Here  was  a  new  subject  of  research ;  but,  by  carefully 
turning  the  placenta  aside,  a  considerable  number  of  small  vessels  could  easily  be 
recognized,  leaving  the  internal  surface  of  the  womb,  traversing  the  inter-utero- 
placental  tissue  just  described,  and  plunging  into  the  substance  of  the  placenta. 
These  consisted  of  arteries  and  veins,  readily  cognizable  as  such  by  the  different 
colored  injections." 

1st.  Arteries. — The  number  of  these  is  large,  and  they  are  more  abundant 
near  the  centre  of  insertion  than  anywhere  else ;  still,  a  few  very  delicate  ones 
are  found  about  an  inch  from  the  placental  circumference.  Generally,  they  are 
quite  small,  varying  from  a  fourth  of  a  line  to  a  line  in  diameter.  They  assume 
very  sensibly  a  spiral  arrangement,  and  their  course  is  oblique,  almost  always 
creeping  along  for  a  third  of  an  inch,  sometimes  more,  before  their  terminal 
extremities  are  directed  towards  the  anfractuosities  of  the  placenta;  and  they 
evidently  penetrate  the  proper  substance  of  the  latter,  though  towards  the  uterus 
they  are  clearly  continuous  with  the  uterine  arteries.  Lastly,  they  have  but  few 
ramifications,  and  these  rarely  anastomose  with  each  other. 

2d.  The  veins  pass  from  the  uterus,  through  the  inter-utero-placental  mem- 
brane, towards  the  placenta,  but  they  have  not  the  same  disposition  as  the 
arteries. 

The  calibre  of  these  veins,  says  M.  Bonami,  is  nearly  equal  to  that  of  the  arte- 
ries, sometimes  even  a  little  larger,  some  of  them  being  from  two  to  three  lines 
in  diameter.  The  characters  by  which  we  could  distinguish  these  from  the 
arteries,  were  conclusive  in  the  piece  under  examination.  Thus,  these  veins 
were  penetrated  by  liquids  thrown  into  the  uterine  venous  system ;  they  were 
rectilinear,  and  their  exceedingly  numerous  ramifications  anastomosed  freely  with 


200  GENERATION. 

each  other,  thereby  forming  vast  plexuses  on  the  cell-walls,  which  penetrated  the 
uterine  surface  of  the  placenta  at  all  points ;  and,  on  the  other  hand,  by  further 
dissection,  could  be  seen  with  the  naked  eye  terminating  in  the  large  uterine 
veins.  Besides  these,  according  to  Meckel  and  Jacquemier,  there  exists  a  vein 
which  encircles  the  periphery  of  the  placenta ;  but  this  coronary  vein  is  rarely 
complete,  as  it  nearly  always  exhibits  one  or  more  interruptions  of  an  inch  or 
two  in  extent,  although  its  continuity  is  sustained  by  a  series  of  veins  anasto- 
mosing with  one  another,  and  its  course  exhibits  numerous  varicose-like  dilata- 
tions. It  communicates,  at  short  distances,  with  the  uterine  veins,  and  receives 
contributions  both  internally  and  externally;  some  of  these  spread  over  the 
uterine  surface  of  the  placenta,  and  anastomose  with  the  veins  that  penetrate  this 
body  at  its  centre ;  the  others,  which  are  less  numerous,  ramify  in  the  substance 
of  the  decidua,  two  or  three  inches  from  the  circumference  of  the  placenta,  and 
communicate  by  their  outer  extremities  with  the  uterine  sinuses,  that  are  situ- 
ated about  two  inches  from  the  placental  periphery ;  but  the  presence  of  this 
coronary  vein  is  not  constant,  for  neither  Velpeau  nor  Bonami  have  ever  met 
with  it. 

There  are,  therefore,  certain  arteries  and  veins  that  penetrate  the  placenta, 
belonging  to  the  maternal  vascular  system ;  but  before  studying  their  distribution, 
let  us  examine  that  of  the  umbilical  vessels.  These,  consisting  of  the  umbilical 
arteries  and  vein,  having  arrived  at  the  foetal  surface  of  the  placenta,  divide  into 
several  large  branches  that  are  found  between  the  amnion  and  chorion.  The 
first  of  these  membranes  maybe  detached  with  great  facility;  but  the  second 
intimately  adheres  to  the  vessels,  which  it  completely  envelopes,  thus  forming  a 
sheath  in  which  one  artery  and  one  vein  are  always  found,  the  vein  being  much 
the  larger;  shortly  after,  each  trunk  divides  into  two  branches,  each  of  these  into 
two  others,  and  thus  they  go  on  subdividing  dichotomously  almost  ad  infinitum. 
The  two  umbilical  arteries  communicate  freely  with  each  other  in  the  substance 
of  the  same  cotyledon,  and  this  anastomosis  may  even  be  seen  without  the  aid  of 
an  injection.  Again,  if  a  coarse  injection  be  thrown  into  one  of  the  arteries,  it 
will  shortly  return  by  the  other ;  though,  if  the  pressure  be  continued,  it  will 
pass  from  the  arteries  into  the  umbilical  vein ;  but,  if  we  commence  by  filling 
the  vein,  the  injection  reaches  the  arteries  with  more  diflaculty.  If  a  very  pene- 
trating mixture  be  used,  the  whole  uterine  surface  of  the  placenta  will  be  con- 
verted into  a  very  delicate  plexus,  which  never  affords  an  outlet  to  the  injected 
li(|uid;  patulous  orifices  do  not  exist,  therefore,  at  the  extremities  of  the  vessels. 

When  a  placenta  has  been  thus  injected,  and  is  then  macerated,  it  soon  ap- 
pears to  resolve  itself  into  a  substance  resembling  woolly  flakes  covered  by  nume- 
rous particles  of  a  soft  pulpy  tissue,  that  is  detached  from  them  with  much- 
difficulty.  These  flakes  present  under  the  microscope  a  large  number  of  granu- 
lations, composed  of  small,  convoluted,  twisted  vessels,  like  those  in  the  chorial 
villi  of  the  cow  or  the  sheep.  These  small  granules  have  been  described  as  acini, 
or  little  grains.  The  vessels  become  longer  as  the  maceration  is  continued,  and 
finally  lose  flexuosity  almost  entirely. 

On  the  whole,  therefore,  the  placenta  is  formed  by  vessels  belonging  to  the 


MODIFICATIONS     OF    THE    HUMAN    OVUM.  201 

mother  as  well  as  by  those  appertaining  to  the  child,  and  each  of  its  cotyledons 
is  constituted  in  the  following  manner:  the  maternal,  or  utero-placental  vessels 
penetrate  at  all  points  of  its  uterine  surface,  forming  in  its  substance  a  network 
of  exceedingly  delicate  meshes,  while  the  umbilical  vessels  that  penetrate  on  the 
foetal  surface  present  those  infinite  ramifications  just  described,  and  these  twist 
around  and  embrace  the  contracted  meshes  of  the  maternal  plexus  in  all  direc- 
tions. Further,  the  connection  existing  between  these  two  orders  of  vessels 
appears  to  result  from  the  membranous  sheath  that  envelopes  them  both,  even 
into  the  substance  of  the  placenta. 

This  sheath  is  furnished  to  one  set  by  the  chorion,  to  the  other  by  the  lamellar 
prolongations  of  the  inter-utero-placental  tissue.  In  other  words,  being  com- 
pressed and  united  with  each  other  through  the  intervention  of  a  common  sub- 
stance, these  divisions  and  subdivisions  form  a  cotyledon  of  the  placenta. 

Again,  all  the  minute  vascular  ramuscules  are  so  intimately  connected  that  it  is 
impossible  to  separate  the  vessels  belonging  to  the  mother  from  those  peculiar  to 
the  foetus,  and  they  can  only  be  distinguished  from  each  other  by  the  different 
colored  injections.  But,  although  the  two  series  thus  interlace,  the  maternal 
branches  never  communicate  by  their  terminal  extremities  with  those  of  the 
foetus;  since  the  finest  injections,  when  most  carefully  made,  have  never  esta- 
blished a  direct  communication  between  these  two  orders  of  vessels, — unless  by 
rupture  of  the  walls. 

The  description  of  Eschricht  is  very  analogous  to  that  of  M.  Bonami ;  thus, 
the  former  concludes  that  two  orders  of  capillary  plexuses  are  in  contact  in  the 
human  placenta,  and  that  the  uterine  arteries  are  continuous  with  the  veins  of 
the  same  name  through  a  capillary  plexus,  equally  delicate  with  the  one  existing 
between  the  umbilical  arteries  and  veins. 

But  the  researches  of  Weber  have  led  to  different  conclusions  as  to  the  mode 
in  which  the  uterine  arteries  run  into  the  veins  of  a  similar  name  in  the  placenta, 
and  these  curious  results  deserve  some  notice,  inasmuch  as  they  seem  to  form  a 
natural  transition  to  the  arrangement  which  we  shall  describe  hereafter. 

He  states  that  the  uterine  arteries  enter  the  after-birth  without  giving  off  any 
arborescent  ramifications;  and,  on  the  other  hand,  that  the  veins  do  not  arise  by 
delicate  ramuscules,  but  present,  at  their  very  origin,  large  trunks,  which,  by 
anastomosing  with  each  other  very  frequently  and  at  all  points,  seem  to  form  in 
this  manner  a  system  of  cells,  whence  the  blood  then  passes  by  some  venous 
trunks  into  the  uterine  veins.  These  latter  are  continuous  with  the  arterial 
tubes  from  their  origin ;  their  walls  are  excessively  thin  in  the  placenta,  being 
there  reduced  to  the  internal  coat,  and  collapse,  so  as  to  be  nearly  invisible  when 
they  contain  but  little  blood.  The  terminal  ramifications  of  the  umbilical  vessels 
project  into  these  venous  sinuses ;  moreover,  the  thin  tunic  of  the  vein  is  pushed 
into  the  interior  of  the  vessel  by  the  foetal  villus  resting  against  its  outer  surface, 
and  it  thus  furnishes  a  sheath  to  the  latter,  which  seems  to  penetrate  to  the 
interior  even  of  the  maternal  vascular  tube,  though  in  reality  it  does  not. 

Kead,  in  August,  1840,  easily  verified,  he  says,  the  existence  of  the  utero- 


202  GENERATION.      * 

placental  vessels,  when  examining  tlie  uterus  of  a  pregnant  woman,  who  died  at 
the  seventh  month. 

After  having  detached  a  portion  of  the  placenta  under  water,  my  attention 
was  drawn  to  a  number  of  rounded  bands  passing  between  the  uterus  and  the 
external  surface  of  the  placenta.  When  the  least  traction  was  made,  their  walls 
became  thinner  as  their  length  increased,  and  had  a  cellular  appearance,  though 
they  were  easily  lacerated ;  whilst  sometimes,  though  more  rarely,  they  seemed 
to  separate  like  the  tufts  of  the  uterine  sinuses.  By  cutting  into  one  of  the 
sinuses,  these  tufts  could  be  traced,  and  seen  to  ramify  in  its  interior;  some 
seemed  to  penetrate  the  patulous  opening  of  the  sinus  only,  while  others  sank  in 
for  about  an  inch,  and  appeared  to  penetrate  even  the  surrounding  sinuses.  I 
could  easily  satisfy  myself  by  injection  and  microscopical  inspection,  that  these 
tufts  were  the  ultimate  ramifications  of  the  umbilical  vessels. 

It  is  scarcely  necessary  to  add,  that  these  tufts  only  penetrated  the  openings  of 
the  sinuses  situated  near  the  internal  surface  of  the  uterus,  and  not  those  more 
deeply  seated.  Their  volume  varies  very  much,  some  appearing  to  fill  the  open- 
ing of  the  sinus  entirely,  whilst  others  only  occupy  it  in  part.  Again,  although 
the  tufts  appeared  loose,  and  floating  in  the  interior  of  the  maternal  vascular 
tube,  yet  they  were  evidently  surrounded  by  the  internal  tunic  of  the  latter, 
which  was  reflected  on  their  external  surface. 

I  have  assured  myself  that  some  of  the  utero-placental  veins  contained  no 
prolongation  of  the  foetal  vessels,  but  in  many  others  the  villous  tufts  (the  ter- 
minations of  the  umbilical  vessels)  could  be  recognized  and  followed  into  the 
uterine  sinuses. 

In  tracing  these  utero-placental  veins  that  contain  no  foetal  vessels  through  the 
decidua  to  the  surface  of  the  placenta,  the  internal  membrane  of  such  veins  is 
found  prolonged  on  the  neighboring  placental  tufts ;  and  further,  by  following  a 
larQ:e  utero-placental  artery  through  the  decidua,  we  may  see  that  as  soon  as  it 
arrives  on  the  face  of  the  placenta,  its  internal  tunic  is  prolonged  on  certain  tufts 
that  are  found  plunged  in  its  orifice. 

The  numerous  branches  of  the  foetal  tufts  which  stop  at  the  placental  surface 
of  the  decidua,  and  neither  penetrate  into  the  uterine  sinuses,  nor  yet  into  the 
orifices  of  the  utero-placental  vessels,  are  fixed  by  their  extremities  to  the  pla- 
cental surface  of  this  membrane.  Consequently,  the  placenta  is  formed  interiorly 
by  numerous  trunks  and  branches  (each  containing  an  artery  and  a  vein),  and 
each  of  these  branches,  both  venous  and  arterial,  is  surrounded  by  a  prolonga- 
tion of  the  internal  tunic  belonging  to  the  maternal  vascular  system,  or  at  least 
by  a  membrane  continuous  with  that  tunic.  Hence,  in  adopting  such  ideas  of 
the  placental  structure,  it  becomes  evident  that  the  internal  tunic  of  the  mother's 
vessels  is  prolonged  on  each  placental  tuft,  in  such  a  manner  that  the  maternal 
blood,  arriving  by  the  utero-placental  arteries,  passes  into  a  large  sac  formed  from 
the  internal  lamina  of  these  vessels,  and  the  blood  is  thus  divided  into  a  thou- 
sand diff'erent  directions  by  the  placental  villi,  which  project  like  fringes  into 
these  vessels,  pressing  in  their  thin,  soft  parietes  before  them,  and  formmg 
sheaths  therefrom  which  completely  envelope  each  trunk  and  each  branch.     The 


MODIFICATIONS    OF    THE    HUMAN    OVUM. 


203 


blood  returns  from  tliis  sac  by  the  utero-placental  veins  without  any  extravasation 
or  abandonment  of  the  vascular  system  to  "which  it  properly  belongs.  Therefore, 
the  foetal  blood,  and  that  of  the  mother,  can  have  no  action  upon  each  other, 
excepting  through  the  spongy  parietes  of  the  foetal  vessels  and  the  thin  sac  that 
surrounds  them. 

It  will  be  seen,  that  but  a  single  step  has  now  to  be  taken  in  order  to  reach 
the  description  given  by  M.  Coste,  the  tnith  of  which  is  placed  beyond  cavil  by 
the  microscopic  investigations  of  M.  Robin. 

It  is  really  impossible  to  obtain  a  correct  idea  of  the  structure  and  develop- 
ment of  the  placenta,  without  being  acquainted  with  the  nature  and  structure  of 
the  villi  of  the  chorion,  as  also  with  the  changes  undergone  by  that  portion  of  the 
uterine  mucous  membrane  (utero-epichorial  decidua)  upon  which  the  ovule  is 
engrafted. 

A.  Villi  of  the  Chorion. — We  have  already  stated  that  before  the  allantoid  is 
developed,  each  villus  of  the  chorion  contains  a  canal,  which  is  open  at  its  base, 
but  terminates  in  a  cul-de-sac  at  its  free  extremity :  after  the  allantoid  is  deve- 
loped, the  terminal  ramifications  of  the  umbilical  vessels,  both  arteries  and  veins, 
penetrate  into  this  canal  as  into  the  finger  of  a  glove.  The  villi,  after  having 
been  thus  rendered  vascular,  become  atrophied,  and  finally  disappear  from  all  that 

Fig.  55. 


This  figure  represents  the  manner  in  which  the  villi  of  the  chorion  ramify. — c  c.  Trunk  o(  the  villus. 
JE.  Terminal  ramification  intact,    g.  A  terminal  branch  broken  off.    v.  A  latsral  branch. 

pjirt  of  the  chorion  which  is  covered  by  the  reflected  or  epichorial  decidua. 
Those,  on  the  contrary,  which  are  in  immediate  contact  with  the  utero-epichorial 
ninccus  membrane  (inter-utero-placental  decidua  of  authors),  undergo  a  consi- 
derable development,  and  ramify  ad  infinitum.  When  viewed  collectively  at 
this  period,  they  have  the  appearance  of  a  soft,  hairy  mass,  very  tufted  and  flaky, 
and  of  a  semi-transparent  gray  rose  color. 


204  GENERATION. 

If  the  villi  which  compose  this  hair-like  mass  of  the  chorion  be  separated  from 
each  other  and  examined,  the  following  characters  will  be  found  applicable  to  all : 
a  common  pedicle,  forming  the  base  or  trunk  of  the  villus,  about  one-sixteenth  of 
an  inch  long,  and  one-half  as  wide,  for  an  ovum  of  six  weeks,  the  dimensions 
varying,  however,  with  the  size  of  the  ovum.  From  this  pedicle  are  put  forth 
numerous  branches,  forming  a  bulky  tuft.  The  largest  of  these  branches,  after 
dividing  two  or  three  times,  are  again  subdivided  into  innumerable  minute 
branchlets. 

Again,  some  of  the  smaller  branches  stand  alone  upon  the  surface  of  the 
chorion,  in  the  interspaces  of  the  tufted  pedicles  just  mentioned. 

The  extremities  of  the  subdivisions  of  the  third  and  fourth  orders  are  here 
and  there  found  to  present  a  sort  of  cylindric  or  flattened  swelling. 

One  of  the  principal  subdivisions  of  the  umbilical  arteries  and  veins  is  distri- 
buted to  each  of  these  pedicles,  and  extends  into  all  of  its  branches,  ramifying  as 
it.^oes. 

Inasmuch  as  the  branches  of  any  one  pedicle  have  no  communication  with 
those  of  a  neighboring  one,  it  follows  that  each  tuft  of  the  chorion  has  a  circu- 
lation of  its  own. 

Although  the  terminal  villi  become  longer,  their  thickness  is  not  sensibly  in- 
creased, for  their  diameter  is  nearly  the  same  after,  as  before  the  development  of 
the  placenta. 

B.  Utero-epichorial  Mucous  Membrane. — These  hypertrophied  villi  come  in 
contact  with  a  very  thick  and  much  softened  portion  of  the  uterine  mucous 
membrane.  As  they  grow  longer,  they  penetrate  into  the  tissue  of  the  mucous 
membrane  itself,  excavating  therein  a  species  of  cells  or  lacunte,  which  can  be 
seen  without  difficulty  upon  the  bottom  of  the  receptacle  represented  in  Plate  II, 
Fig.  51. 

Since  the  arteries,  but  more  especially  the  veins,  are  so  developed  at  this  point 
that  the  frequent  dilatations  of  the  latter  form  large  cavities  or  sinuses,  from  one- 
eighth  to  one  quarter  of  an  inch  in  diameter,  the  vascular  villi  of  the  chorion 
necessarily  come  in  contact  with  the  walls  of  the  uterine  vessels.  According  to 
MM.  Coste  and  Ilobin,  the  latter  are  even  worn  through  by  the  villi  of  the  chorion, 
which  having  thus  gained  entrance  into  their  cavities,  are  suspended  freely  in  the 
blood  which  fills  them.  We  cannot  regard  this  immersion  of  the  branches  of  the 
umbilical  vessels  as  proved,  and  therefore  prefer  the  opinion  of  Reid,  Weber, 
Bonami,  and  some  others,  that  their  relation  with  the  maternal  vessels  is  one  of 
simple  contact.  In  neither  hypothesis  can  a  direct  communication  be  admitted, 
for,  as  we  shall  soon  see,  each  terminal  villus  of  the  chorion  is  imperforate  at  its 
extremity,  and  contains  an  artery,  which  is  continuous,  without  any  line  of  demar- 
cation, with  a  vein. 

Soon  these  infinitely  numerous  and  elongated  villi  become  united  to  each  other 
by  means  of  an  amorphous  substance,  which  is  deposited  in  small  quantity 
amongst  them,  so  as  to  give  to  each  tuft  of  the  same  pedicle  the  compactness 
which  each  placental  cotyledon  presents  at  a  more  advanced  period  of  pregnancy. 

The  villi  taken  from  the  placenta  immediately  after  labor,  differ  from  those 


MODIFICATIONS    OF    THE    HUMAN    OVUM.  205 

described  only  in  the  greater  number  of  their  ramifications,  and  the  larger  size 
of  the  pedicles  and  of  the  principal  branches  which  they  put  forth. 

The  foetal  portion  of  the  placental  tissue  is  formed,  in  short,  of  interlaced  fila- 
ments, which  are  simply  the  chief  branches  of  the  villi  of  the  chorion,  whose 
ramifications  can  be  followed  to  their  termination  only  by  the  use  of  a  lens,  so 
inextricably  entangled  are  they,  and  agglutinated  by  the  amorphous  matter  of 
which  we  have  spoken.  They  thus  form  by  their  agglomeration,  a  tissue  of  a 
reddish-gray  color,  soft,  elastic,  giving  way  to  pressure  of  the  finger,  and  yielding 
a  filamentous  fragment  by  tearing. 

The  structure  of  all  the  villi  is  not,  however,  identical  at  the  termination  of 
pregnancy.  Although  the  greater  number  preserve  until  the  end  the  double 
vascular  canal  which  they  presented  at  the  beginning,  the  vessels  of  a  few  be- 
come atrophied,  and  like  the  non-placental  villi,  finally  constitute  a  very  slender 
filament  devoid  of  a  canal.  Fig.  56,  for  which  I  am  indebted  to  the  kindness 
of  M.  Robin,  exhibits  these  difi"erences,  besides  showing  very  clearly  the  admi- 
rable disposition  of  the  fcetal  vessel  within  the  villus  itself.* 

Thus  n  and  t  represent  a  terminal  prolongation  of  the  branches  of  a  placental 
villus,  ovoid  in  shape,  with  a  contracted  pedicle  and  obliterated  cavity ;  at  B  is 
another  terminal  prolongation  of  the  same  villus,  having  the  structure  which 
almost  all  of  them  retain  in  the  placenta.  It  is  composed  of  an  external  enve- 
lope B,  or  wall  of  the  villus,  of  a  structure  identical  with  that  of  the  chorion. 
Its  thickness,  and  consequently  that  of  the  substance  separating  the  blood  of  the 
foetus  from  that  of  the  mother,  may  be  estimated  approximatively.  It  is  about 
•0004  of  an  inch. 

This  villus  presents  internally  a  partition  A,  dividing  its  cavity  into  two  vas- 
cular tubes.  The  tubes  are  situated  beside  each  other,  like  the  barrels  of  a 
double-barrelled  gun ;  they  bend  toward  each  other  at  a",  so  as  to  form  a  single 
canal  at  the  extremity  of  the  villus,  which  is  arterial  at  D  E,  but  venous  at  g'  g. 
This  partition  A  has  only  half  the  thickness  of  the  external  wall  B.  It  has  a 
spur-like  termination  at  a",  and  adheres  by  its  base  at  a'  to  the  wall  of  the  villus. 

When  this  disposition  of  the  terminal  ramifications  is  once  understood,  all  dis- 
cussion, as  M.  Robin  remarks,  respecting  a  direct  communication  between  the 
maternal  and  foetal  vascular  systems,  is  ended. 

Each  of  the  capillary  vessels  of  this  double  canal  empties  into  a  corresponding 
one  of  larger  size,  at  the  point  of  junction  or  of  separation  of  a  ramification  with 
a  larger  branch ;  for  example  (Fig.  56),  the  arterial  tube  D  E  empties  at  a'  into 
the  trunk  of  the  same  nature  of  the  principal  branch  c  v,  and  the  venous  tube 
g'  g  discharges  at  the  point  C. 

The  placenta  is  therefore  composed  of  two  parts,  which  are  very  distinct,  in  a 
physiological  point  of  view,  although  they  are  confounded  in  a  single  mass  at  the 
end  of  gestation.     One  of  these  is  the  foetal  portion,  and  is  more  especially 

•  The  ininute  details  into  which  I  am  about  to  enter,  are  the  analysis  of  the  researches  of 
my  learned  colleague  and  friend,  M.  Robin.  They  are  for  the  most  part  recorded  in  an 
excellent  memoir  published  by  him,  and  also  in  the  thesis  of  M.  Cayla,  one  of  his  pupils. 


206  GENERATION. 

adherent  to  the  chorion,  fi-om  which  it  takes  its  origin ;  the  other,  the  maternal 
portion,  is  a  greatly  thickened  part  of  the  uterine  mucous  membrane. 


The  figure  represents  a  fragment  of  the  villi  of  the  chorion  obtained  from  the  placenta.    It  exhibits 
prolongations  of  various  appearance.    Magnified  360  diameters. 

It  is  very  difficult  to  say  what  is  the  real  mode  of  connection  between  these 
two  elements  of  the  placenta,  since  such  different  results  have  followed  the  dis- 
sections of  the  most  skilful  anatomists. 

Their  continuity,  or  direct  communication,  is  at  present,  however,  out  of  the 
question,  for  all  are  united  in  regarding  their  relation  as  one  of  simple  contact, 
a  greater  or  less  extent  of  adhesion. 

Simultaneously  with  the  expulsion  of  the  ovum,  the  maternal  placenta  is 
thrown  off  in  connection  with  the  foetal  portion,  and  forms  a  layer  of  about  the 
one-sixteenth  of  an  inch  in  thickness  upon  the  convex  surface  of  the  cotyledons, 
and  of  still  greater  depth  in  their  interstices.  Thus,  notwithstanding  the  very 
active  part  which  this  portion  of  the  mucous  membrane  has  played  during  preg- 
nancy, it  nevertheless  shares  the  same  fate  with  the  parietal  decidua,  being  ex- 
pelled with  the  after-birth  at  the  moment  of  delivery. 

The  placenta  appears  to  be  destitute  of  nerves  and  lymphatic  vessels. 

All  the  cotyledons  composing  the  placental  mass,  are,  as  we  have  said,  united 
by  the  interlobular  membrane.  Occasionally,  however,  one  or  several  of  these 
lobes  are  separated  from  the  others,  and  seem  to  form  another  placenta  by  their 
isolation ;  in  this  way  it  has  happened  that  several  placentas  have  been  attributed 
to  a  single  foetus,  and,  perhaps,  the  facts  mentioned  at  the  beginning  of  this 
article  are  to  be  accounted  for  in  the  same  way. 

The  placenta  may  be  inserted  upon  any  part  of  the  uterine  cavity  and  even 
upon  its  orifice,  though  most  usually  it  is  fixed  near  the  fundus  of  the  organ.  It 
has  been  customary  to  account  for  these  varieties  of  insertion,  by  saying  that  the 


MODIFICATIONS    OF    THE    HUMAN    OVUM.  207 

latter  is  determined  by  the  most  vascular  portion  of  the  organ;  overlooking  the 
fact,  that  although  the  point  of  attachment  be  indeed  more  vascular  than  any 
other  part  of  the  uterine  parietes,  it  is  simply  because  of  the  insertion,  thus  con- 
founding the  cause  with  the  effect.  According  to  some  authors,  the  weight  of 
the  ovule  determines  the  point  of  insertion  of  the  placenta,  which,  if  true,  should 
most  frequently  take  place  upon  the  neck.  Observation,  however,  refutes  this 
opinion.  Finally,  according  to  MM.  Moreau  and  Velpeau,  when  the  ovule 
enters  the  womb,  it  is  obliged  to  separate  the  decidua  from  the  wall  of  the  uterus, 
and  therefore  naturally  tends  towards  the  points  of  least  resistance. 

The  details  which  we  have  given  respecting  the  mode  of  formation  of  the 
decidua,  show  that  the  latter  opinion  is  without  foundation.  The  following  seems 
to  us  to  be  the  most  probable  explanation.  Generally,  by  the  time  the  ovule 
enters  the  uterine  cavity,  the  latter  is  filled  to  repletion  by  the  folded  and  swollen 
mucous  membrane.  This  state  of  things  renders  it  almost  impossible  that  it 
should  progress  very  far,  and  the  consequence  is,  that  in  the  vast  majority  of 
cases  it  lodges  in  one  of  the  numerous  folds  near  the  fundus,  and  becomes 
attached  in  the  vicinity  of  the  orifice  of  the  tube  by  which  it  entered.  The 
placenta  is,  in  fact,  generally  found  in  this  neighborhood.  Why,  in  some  cases, 
it  should  be  situated  in  the  inferior  segment  of  the  womb,  is  of  more  difficult 
explanation,  except  upon  the  supposition  that  fecundation  was  effected  after  the 
arrival  of  the  ovule  in  the  uterine  cavity ;  in  which  case,  in  consequence  of  the 
less  swollen  condition  of  the  mucous  membrane,  it  may  have  been  able  to  obey 
the  laws  of  gravity  immediately  upon  entering  the  cavity,  and  thus  descend  to- 
wards the  lowest  points. 

§  2.  The  Umbilical  Cord. 

The  umbilical  cord  is  the  flexible  trunk,  which  unites  the  abdomen  of  the 
child  to  the  placenta ;  it  does  not  exist  during  the  early  weeks  of  pregnancy,  and 
its  formation  only  commences  when  the  embryo  is  completely  separated  from  the 
blastodermic  vesicle,  which  thereby  becomes  the  umbilical  vesicle;  when  the 
allantois,  by  being  confounded  with  the  external  lamina  of  the  blastoderm,  no 
longer  constitutes  a  distinct  vesicle,  but  is  merely  a  simple  cord  upon  which  the 
two  umbilical  arteries  and  the  vein  ramify ;  and  when  all  these  parts  have  re- 
ceived an  enveloping  sheath  from  the  amnios.  Now  it  scarcely  appears  thus 
formed  until  towards  the  end  of  the  first  month,  being  composed  at  this  period, 
in  all  normal  emhryos  of  the  age  of  the  one  which  we  shall  describe  (page  211), 
of  three  distinct  parts:  1,  of  an  enveloping  canal,  whose  walls  are  formed  by  a 
reflexion  of  the  amnios,  and  which  is  continuous  at  the  umbilicus  with  the  skin 
of  the  embryo ;  2,  of  two  pedicles  proceeding  from  the  foetal  appendages,  around 
which  this  amniotic  canal  forms  a  sheath,  and  which  communicate,  the  one  under 
the  name  of  the  periic^e  of  the  iimhilical  vesicle,  with  the  ileo-ccecal  fold  of  intes- 
tine, and  the  other,  under  that  of  urachus,  or  the  2>ecUcle  of  the  allantois,  with 
the  bladder. 

But  soon  after,  as  the  development  progresses,  and  the  pedicle  of  the  umbilical 
vesicle  is  absorbed,  the  cord  becomes  simplified,  and  is  reduced  to  the  amniotic 


208  GENERATION. 

sheath  and  the  urachus,  accompanied  by  the  umbilical  vessels,  with  which  this 
sheath  is  confounded  by  the  obliteration  of  the  canal  that  constitutes  it.  The 
effacement  of  this  canal,  along  which  only  the  urachus  and  its  accompanying 
vessels  pass,  progresses  from  the  chorial  extremity  of  the  cord  towards  the  umbi- 
licus, or  abdomen  of  the  embryo;  and,  as  the  progressive  obliteration  approaches 
the  latter,  it  encounters  the  gut  which  advances  beyond  the  umbilicus,  and  forms 
a  hernia  in  the  cord  itself  j  but  this  rupture  is  naturally  reduced,  in  consequence 
of  the  pressure  exercised  on  the  intestine  by  the  progress  of  effacement,  which 
ultimately  reaches  the  navel,  and  presses  back  into  the  abdomen  everything  met 
with  outside  of  its  cavity.  However,  in  some  instances  this  process  is  not  com- 
pleted in  so  efficacious  a  manner,  and  the  intestine  in  such  cases  remaining 
beyond  the  umbilicus,  produces  the  malformation  known  as  congenital  hernia; 
a  hernia  that  is  nothing  more  than  the  persistence  of  an  anatomical  disposition, 
which  always  exists  temporarily  at  a  certain  period  of  the  embryonic  life. 

The  cord,  at  the  end  of  the  first  month,  is  still  thin,  cylindrical,  and  very 
small ;  but  from  the  fourth  to  the  eighth,  and  even  the  ninth  week,  it  acquires  a 
considerable  proportional  volume ;  and  it  exhibits  either  some  enlargements, 
vesicles,  or  swellings,  two,  three,  or  four  in  number,  which  are  separated  from 
each  other  by  a  corresponding  number  of  bands,  or  contractions. 

During  the  third  month  it  diminishes  in  size,  in  consequence  of  a  retraction  of 
these  tuberosities;  but  again,  commencing  from  this  latter  period,  it  continues  to 
grow  proportionally  to  the  other  parts  of  the  foetus  until  the  end  of  gestation. 

The  cord  varies  greatly  in  length  at  term ;  generally,  it  is  from  twenty-one  to 
twenty-three  inches ;  some  have  been  observed,  however,  from  six  inches  to  five 
feet  (one  metre  fifty-three  centimetres) ;  others,  still  more  rare,  have  reached 
five  feet  nine  inches  in  length  (one  metre,  seventy-five  centimetres).  I  delivered 
a  woman  with  the  forceps,  June  23d,  1841,  in  whom  the  head  had  been  retained 
above  the  superior  strait,  and  where  the  cord  was  only  nine  inches  long.  These 
extremes  are  very  rare ;  nevertheless,  they  are  not  the  utmost  varieties  the  cord 
may  offer  in  its  extreme  limits,  for  it  has  been  known  not  to  exceed  five  inches, 
and  has  even  been  as  short  as  two  inches. 

In  a  case  reported  by  Mende,  it  was  so  short  that  the  placenta  absolutely 
seemed  fixed  to  the  child's  abdomen.  Its  size  likewise  varies  in  different  sub- 
jects, being  generally  about  that  of  the  little  finger,  sometimes  much  smaller, 
and  at  others  very  large ;  but  in  all  these  cases  its  volume  depends  much  less  on 
that  of  the  vessels  than  on  the  quantity  of  fluids  accumulated  in  the  surrounding 
tissue. 

The  nerves  and  lymphatic  vessels,  which  certain  authors  have  described  as 
belonging  to  the  cord,  are  still  a  subject  of  research ;  admitted  by  some  and  de- 
nied by  others,  their  existence  is  at  least  problematical. 

The  arteries  are  two  in  number,  and,  following  the  course  of  the  blood,  they 
arise  from  the  bifurcation  of  the  abdominal  aorta  in  the  foetus,  and  reach  the 
umbilicus,  whence  they  traverse  the  entire  length  of  the  cord,  describing  nume- 
rous flexuosities  as  far  as  the  placenta,  in  the  tissue  of  which  we  have  already 
followed  their  ramifications. 


MODIFICATIONS     OF    THE    HUMAN     OVUM.  209 

The  vein,  still  following  the  route  of  the  blood,  arises  from  the  numerous 
ramuscules  studied  in  the  placenta ;  the  venous  radicles  of  each  lobe  unite  to  form 
branches,  which,  in  their  turn,  aggregate  on  the  foetal  surface  of  the  after-birth, 
to  form  there  the  trunk  of  the  umbilical  vein;  and  the  latter,  having  arrived  at 
the  umbilical  ring,  abandons  the  two  arteries,  and  runs  towards  the  livei*.  (See 
Circulation  of  the  fcetus.')  The  vein  is  nearly  equal  in  size  to  the  two  arteries 
united;  but  it  is  much  less  flexuous,  and  consequently  its  course  is  shorter. 

These  vessels  are  wound  upon  each  other  in  a  way  nearly  similar  to  the  twigs 
of  osier  forming  the  handle  of  a  basket ;  they  give  oif  no  branches  in  the  cord, 
and  it  has  been  remarked  that  the  twisting  of  the  vessels,  which  only  begins  after 
the  second  month,  takes  place,  nine  times  in  ten,  from  left  to  right.  The  vein 
usually  occupies  the  axis  of  the  cord,  and  the  arteries  wind  uniformly  around  it. 
Of  course,  this  enrolling  must  depend  somewhat  on  the  torsions  of  the  embryo 
itself,  and  then  the  entire  cord,  together  with  its  sheath,  is  involved,  as  not 
unfrequently  happens;  but  when  the  cord  is  straight,  and  the  arteries  are  twisted 
at  least  more  than  it  is,  these  contorsions  seem  to  result  from  a  more  rapid  growth 
of  the  vessels  within  the  sheath,  than  of  the  sheath  itself  (Haller).  Now,  the 
embryo  and  placenta  being  immovable,  the  turns  starting  from  these  two  points 
will  necessarily  meet  each  other,  and  this  indeed  frequently  takes  place.  Two, 
and  even  three  umbilical  veins  have  been  met  with  in  some  cases ;  in  others, 
instead  of  two  arteries  there  is  but  one.  Osiander  once  found  three  of  the  latter. 
It  is  worthy  of  remark,  that  neither  the  arteries  nor  the  veins  have  valves  at  any 
part  of  their  course. 

These  vessels  are  surrounded  by  a  gelatinous  substance  called  Wharton's  gela- 
tine, which  is  variable  in  its  quantity,  thereby  giving  rise  to  the  division  made 
by  accoucheurs  into  the  thin  and  fat  cords.  This  substance  is  continuous  on  one 
part  with  the  sub-peritoneal  cellular  tissue  of  the  ftietus,  and,  on  the  other,  ac- 
companies the  vessels  into  the  placenta.  Being  spongy  in  character,  it  is  consti- 
tuted by  a  clear,  tenacious  liquid,  contained  in  the  cellular  areolae,  that  commu- 
nicate so  freely  with  each  other.  The  cord  frequently  has  one  or  more  knots 
when  it  is  very  long,  some  of  which  are  formed  during  pregnancy,  and  often 
even  at  an  early  stage ;  but  others  are  only  produced  at  the  period  of  labor :  they 
never  become  so  tightened  (in  gestation)  as  to  compromise  the  life  of  the  child, 
to  whose  movements  they  are  certainly  due ;  but  we  can  understand  that  the  cord 
may  become  tightly  drawn  during  labor,  from  being  shortened  by  circular  turns 
around  the  trunk  or  neck ;  the  knots,  in  such  cases,  may  be  so  hardened  as  to 
intercept  the  circulation  completely,  and  the  death  of  the  foetus  will  necessarily 
result  if  the  labor  be  prolonged.  In  one  case,  figured  in  the  work  of  JI.  Bau- 
delocque,  the  cord  was  knotted  three  times  at  the  same  place,  and  was  interlaced 
like  a  mat.^ 

'  The  ancients  thought  they  could  determine  the  fecnndity  of  the  female  by  these  knots: 
thus,  according  to  Avicenna,  the  more  knots  the  morn  will  be  the  future  conceptipns ;  and  if 
they  occur  at  some  distance  apart,  the  pregnancies  will  also  be  more  distant  from  each  other. 
— [hralis  Spachii  gynccceorum  Ubri.) 

14 


210 


a  E  N  E  R  A  T  I  0  N. 


Fig.  57. 


An  aiioiua:., ,  ^.-'c^-.-L-d  by  Bejickiser. 


M.  Soete,  an  accoucheur  at  Gheluwe,  has  described  a  very  singuhir  case  of 

double  pregnancy,  in  which  the  two  foetuses 
were  enclosed  in  the  same  bag,  and  the  two 
cords  formed  a  perfect  knot  with  each  other. 
Besides  these  knots,  true  nodosities  like- 
wise exist  at  times  in  the  cord,  produced 
either  by  the  duplicature  or  the  varicose 
state  of  one  of  its  vessels. 

We  have  already  stated  that  the  cord  is 
attached  by  one  extremity  to  the  umbilicus 
of  the  child,  and  by  the.  other  to  some  point 
of  the  foetal  surface  of  the  placenta;  but 
this,  however,  is  not  always  the  case,  for 
the  facts  are  too  numerous  which  go  to 
prove  that  the  cord  may  indeed  be  inserted  on  the  head,  neck,  shoulders,  and 
other  parts  of  the  foetal  trunk,  not  to  admit  some  of  them,  at  least ;  such,  for 
example,  as  the  one  observed  by  M.  Jules  Clo([uet,  at  Brussels.  The  placental 
extremity  of  the  cord  also  presents  some  anomalies ;  it  is  usually  fixed  very  near 
the  centre,  but  sometimes  is  found  attached  to  a  part  of  the  periphery,  bearing 
then  the  tirle  of  the  hattledoor-placentn.  Nor  is  it  always  attached  to  a  point  of 
the  foetal  surface  of  the  placenta.  For  instance,  ]?enckiser  has  collected  in  his 
thesis  numerous  cases  in  which  the  cord  was  inserted  at  some  point  on  the  peri- 
phery of  the  membranes ;  and  having  arrived  there,  the  vessels  of  the  cord  then 
divide  into  five  or  six  large  trunks,  the  branches  of  which,  by  ramifying  between 
the  membranes,  reach  the  placental  circumference,  and  plunge  into  the  parcn- 
chyma  of  this  body.     (See  Fig.  57.) 

All  such  modifications,  however,  merely  depend  on  the  way  in  which  the  allan- 
tois  contracts  its  adhesions  with  the  point  of  the  ovum  in  contact  with  the  womb. 
In  ftict,  the  placenta  is  always  developed  there,  and  if  the  allantois  happens  to 
strike  the  chorion  at  a  part  somewhat  removed  from  that  which  is  in  apposition 
with  the  internal  uterine  surface,  the  umbilical  vessels  must  evidently  have  a 
tendency  towards  the  latter,  just  as  the  roots  of  a  plant  always  stretch  towards 
the  spot  which  will  afford  them  the  most  nourishment. 


CHAPTER    IV. 


OF   TUE   FCETUS. 


We  shall  not  attempt  to  study  the  foetus  by  describing  the  different  organs, 
and  the  various  tissues  successively,  that  enter  into  its  structure  at  the  moment 
of  birth,  nor  by  tracing  each  of  them  through  the  modifications  it  undergoes  at 
the  divers  periods  of  the  intra-uterine  life ;  for  such  a  course  would  evidently 


ri  m. 


ri6.  58. 


S^,.59. 


J 


\i     — ^ 


"■'^^^ 


'I'  "jWa...  '^       "s: 


Fio  60. 


f 


"^y^-- 


«         K       " 


7  .<.!.,  )..ir.f  /iM     W.i/.lrfW 


OF    THE    FCETUS.  211 

compel  us  to  overstep  the  limits  imposed  by  the  nature  and  character  of  tliis 
work.  Therefore,  laying  aside  all  embryological  researches,  we  shall  content 
ourselves  with  mentioning  a  few  interesting  particulars  oi  onjanoijcny  ;  and  while 
considering  the  fa^tus  in  a  general  manner,  we  shall  point  out  succinctly  the  suc- 
cessive development  of  its  form  and  its  external  parts.  But  before  entering  upon 
this  subject,  we  believe  it  will  prove  profitable  to  present,  in  a  figure,  the  various 
details  already  furnished,  as  such  an  expo.-sition  will  complete  the  description 
previously  made,  and  facilitate  a  knowledge  of  the  facts  we  have  yet  to  speak  of. 


EXPLANATION  OF  THE  FIGURES  IN  PLATE  IIL 

Fig.  58.  The  human  ovum,  of  its  natural  size,  at  about  the  thirtieth  or  thirty-sixth  day. 

Fig.  59.  The  same  ovum  (of  its  natural  size)  laid  open  to  show  its  constituent  parts. 

A  A.  The  chorion. 

B.  The  amnion. 

c.  The  foetus. 

D.  The  umbilical  vesicle. 

Fig.  60.  The  same  ovum  highly  magnified,  and  opened  in  such  a  way  as  to  exhibit 
the  principal  relations  existing  between  the  embryo  and  its  appendages.  The  walls  of 
the  abdomen  and  chest  have  been  cut  away  so  as  to  bring  the  viscera  into  view,  and  the 
umbilical  cord  has  also  been  split  up,  for  the  purpose  of  showing  how  the  appendages  of 
the  foetus  are  brought  into  relation  with  this  latter. 

A  A.  The  chorion,  consisting  of  two  layers,  placed  back  to  back,  and  confounded  with 
each  other,  but  which  have  been  dissected  apart  for  a  limited  extent  at  a^  k\ 

B  B.  The  amnion,  laid  open,  so  as  to  show  how  it  is  continuous  with  the  umbilical 
cord,  along  which  it  is  reflected,  thereby  forming  a  sheath,  which,  under  the  form  of  the 
canal  b'  b'',  is  directly  continuous  with  the  umbilicus  or  the  abdominal  walls  c  c  of  the 
embryo. 

D.  The  umbilical  vesicle,  and  W  its  pedicle. 

D''''.  The  point  where  this  pedicle  communicates  with  the  intestine  e. 

E.  The  loop  of  intestine  prolonged  into  the  cord. 

F.  The  urachus,  continuous  by  one  extremity,  <7,  with  the  chorion,  and  by  the  other 
with  the  rectum  at  the  point  H. 

ii.  The  umbilical  arteries. 

j.  The  umbilical  vein. 

y.  The  part  of  the  right  auricle  from  which  the  umbilical  vein  comes  off. 

K.  The  vena  cava  inferior. 

M.  The  inferior  surface  of  the  liver. 

N.  The  omphalo-mesenteric  vein. 

0.  The  point  where  this  vein  empties  into  the  umbilical  vein. 
P.  The  omphalo-mesenteric  artery. 

1.  The  heart. 

2.  The  arch  of  the  aorta. 

3.  The  pulmonary  artery. 

4.  The  lung  of  the  right  side. 

5.  The  Wolffian  body. 

6.  The  branchial  fissure,  which  is  converted  into  the  external  car. 

7.  The  lower  jaw. 


212  GENERATION. 

8.  Tlio  upper  jaw. 

9.  Tlio  nostril  of  the  right  side. 

10.  The  nasal  canal  still  Ibrming  a  kind  of  fissure,  which  extends  from  the  eye  to  the 
nostril. 

11.  The  caudal  extremity,  or  coccyx,  projecting  like  a  tail. 

12.  The  upper  extremity. 

13.  The  lower  extremity. 

ARTICLE    I. 

DIMENSIONS    AND   WEIGHT    OF   THE    FffiTUS   AT    THE   DIFFERENT   PERIODS 
OF   INTRA-UTERINE    LIFE. 

At  the  time  when  the  embryo  first  begins  to  be  distinct,  that  is,  about  the 
third  week,  it  is  obh:)ng,  swollen  in  the  middle,  obtuse  at  one  extremity,  though 
drawn  to  a  blunt  point  at  the  other,  and  straight,  or  nearly  so,  being  somewhat 
curved  forwards.  It  is  therefore  vermiform  in  shape,  of  a  grayish-white  color, 
semi-opaque,  almost  without  consistence,  and  gelatinous,  varying  from  two  to 
four  lines  in  length,  and  weighing  one  or  two  grains.  At  this  period,  the  only 
trace  of  the  head  is  a  small  tubercle  separated  from  the  rest  of  the  body  by  a 
notch,  but  no  rudiments  of  the  extremities  are  observed,  nor  is  there  a  cord  at 
first. 

The  embryo  is  clearly  surrounded  by  the  amnion,  which  lies  quite  near  it,  in 
the  form  of  a  delicate  membrane,  leaving  it,  however,  always  free.  The  abdo- 
minal cavity  is  opened  for  a  very  considerable  extent  in  front.  The  embryo 
becomes  more  consistent  towards  thef/th  iceek:  its  head  then  increases  greatly, 
in  proportion  to  the  remainder  of  the  body,  and  the  rudimentary  eyes  are  indi- 
cated by  two  black  spots  turned  towards  the  sides;  the  development  of  the 
thoracic  extremities  is  announced  by  two  small,  obtuse  nipples,  situated  on  the 
sides  of  the  trunk;  it  is  nearly  two-thirds  of  an  inch  long,  and  weighs  about  fifteen 
grains ;  the  cord  exists  in  a  rudimentary  condition,  and  the  abdominal  members 
are  likewise  present,  in  the  form  of  two  rounded  pimples.  The  vertebral  divi- 
sions are  quite  apparent,  all  along  the  back,  although  the  caudal  vertebra;  closely 
approach  the  front  part  of  the  head,  in  consequence  of  the  anterior  curvature  of 
the  embryo. 

Already  does  the  heart  exhibit,  in  its  external  form,  a  tolerably  close  resem- 
blance to  that  in  the  adult;  for,  we  may  even  now  observe  the  fissure  that  will 
afterwards  separate  the  auricles,  as  also  one  corresponding  to  the  inter-ventricular 
partition ;  but  there  is,  in  reality,  only  one  ventricle,  from  which  both  the  aorta 
and  the  pulmonary  artery  arise.  And,  further,  there  is  but  one  auricle;  or, 
rather,  the  two  communicate  so  freely  that  the  intermediary  contraction  which 
should  divide  them  is  still  very  imperfect;  for  the  partition  is  formed  by  the 
progressive  contraction  of  the  orifice  of  communication,  and  this  incomplete  open- 
ing, which  sometimes  persists  in  the  septum  until  birth,  is  known  under  the 
name  of  the  foramen  of  Botal.  But,  after  birth,  the  opening  becomes  oblite. 
rated,  and  the  two  auricles  are  thenceforth  isolated  by  a  complete  partition. 


OF    THE    FCETUS.  213 

The  single  ventricle  will  be  converted  into  two  cavities,  by  the  intervention  of 
a  septum  which  will  be  frradually  developed  from  the  summit  towards  the  base, 
beina;  placed  between  the  two  arteries  (the  pulmonary  and  aorta),  and  so  disposed 
that  one  of  them  shall  open  into  the  right  and  the  other  into  the  left  cavity. 

The  lungs  at  this  period  are  constituted  of  five  or  six  lobules,  in  which  we  can 
readily  extinguish  the  bronchial  extremities,  terminating  in  slightly  swollen  cul- 
de-sacs.  Moreover,  two  large  glandular  structures  lie  along  the  vertebral  column 
at  this  period,  extending  longitudinally  on  each  side,  from  the  lung  to  the  bottom 
of  the  pelvis.  These  are  the  Wolffian  bodies.  They  are  constituted  by  an  excre- 
tory canal,  which  runs  throughout  their  whole  length,  being  placed  on  their 
external  margin,  and  terminating  below  in  the  transitory  cloaca.  The  canal  puts 
forth,  on  one  of  its  sides  only,  a  series  of  more  or  less  elongated  cooca,  which 
roll  or  curl  up,  so  as  to  form  a  considerable  mass  by  their  agglomeration.  These 
coeca  secrete  a  liquid,  which  is  subsequently  emptied  into  the  cloaca  by  means  of 
the  canal. 

The  WolflBan  bodies  anticipate  the  function  of  the  kidneys  until  the  latter  are 
developed,  and  hence  they  have  been  denominated  the  false  kidneys  ;  but  they 
disappear  as  soon  as  the  true  organs  can  replace  them,  leaving  no  trace  of  their 
past  existence.  Just  alongside  of  the  excretory  canal,  in  the  Wolffian  body,  a 
second  one  is  seen  to  accompany  it  throughout,  and  even  in  like  manner  to  empty 
into  the  cloaca.  But  this  second  canal  is  perfectly  distinct  from  the  other,  and 
will  become,  in  the  adult,  either  the  oviduct  or  the  vas  deferens,  according  as  the 
new  being  shall  be  of  the  male  or  female  sex. 

In  the  early  stages  of  embryonic  life,  there  likewise  exists  on  each  side  of  the 
neck,  in  the  human  foetus,  as  also  in  the  mammiferje,  four  transverse  fissures 
which  open  into  the  pharynx.  These  are  separated  from  one  another  by  certain 
bands,  or  fleshy  partitions,  that  correspond  with  the  branchial  arcs  of  fishes ;  for 
the  vascular  apparatus  distributed  there,  affects,  to  a  certain  extent,  the  same 
form  temporarily,  that  it  has  permanently  in  the  inferior  vertebratse.  We,  there- 
fore, see  that  the  bulb  of  the  aorta,  instead  of  curving  immediately  in  a  single 
arch,  divides,  on  the  contrary,  into  three  or  four  branches,  on  each  side  of  the 
neck;  and  after  these  branches  have  each  accompanied  a  branchial  arch,  they 
reunite,  at  a  common  point,  to  form  the  descending  aorta;  however,  they  are  soon 
effaced,  along  with  the  corresponding  fissures,  and  but  two  remain  on  the  left 
side,  one  of  which  is  converted  into  the  arcus  aortae,  while  the  other,  after  having 
existed  as  an  arterial  canal,  will  form  the  common  trunk  of  the  pulmonary  arteries. 

The  branchial  fissures  just  under  consideration  also  disappear,  with  the  excep- 
tion of  a  single  one  (the  first  on  each  side),  which  is  converted  into  the  external 
ear,  as  may  be  seen  in  the  figure.    (See  Plate  III.) 

At  this  period,  the  upper  jaw  is  still  composed  of  two  papulae,  one  for  each 
side.  These  pimples,  or  isolated  mandibles,  gradually  approach  the  median  line, 
and  there  unite  in  a  single  body,  which  forms  the  jaw  such  as  we  find  it  in  the 
adult. 

The  nostrils  are  separated  by  the  incisive  papulae,  which  keep  them  apart  for 
some  time ;  then,  as  the  latter  diminish  in  size,  they  approach  each  other  and 


214  GENERATION. 

assume  tlicir  definitive  form  ;  but,  in  the  nieanwliile,  they  are  separately  split 
down  to  the  mouth,  and  it  is  the  permanence  of  this  transitory  state  that  consti- 
tutes the  double  hare-lip.  All  of  the  branchial  fissures  have  disappeared  by  the 
sixth  week,  leaving  only  a  slight  cicatrix  behind. 

The  first  centres  of  ossification  appear  during  the  seventh  week,  first  on  the 
clavicle  and  then  on  the  lower  jaw.  The  intestine  still  extends  for  a  considerable 
distance  along  the  interior  of  the  umbilical  cord,  but  the  omphalo-mcsenteric 
canal  is  nearly  obliterated,  although  it  may  yet  be  traced  as  far  as  the  umbilical 
vesicle,  where  it  is  reduced  to  a  very  delicate  thread.  The  anus  remains  closed ; 
and  the  bodies  of  Wolff  alone  exist  near  the  vertebral  column.  It  is  only  then 
that  the  kidneys  and  capsula3  renales  begin  to  appear,  and  soon  after  them  the 
sexual  organs.  The  urinary  bladder  is  first  manifested  under  the  form  of  a  tumor 
that  is  continuous  with  the  urachus.  At  this  time,  the  embryo  is  nearly  an  inch 
in  length. 

At  (wo  7710)1  ths,  the  tubercles  of  the  extremities  become  more  prominent.  The 
forearm  and  hand  can  be  distinguished,  but  not  the  arm ;  the  hand  is  larger  than 
the  forearm,  but  it  is  not  supplied  with  fingers.  The  cord  has  not  as  yet  assumed 
a  spiral  arrangement,  but  it  is  infundibuliform  in  shape,  the  base  corresponding 
to  the  abdomen,  being  continuous  with  it,  and  containing  a  large  quantity  of  in- 
testine;  it  is  four  to  five  lines  in  length,  and  is  inserted  near  the  lowest  point  of 
the  abdomen.  A  small  tubercle,  furnished  Avitli  one  or  more  very  contracted 
openings,  may  be  distinguished  between  it  and  the  termination  of  the  .spine, 
which  are  the  rudimentary  external  organs  of  generation;  but  the  extreme 
length  of  the  clitoris  renders  the  distinction  of  the  sexes  difficult  at  this  period. 

The  embryo  is  from  one  and  a  half  to  two  inches  long,  and  weighs  from  three 
to  five  drachms,  the  head  forming  more  than  one-third  of  the  whole.  The  eyes 
are  prominent,  but  the  lids,  from  being  still  rudimentary,  do  not  cover  the  eye- 
ball ;  the  nose  forms  an  obtuse  eminence ;  the  nostrils  are  rounded  and  sepa- 
rated ;  the  mouth  is  gaping,  and  the  epidermis  can  be  distinguished  from  the 
true  skin. 

At  ten  weeks,  the  embryo  is  from  one  and  a  half  to  two  and  a  half  inches  in 
length,  and  weighs  an  ounce  or  an  ounce  and  a  half.  The  palpcbrro,  having  be- 
come more  apparent,  descend  in  front  of  the  eye,  and  the  puncta  lachrymalia  are 
now  visible ;  the  buccal  fissure,  which  has  increased  in  size,  begins  to  be  oblite- 
rated by  the  commencing  development  of  the  lips. 

The  thoracic  parietes  are  apparent;  hence  the  heart's  movements  cease  to  be 
visible.  The  fingers  are  distinct,  and  the  toes  look  like  little  tubercles  held 
together  by  a  soft  substance.  The  cord  is  longer  than  the  embryo,  and  begins 
to  assume  the  spiral  arrangement;  it  is  less  infundibuliform  than  previously, 
and  is  not  inserted  so  low  down  on  the  abdomen,  but  its  base  always  contains  a 
portion  of  intestine. 

At  the  end  of  the  third  month,  the  embryo  weighs  three  to  four  ounces,  and 
measures  from  five  to  six  inches;  the  ej'eball  is  seen  through  the  lids;  the  mem- 
brana  pupillaris  is  more  manifest;  the  forehead  and  nose  are  clearly  traceable, 
and  the  lips  well  marked  and  not  turned  outwards.     The  neck  now  establishes  a 


OF     THE     FCETUS.  215 

visible  separation  between  the  head  and  thorax;  the  latter  cavity  is  closed  at  all 
points,  but  is  still  very  slightly  developed  relatively  to  the  other  cavities.  The 
cord  contains  no  intestine,  and  its  spiral  turns  are  more  numerous  and  evident. 
The  nails  begin  to  appear  as  thin  membranous  plates;  the  sex  is  distinct,  and  the 
integuments,  which  heretofore  were  only  a  soft,  viscous  covering,  acquire  more 
consistence,  but  are  still  very  thin,  transparent,  of  a  roseate  hue,  and  without  an 
apparent  fibrous  texture. 

At  the  fourth  month,  the  embryo  takes  the  name  of  foetus ;  its  growth  is 
not  so  rapid  in  the  commencement,  as  at  the  end  of  this  month.  The  body  is 
six  to  eight  inches  in  length,  and  weighs  from  seven  to  eight  ounces.  The  fon- 
tanelles  are  very  large,  as  are  also  the  sutures ;  and  some  short,  whitish,  silveiy 
hairs  may  be  observed  on  the  head.  The  face  still  remains  but  little  developed, 
although  more  elongated  than  it  has  previously  been.  The  eyes,  nostrils,  and 
mouth  are  closed,  and  when  the  occlusion  of  the  lids  happens  to  be  incomplete, 
it  is  generally  at  the  internal  part.  The  tongue  may  be  distinguished  behind 
the  buccal  fissure,  and  the  projection  of  the  chin  is  observable.  The  cord  is  in- 
serted higher  up  on  the  abdomen,  whence  the  centre  of  the  body  is  an  inch  or 
two  above  the  umbilicus.  The  skin  has  a  rosy  color,  and  begins  to  be  covered 
by  down,  and  some  fat,  tinged  with  red,  is  deposited  in  the  areola)  of  the  sub- 
cutaneous cellular  tissue,  and  the  muscles  now  produce  a  sensible  motion.  A 
foetus  born  at  this  period  might  live  for  several  hours.  Whilst  I  was  Interne  at 
the  Hotel  Dieu,  I  received  one  that  had  scarcely  reached  the  fourth  month.  It 
lived,  however,  from  half-past  seven  to  half-past  eleven  o'clock. 

At  five  months,  the  length  of  the  body  is  eight  to  ten  inches,  and  it  weighs 
from  eight  to  eleven  ounces.  The  skin  is  more  consistent,  and  many  patches  of 
sebaceous  matter  may  already  be  seen,  but  the  pupils  cannot  be  distinguished. 

At  six  months,  the  length  is  eleven  to  twelve  and  a  half  inches,  and  the  weight 
about  one  pound  (avoir.).  The  hair  is  both  longer  and  thicker,  the  eyes  closed, 
the  eyelids  somewhat  thicker,  and  their  margins,  as  well  as  the  eyebrows,  are 
studded  with  very  delicate  hairs.  Agreeably  to  most  authors,  the  membrana 
pupillarls  always  exists ;  on  the  contrary,  the  pupil  at  this  period  has  seemed 
very  large,  both  to  M.  Velpeau  and  myself.  The  skin  is  better  organized,  for 
the  dermis  and  the  epidermis  may  be  distinguished,  though  its  surface  is  wrinkled 
and  puckered,  owing  to  the  small  quantity  of  subcutaneous  fat.  The  nails  are 
solid  already.     The  scrotum  is  very  small,  quite  red,  and  empty. 

At  seven  months,  the  foetus  acquires  a  length  of  twelve  and  a  half  to  fourteen 
inches ;  all  its  parts  have  become  firmer  and  more  voluminous,  and  their  respec- 
tive dimensions  better  proportioned.  The  bones  belonging  to  the  vault  of  the 
cranium  exhibit  near  their  centres  a  considerable  prominence  at  the  point  where 
the  first  rudiments  of  ossification  occur,  whence  it  follows  they  are  less  uniformly 
arched  than  at  the  succeeding  periods,  and  more  curved  than  in  the  former 
months,  when  they  were  in  reality  nearly  flat.  The  pupillary  membrane  disap- 
pears completely  ;  indeed,  according  to  M.  Yelpcau,  this  membrane  does  not  exist 
at  any  period  of  the  intra-uterinc  life.  The  iris  commences  as  a  simple  ring, 
which  then  grows  in  a  concentric  manner,  leaving  at  last  only  the  opening  called 


216  GENERATION. 

tlie  pupil.  The  eyelids  are  partly  open,  and  the  testicles  begin  to  descend  into 
the  scrotum. 

At  ehjlit  months,  the  foetus  seems  to  grow,  as  Desormeaux  remarks,  rather  in 
thickness  than  in  length ;  it  is  only  sixteen  to  eighteen  inches  long,  and  yet 
weighs  from  four  to  five  pounds.  The  skin  is  very  red,  and  covered  with  long 
down,  and  a  considerable  quantity  of  sebaceous  matter.*  The  lower  jaw,  which 
was  at  first  very  short,  is  now  as  long  as  the  upper  one.  The  scrotum  usually 
contains  one  testicle,  generally  that  on  the  left  side. 

Finally,  at  term,  the  foetus  is  about  nineteen  to  twenty-three  inches  long,  and 
weighs  from  six  to  seven  pounds.  Although,  in  consequence  of  the  development 
at  the  inferior  part  of  the  trunk,  the  umbilical  ring  is  now  considerably  removed 
from  the  hypogastric  region,  yet  the  insertion  of  the  cord  does  not  correspond,  as 
has  been  stated,  with  the  centre  of  the  body.  Thus,  in  a  foetus  whose  total 
length  is  twenty  inches,  we  shall  generally  find  ten  and  a  half  to  eleven  inches 
from  the  crown  to  the  umbilicus. 

Indeed,  from  the  researches  of  M.  Moreau,  communicated  to  the  Academy  of 
Medicine,  it  appears  that  in  ninety-four  children  born  at  nine  months,  four  only 
had  the  umbilical  insertion  in  the  middle  of  the  body,  while  in  ninety  others  it 
was  below  this.  The  mean  of  the  variations  was  nearly  an  inch.  M.  Ollivier,  of 
Angers,  has  also  observed  the  same  thing  in  thirty  children  examined  by  him. 

The  weight  and  length  of  children  at  birth  have  been  wonderfully  exagge- 
rated in  many  cases ;  thus,  some  are  recorded  of  a  yard  or  more  in  length,  and 
others  that  weighed  eighteen,  twenty,  twenty-four,  and  even  thirty  pounds. 
These  statements  must  certainly  be  great  exaggerations;  for  the  most  voluminous 
of  three  thousand  children,  born  under  my  charge,  either  in  the  Hotel  Dieu  or 
at  La  Cliniquo,  weighed  ten  pounds,  and  it  was  an  enormous  one. 

Of  four  thousand  children  delivered  at  La  Maternite,  one  only  weighed  twelve 
pounds.     (Lachapelle.) 

Baudelocque  asserts,  that  he  superintended  the  delivery  of  one  twelve  pounds 
and  three  quarters;  and  Merriman,  one  weighing  fourteen  pounds;  Kichard 
Crofts,  another  of  fifteen  pounds ;  lastly,  3Ir.  J.  D.  Owens,  a  surgeon  at  Ilay- 
moor,  near  Ludlow,  has  seen  a  stillborn  infant  that  weighed  seventeen  pounds 
twelve  ounces,  and  had  the  following  dimensions  : 

Ocoipito-frontal  diameter,    ......  7}  inches. 

Occipito-mental         "  .  .  .  :  .  .      8^       " 

Bi-parietal  "......  5         " 

Total  length,     .  .  .  .  .  .  .  .      24       " 

'  About  the  middle  term  of  the  intra-uterine  life,  the  skin  is  covered  by  a  constantly-in- 
creasing mass  of  a  fat,  slii)pery,  viscous  substance,  yellowish-white  in  color,  called  the  sebaceous 
coat.  This  substance  is  more  abimdant  on  some  embryos  than  on  others,  and  is  in  greater 
quantity  on  certain  places,  as,  for  example,  the  head,  axilla,  and  groins;  it  is  insoluble  in 
water,  alcohol,  and  oil,  and  only  partially  soluble  in  potash.  It  is  not  a  precipitate  furnished 
by  the  amniotic  liquors,  as  some  persons  have  imagined,  for  there  is  none  of  it  on  the  exter- 
nal surface  of  the  amnios,  nor  on  the  umbilical  cord  ;  it  is  a  secretion  of  the  ftEtal  skin,  and, 
so  far  as  we  can  judge  by  its  composition,  is  a  mixture  of  effete  epidermis  and  matters 
furnished  by  the  sebaceous  glands,  which  assists  perhaps  in  the  hour  of  labor  by  facilitating 
the  expulsion  of  the  child. 


OF    THE    FCETUS.  217 

In  the  month  of  May,  1849,  I  was  called  in  consultation  by  Dr.  Riembault  in 
a  case  of  shoulder  presentation.  Several  attempts  at  version  had  been  made  by 
himself  and  another  physician,  and  it  was  with  the  greatest  difficulty  that  I  suc- 
ceeded in  accomplishinp;  it.  The  child,  which  was  born  dead,  appeared  to  me  a 
very  large  one,  and  I  estimated  its  weight  at  from  ten  to  twelve  pounds.  After 
my  departure,  M.  Riembault,  who,  like  myself,  had  been  struck  with  its  size, 
weighed  it  carefully,  once  with  a  steelyard,  and  twice  in  different  balances,  and 
ascertained  its  weight,  by  the  three  trials,  to  be  eighteen  pounds.  Its  extreme 
length  was  two  feet  one  and  a  half  inches,  the  bi-acromial  diameter  nine  inches, 
the  greater  circumference  of  the  head  sixteen  and  one-eighth  inches,  and  the 
lesser  circumference  nine  inches.  M.  Riembault  has  assured  me  repeatedly,  that 
he  could  guarantee  the  accuracy  of  these  statements,  since  being  himself  as- 
tonished at  the  results  of  the  measurements,  he  had  taken  the  precaution  to 
repeat*  them  several  times. 

The  mother  stated  that  her  last  menstrual  period  occurred  July  12th,  1848, 
and  that  she  expected  to  be  confined  about  the  12th  of  April,  1849.  The  size 
of  the  abdomen  had  been  so  great  since  March,  as  to  lead  her  to  suppose  that  she 
was  pregnant  with  twins.  The  first  pains  were  experienced  on  the  evening  of 
the  6th  of  May,  that  is  to  say,  nearly  a  month  later  than  she  had  anticipated. 
Whether  the  pregnancy  had  really  run  over  its  usual  term,  and  whether  the 
extraordinary  size  of  the  child  was  attributable  thereto,  are  questions  which  it  is 
impossible  to  decide. 

On  the  whole,  therefore,  we  may  conclude  that  the  foetal  growth  is  rapid  for 
the  first  three  months,  then  slackens  off  about  the  middle  of  pregnancy,  and  again 
becomes  greatly  accelerated  during  the  last  three  months. 

Chaussier  has  given  the  following  as  the  proportions  exhibited  by  the  different 
parts  of  the  fcetus  at  birth  (taken  from  a  child  nineteen  and  a  half  inches  long), 
namely : 

From  the  top  of  the  head  to  the  pubis,     .              .             .              .              IS^  inches. 

"      the  pubis  to  the  feet,     .              .              .  .              •             .         7^  " 

"      the  clavicle  to  the  bottom  of  the  sternum,  .              .             .                2  " 

"      the  latter  to  the  pubis,                .              .  .              .              .         6:^  " 

With  regard  to  the  transverse  measurement  he  found  as  follows  : 

From  the  top  of  one  shoulder  to  the  other  (bisacromial  or  transverse 

diameter  of  the  thorax),  .....  4|  inches. 

From  the  sternum  to  the  spine  (antero-posterior  diameter),  •  .  3|       " 

"      ilium  to  ilium  (transverse  diameter  of  the  pelvis),  .  3         " 

"      one  femoral  tuberosity  to  the  other,       .  .  .  .  3§       " 

We  shall  examine  hereafter  the  dimensions  of  the  head. 

Fortunately,  these  diameters  are  reducible ;  thus,  the  bis-acromial  in  particu- 
lar, which  presents  four  and  three-quarter  inches,  may  be  reduced  to  three  and 
three-quarter  inches,  by  compression. 


218  GENERATION. 

ARTICLE    II. 

HEAD    OF   THE    FCETUS   AT   TERM. 

The  head  of  tlie  foetus  merits  the  particular  attention  of  the  accoucheur,  as 
being  really  the  most  voluminous  and  least  compressible  part  of  the  child.  It  is, 
therefore,  highly  important  to  ascertain  whether  its  several  diameters  are  propor- 
tional to  those  we  have  heretofore  studied  in  the  pelvis.  The  head  is  likewise, 
in  the  majority  of  cases,  the  part  which  presents  during  labor;  consequently,  it 
is  very  necessary  that  we  should  be  fully  acquainted  with  all  its  characters,  in 
order  to  recognize  them  at  this  period. 

The  foetal  head,  considered  as  a  whole,  is  ovoidal  in  form,  the  larger  extremity 
being  posterior,  and  the  smaller  anterior;  as,  in  the  adult,  it  is  composed  of  the 
cranium  and  face;  but  as  the  latter  does  not  claim  a  particular  notice,  we  refer, 
for  a  knowledge  of  its  different  parts,  to  the  works  on  anatomy.  Several  bones 
enter  into  the  formation  of  the  cranium  ;  they  are — 

^he  frontal. — A  symmetrical  bone,  forming  the  forehead,  as  well  as  the  supe- 
rior-anterior part  of  the  face.     It  is  divided  in  the  foetus  into  two  portions. 

The  two  parietal. — One  upon  the  right,  the  other  on  the  left  side,  meeting  at 
the  median  line  :  they  are  situated  upon  the  superior  latei'al  parts  of  the  head, 
and  concur  to  form  the  vault  of  the  cranium. 

The  occipital. — A  symmetrical  bone,  constituting  the  posterior  part  of  the  skull, 
as  also  a  portion  of  its  base. 

The  temporal. — Two  bones,  placed,  one  on  the  right,  and  the  other  on  the  left 
side,  below  and  beneath  the  parietal,  completing  the  lateral  portions  of  the 
cranium,  and  contributing  to  the  formation  of  its  base ;  lastly,  the  sp)henoid  and 
the  ethmoid,  which  belong  exclusively  to  the  base.  These  bones  are  not  united  to 
each  other  at  birth  by  serrated  articulations,  as  they  are  in  the  adult  (^immovable 
st/nartlirosis),  but  are  separated,  those  of  the  vault  especially,  by  membranous 
intervals,  of  greater  or  less  extent,  according  to  the  degree  of  ossification.  The 
intervals  have  received  the  name  oi  sutures,  ov  fontanelles. 

This  arrangement  of  the  vault  of  the  cranium  has  several  advantages.  It 
facilitates  the  development  of  the  brain,  and  what  is  hardly  less  important  in  the 
view  of  the  accoucheur,  it  allows  of  a  certain  reduction  of  the  diameters  of  the 
head.  When  the  latter  is  compressed  forcibly,  the  margins  of  the  bones  ap- 
proach each  other  and  may  even  overlap. 

The  extent  of  this  overlapping  is  liable  to  be  thought  greater  than  it  really  is, 
for,  as  M.  Malgaigne  remarks,  if  we  examine  the  matter  closclj',  we  shall  find 
that  the  membrane  interposed  between  the  parietal  bones  is  too  firm  to  be  drawn 
out,  and  too  narrow  to  permit  a  notable  overriding;  and  further,  that  it  usually 
maintains  these  two  bones  so  close  togctlier,  that  the  superior  margin  of  one  laps 
over  the  other,  leaving  even  on  the  dried  skull  a  true  normal  crossing.  Some  of 
those  sutures,  or  fontanelles,  are  highly  important  in  an  obstetrical  sense,  and  we 
shall  next  proceed  to  their  consideration. 


OF    THE    FCETUS.  £19 

Tlie  Sagittal  Suture. — This  great  or  antero-posterior  suture  extends  from  the 
root  of  the  nose  to  the  superior  angle  of  the  occipital  bone ;  being  formed  in 
front  by  the  interval  that  divides  the  frontal  bone  into  two  halves,  and  in  the 
middle,  and  posteriorly,  by  that  between  the  parietals.  At  the  superior  and  in- 
ternal angle,  formed  by  the  two  portions  of  the  frontal  bone,  this  suture  is  joined 
at  the  sides  by  the  tvro  fronto-parktal  or  transverse  (coronal)  sutures,  which  are 
formed  by  the  space  existing  betwixt  the  superior  border  of  the  frontal  and  the 
anterior  margin  of  the  parietal  bones,  and  crossing  the  former  suture  nearly  at 
right  angles. 

Having  arrived  at  the  superior  angle  of  the  os  occipitis,  it  seems  to  bifurcate, 
and  give  rise  to  two  oblique  lateral  sutures  formed  by  the  posterior  borders  of  the 
parietal  bones,  and  the  superior  one  of  the  occipital.  These  latter  are  called  the 
lamhdoidal  sutures,  probably  from  their  resemblance  to  the  Greek  capital  A 
(lambda').  Just  at  the  points  where  the  fronto-parietal  and  the  lambdoid  sutures 
join  the  sagittal  one,  two  membranous  spaces,  much  larger  than  those  just  de- 
scribed, are  found  to  exist,  which  have  received  the  name  of  the  fontanelles. 

The  great  or  anterior  fontancJle  is  the  one  formed  by  the  junction  of  the  two 
transverse  sutures  with  the  sagittal.  It  is  also  called,  from  the  fact  of  its  corre- 
sponding with  the  bregma,  the  hregmatic  fontanelle  ;  in  general,  it  presents  an 
extensive  surface,  bounded  by  four  bony  angles,  produced  by  the  lateral  sutures 
leaving  it  nearly  at  right  angles.  It  is  lozenge-shaped,  and  is  usually  much  more 
prolonged  into  the  frontal  than  between  the  parietal  bones.  Sometimes  even, 
according  to  M.  Gerdy,  Jun.,  it  scarcely  ceases  short  of  the  nose,  the  margins  of 
the  coronal  suture  being  parted  throughout  their  whole  extent  by  an  interval 
which  gradually  diminishes  from  above  downwards,  being  only  about  one  or  two 
lines  wide  toward  the  root  of  the  nose.  It  is  not  at  all  uncommon  to  find  at  the 
lower  part  of  this  suture  a  rounded  or  oval  membranous  space,  varying  from  three 
to  seven  lines  in  its  diameter. 

The  posterior  or  occipital  fontanelle  is  formed  by  the  union  of  the  two  lamb- 
doid sutures  with  the  termination  of  the  sagittal  suture ;  it  is  smaller  than  the 
preceding,  and  of  a  triangular  form,  being  bounded  by  three  bony  angles.  The 
lateral  sutures  leave  it  at  an  acute  angle.  The  bony  angles  are  generally  found 
in  contact,  no  membranous  interval  being  left  between  them.  Sometimes  the  two 
portions  of  the  os  occipitis  are  not  fused  into  each  other  at  birth,  and  in  such 
cases  a  median  suture  exists,  which  separates  them,  and  terminates  in  the  pos- 
terior fontanelle.  The  latter  has  then  a  lozenge  shape,  and  is  subtended  by  four 
o.sseous  angles,  and  can  only  be  distinguished  from  the  anterior  by  the  obliquity 
of  the  lambdoidal  sutures.  The  opjwsite  condition  is  observed  at  times,  the 
triangular  space  known  as  the  posterior  fontanelle  not  existing  at  all,  because  the 
projecting  angle  of  the  occiput  then  fits  in  and  fills  up  the  entering  one  formed 
by  the  parietal  bones ;  still  the  convergence  of  the  three  sutures,  and  the  promi- 
nence of  the  bony  margins  which  overlap  each  other,  will  aid  the  diagnosis 
(Malgaigne) ;  for  when  the  head  is  engaged  in  the  excavation,  and  has  become 
strongly  compressed,  the  superior  angle  of  the  occipital  bone  is  completely  con- 
cealed by  the  internal  or  supero-posterior  angles  of  the  parietals ;  and  if  the  touch 


220 


GENERATION. 


is  resorted  to  under  such  circumstances,  the  finger  can  only  recognize  the  position 
by  detecting  the  little  hollow  formed  by  the  depressed  occipital  angle.  Of  course, 
particular  attention  must  be  given  in  this  case  to  the  oblique  direction  of  the 
lambdoidal  sutures. 

The  not  unfrequent  existence  of  spaces  upon  the  cranium,  where  the  ossifica- 
tion is  less  advanced  than  usual,  is  another  source  of  error.  For  this  defective 
ossification  is  substituted  a  membranous  expansion,  which  might  be  mistaken  for 
a  fontanelle. 

Such  an  error  might  the  more  readily  have  occurred  in  the  four  cases  of  this 
kind  which  I  have  had  an  opportunity  of  observing,  from  the  fact  of  the  acci- 
dental fontanelle  being  situated  just  in  the  course  of  the  sagittal  suture,  about 
equi-distant  from  the  anterior  and  the  posterior  ones;  and  as  this  point  is  pre- 
cisely where  the  finger  first  falls,  in  practising  the  touch,  we  might  mistake  it  for 
a  fontanelle.  But,  by  a  little  attention,  it  will  always  be  easy  to  avoid  this  error, 
by  ascertaining  that  no  lateral  sutures  pass  off  from  this  membranous  interval. 

There  yet  remain  some  other  sutures,  and  some  other  fontanelles  on  the  infe- 
rior lateral  parts  of  the  cranium ;  but  as  they  are  devoid  of  interest  we  shall  not 
describe  them. 

Diameters  of  the  Head. — The  terra  diameter  has  been  applied  to  certain  ficti- 
tious linos,  which  traverse  the  head  in  a  determinate  direction.  To  avoid  over- 
loading the  memories  of  students,  we  shall  not  multiply  their  number  as  some 
have  done ;  but,  following  the  example  of  M.  Velpeau,  shall  describe  only  seven 
at  first,  as  it  will  be  very  easy  to  supply  the  deficiency  hereafter  in  treating  of  the 
mechanism  of  labor. 

Seven  diameters,  then,  may  be  distinguished  for  the  foetal  head,  which  we 
divide,  in  order  to  facilitate  their  study,  into  the  antero-posterior,  the  transverse, 
and  the  vertical. 

1st.  The  antero-posterior  diameters  are  :  the  occipito-mental,  a  h  (Fig.  Gl), 

Fi-.  G2. 


■extending  from  the  posterior  fontanelle  to  the  chin ;  this  is  the  longest  of  all, 
being  five  and  a  quarter  inches.  The  occipito-frontal,  d  e,  which  extends  from 
the  occipital  protuberance  to  the  frontal  boss  (also  called  the  antero-posterior 
diameter)  :  it  measures  four  and  a  quarter  to  four  and  a  half  inches.  The  sub- 
occipito-bregmatic,  c  /,  extends  from  the  middle  of  the  space  between  the  fora- 
men magnum  and  the  occipital  protuberance  (to  the  anterior  fontanelle. —  Transl.), 
and  is  three  and  three-quarter  inches. 


OF    THE    FCETUS.  221 

2d.  The  transverse  diameters  are  two  in  number :  one,  the  bi-parietal,  a  b 
(Fis.  62),  goes  from  one  parietal  protuberance  to  the  other;  it  is  from  three  and 
a  half  to  three  and  three-quarters  inches  long.  The  other,  the  bi-temporal,  c  d, 
passes  from  the  root  of  the  zygomatic  process  on  one  side  to  the  same  point  oppo- 
site.    It  is  two  and  three-quarters  to  three  inches  long. 

3d.  Lastly,  there  are  two  vertical  diameters :  first,  the  vertical  diameter,  pro- 
perly so  called,  or  the  trachelo-hregmatic,  i  g,  traverses  the  head  perpendicularly, 
passing  from  the  most  elevated  point  of  the  vertex  to  the  anterior  part  of  the 
occipital  foramen.'  It  is  three  and  three-quarter  inches  long.  Professor  Moreau 
points  out  another  diameter,  which  he  calls  the  cervico-bregmatic,  c  h  (Fig.  61); 
this  leaves  the  preceding  somewhat  obliquely,  and  runs  from  the  anterior  part  of 
the  occipital  foramen  to  the  anterior  fontanelle ;  it  is  three  and  three-quarter 
inches  in  length;  the  second,  iha  fronio-mental,  or  the  facial,  d  a,  extends  from 
the  frontal  boss  to  the  point  of  the  chin.     This  is  three  inches. 

Circumferences. — A  circumference  has  been  assigned  to  each  of  the  above- 
mentioned  diameters,  since  it  is  very  easy  to  describe  from  the  middle  of  every 
one  of  them,  as  a  centre,  a  circle  whose  radius  is  equal  to  one-half  of  the  diameter, 
and  whose  circumference  shall  pass  through  the  two  extremities  of  the  latter. 

As  a  matter  of  course,  the  greatest  circumference  of  the  head  corresponds  with 
the  occipito-raental  diameter,  and  passing  at  the  same  time  obliquely  over  the 
sides  of  the  face  and  through  the  extremities  of  the  diameter,  has  a  nearly  hori- 
zontal direction. 

Most  authors  describe  it  as  dividing  the  head  into  two  equal  lateral  halves, — 
a  mode  of  regarding  it,  which,  as  M.  Jacquemier  judiciously  remarks,  is  devoid 
of  meaning  as  applied  to  obstetrical  practice. 

The  occipito-frontal  periphery,  agreeing  with  the  diameter  of  the  same  name, 
runs  horizontally,  a  little  below  the  extremities  of  the  transverse  diameter,  and 
separates  the  vault  from  the  base.  The  sub-oecipito-bregmatic  circumference 
passes  through  the  extremities  of  both  the  occipito-bregmatic  and  the  bi-parietal 
diameters,  being  thus  common  to  both. 

The  two  latter  are  the  most  important  of  all,  because  they  successively  come 
into  relation  with  the  parietes  of  the  pelvis  in  the  progress  of  natural  labor. 

The  circumferences  belonging  to  the  other  diameters  scarcely  offer  any  interest, 
and  we  shall,  therefore,  merely  mention  them  in  passing ;  in  number  they  equal 
the  diameters. 

The  fronto-mental  circumference,  however,  should  be  noticed  as  passing  over 
the  forehead,  cheeks,  and  chin  :  being  also  called,  on  that  account,  the  facial 
circumference. 

The  diameters  just  described,  although  but  slightly  reducible  in  their  dimen- 
sions, are  not  absolutely  invariable.  Thus  it  is  only  necessary  to  witness  a  few 
difficult  labors  to  become  satisfied,  that  in  such  cases,  the  head  is  most  frequently 
elongated  in  the  direction  of  the  occipito-mental  diameter,  and  flattened  in  its 
transverse  one.  And  we  further  learn,  from  the  experiments  of  Baudelocque, 
that  the  bi-parietal  diameter  (see  art.  Forceps)  may  be  reduced  one-fourth,  or 
one-third  of  an  inch,  by  the  aid  of  instruments ;  indeed,  we  have  even  known 


222 


GENERATION. 


this  diameter  to  be  diminished  much  more  than  that  under  the  efforts  of  the 
womb  alone,  without  any  accident  occurring  to  the  child. 

Independently  of  those  variations  in  length  of  the  diameters  of  the  head  in 
individual  cases,  which  it  is  impossible  to  foresee,  there  is  one  which  is  almost 
uniform  for  each  sex,  and  of  importance  to  be  acquainted  with.  The  head  of 
the  male  foetus  is  generally  larger  than  that  of  the  female  ;  the  difference,  accord- 
ing to  Clark,  being  about  the  one-twenty-eighth  or  the  one-thirtieth.  This  dif- 
ference exerts  a  notable  influence  upon  the  duration  of  labor  even  in  well-formed 
women,  and  may  consequently  have  an  injurious  effect  upon  the  health  of  the 
mother,  and  upon  both  the  life  and  health  of  the  foetus. 

Thus  it  is  shown  by  the  researches  of  Dr.  Simpson  :  1.  That  the  majority  of 
the  children  which  die  during  labor  are  males ;  the  proportion  of  still-born  boys 
to  still-born  girls  being  as  151  :  100.  2.  That  of  children  born  living,  there  are 
more  boys  than  girls  presenting  some  morbid  condition,  or  some  lesion  produced 
during  labor,  and  consequently  more  likely  to  succumb  within  the  first  weeks  of 
their  existence.  3.  That  of  the  mothers  who  die  during  labor,  or  in  consequence 
of  it,  the  majority  have  given  birth  to  boys. 

It  will  be  readily  understood  that  the  sex  of  the  child  will  have  a  still  greater 
influence  upon  the  result  of  the  labor  where  the  pelvis  is  slightly  contracted ;  and 
that  with  the  same  diameters,  the  life  of  a  male  foetus  would  be  often  compro- 
mised, when  a  girl  might  pass  with  little  difiiculty  and  no  danger. 

AYe  present,  in  the  following  table,  the  diameters  of  the  foetal  head,  as  also 
those  of  the  pelvis,  before  described ;  hoping  that,  when  thus  collected,  their 
study  will  be  rendered  more  easy : 


Diameters  of  the  pelvis. 
(Ill  inclies.) 

Anteroposterior. 

Transverse. 

Oblique. 

Sacro-cotyloiJ. 

Superior  strait,    .     .     . 
Inferior  strait,     ,     .     . 
Excavation,   .... 

4i 

4i  to  4| 

4|  to  5g 

4i 

4i  to  4^ 

4  to4| 

U               11 

FCETAL  HEAD. 

C  Occipito-mental, 

5^           inches 

Longitudinal  diameters,     . 

.     J.  Occipito-frontal, 

4^               do. 

Sub-occipito-bregmatic, 

3|               do. 

Transverse         do. 

f  Bi-parietal, 
1^  Bi-temporal, 

3^  to  3|     do. 
3                 do. 

Vertical                do. 

f  Trachelo-bregmatic,  . 

3i  to  3|     do. 

(  Fronto-mental,  . 

3                 do. 

The  fundamental  principles  of  midwifery  are  deduced  from  the  correspondence 
between  the  foetal  dimensions  and  those  of  the  pelvis.  It  happens,  in  fact,  that 
the  child  at  term  can  only  clear  the  pelvic  canal  by  presenting  one  end  of  its 
long  diameter;  that,  whichever  extremity  this  may  be,  the  delivery  will  still 
remain  impossible  if  the  head  should  present  in  such  a  manner  as  to  have  its 
occipito-mental  diameter  parallel  to  those  at  the  inferior  strait;  that,  conse- 


OF    THE    FCETUS. 


223 


quentlj,  the  occiput  must  always  engage  before  the  chin,  or  vice  versa ;  and, 
lastly,  that  the  most  favorable  position  of  the  head,  requires  the  latter  to  be 
stron^-ly  flexed  upon  the  trunk,  so  that  its  smallest  diameter  (the  sub-occipito- 
bregniatic)  shall  be  parallel  to  the  plane  of  the  strait ;  and  that  to  be  in  its 
most  favorable  relation  with  the  pelvis,  the  occiput  must  correspond  with  one  of 
the  extremities  of  an  oblique  diameter. 

The  articulation  of  the  head,  with  the  vertebral  column  and  the  movements  it 
permits,  should  also  be  carefully  studied  :  thus,  the  occiput  is  connected  to  the 
atlas  by  a  close  union,  which  only  admits  the  motions  of  flexion  and  extension, 
which  in  the  foetus  are  flir  more  extensive  than  in  the  adult ;  the  atloido-axoid 
articulation,  on  the  contrary,  being  ginglymoid,  only  permits  a  rotation,  which  is 
limited  to  the  fourth  of  a  circle.  Whence  the  conclusion  is  manifest,  that  when- 
ever the  head  is  caused  to  rotate — the  body  being  fixed — great  care  must  be 
exei-cised  not  to  pass  the  limits  indicated ;  for  generally  the  foetus  would  thereby 
suffer  a  mortal  lesion.  We  say  generally,  not  always,  because  two  cases  cited  by 
Prof.  Paul  Dubois,  evidently  prove  that  children  may  not  only  survive  this  acci- 
dent, but  even  seem  to  experience  no  bad  effects  whatever  from  it. 

The  great  laxity  of  the  articular  ligaments  in  the  infant  can  alone  explain  the 
little  danger  attending  an  occurrence  which  would  prove  so  disastrous  in  the 
adult.  Finally,  the  natural  situation  of  the  head  is  such  in  the  new-born  child, 
that  the  chin  descends  much  lower  than  the  occiput,  and  the  axis  of  the  trunk 
traverses  the  cranium  obliquely  from  base  to  summit,  and  from  before  backwards, 
passing  a  little  in  front  of  the  posterior  fontanelle. 

AKTICLE   III. 


POSITION    AND   ATTITUDE    OF   THE    FCETUS. 


The  foetus  lies  curved  on  its  anterior  plane 
within  the  bag  formed  by  the  membranes  ; 
usually,  the  head  is  somewhat  flexed,  the 
chin  resting  on  the  anterior  superior  part  of 
the  breast;  the  neck  is  so  short  that  a  slight 
degree  of  flexion  will,  says  M.  Dubois,  pro- 
duce this  effect;  the  feet  are  bent  up  in  front 
of  the  legs — the  latter  strongly  flexed  on  the 
thighs,  and  these  again  are  applied  to  the 
anterior  surface  of  the  abdomen  ;  the  knees 
are  separated  from  each  other,  but  the  heels 
lie  close  together  on  the  back  part  of  the 
thighs;  the  arms  are  placed  on  the  sides  of 
the  thorax;  the  forearms  are  flexed  and 
thrown  across  the  sternum,  so  as  to  receive, 
as  it  were,  the  chin  between  the  hands. 
The  foetus,  thus  folded  on  itself,  constitutes 
a  nearly  ovoidal  mass ;  the  longest  diameter 
of  which  is  about  eleven  inches,  having  its 


Fi-.  63. 


The  usual  position  of  the  child  in  the  worab. 


224  GENERATION. 

larger  extremity  represented  by  the  breech,  which  is  turned  towards  the  fundus 
uteri,  while  the  smaller,  formed  by  the  head,  is  directed  downwards.  Now,  it  is 
evident  that  this  constrained  position  could  not  have  been  produced  by  the  mere 
pressure  of  the  uterine  walls  on  the  child,  since  the  latter  is  in  a  cavity  much 
larger  than  its  whole  volume ;  hence,  it  must  be  referred  to  the  individual  itself. 

The  dependent  position  of  the  head  at  term  is  so  common,  that  we  are  natu- 
rally led  to  inquire  why  such  should  be  the  case  ?  Formerly,  it  was  supposed  that, 
after  having  reached  the  uterus,  the  head  occupied  the  fundus  for  the  first  seven 
months  of  gestation,  and  the  pelvic  extremity  its  inferior  part ;  but  that  towards 
the  expiration  of  this  period,  the  foetus  reversed  its  position ;  the  head  approach- 
ing the  orifice,  and  the  breech  going  above. 

This  was  the  received  doctrine  until  the  arguments  of  Dclamotte,  Smellie,  and 
more  especially  of  Baudelocque,  completely  subverted  it;  and  since  then,  it  has 
been  generally  admitted  that  the  foetus,  suspended,  so  to  speak,  in  the  amniotic 
fluid,  by  the  umbilical  cord,  would  naturally  observe  the  law  of  gravity;  that  is, 
the  head  being  the  heaviest  part  would  descend.  This  explanation  was  almost 
universally  adopted,  when  M.  Dubois,  after  re-examining  the  question,  proposed 
another  theory.  He  urged  the  following  objections  (whose  value  we  fully  acknow- 
ledge) against  the  influence  of  specific  gravity,  to  which  the  great  frequency  of 
vertex  presentations  had  been  so  uniformly  attributed,  viz.  :  1.  If  a  child  be 
plunged  into  a  considerable  quantity  of  any  liquid,  contained  in  a  bathing-tub, 
for  instance,  so  that  its  descent  will  be  very  slow,  in  order  to  afi"ord  the  head  suf- 
ficient time  to  exert  its  superiority  in  weight,  we  shall  find  all  parts  of  the  foetus 
to  descend  with  an  equal  rapidity,  and  consequently,  either  the  back  or  one 
shoulder  will  first  reach  the  bottom  of  the  tub.  This  result,  which  is  contrary 
to  the  general  belief,  is  more  in  accordance  with  what  is  learned  from  an  atten- 
tive examination  of  the  foetal  structure;  indeed,  when  a  comparison  is  made, 
between  the  volume  of  the  cephalic  and  the  pelvic  halves  of  the  foetus,  it  would 
naturally  appear  that  their  weight  must  be  nearly  balanced;  the  cranial  cavity, 
it  is  true,  contains  a  well-developed  brain,  but  the  abdomen  encloses  the  liver, 
which  is  no  less  so,  as  also  the  intestines  and  bladder,  together  with  the  meconium 
and  the  urine  accumulated  therein  during  pregnancy;  2.  It  is  really  impossible 
to  believe  that  the  foetus  is  suspended  by  the  cord  alone,  except  during  the  early 
stages,  for  even  at  the  third  month  the  cord  is  longer  than  the  greatest  diameter 
of  the  uterine  cavity,  and  therefore  its  insertion  near  the  pelvic  extremity  can  in 
nowise  contribute  to  the  more  frc(|uent  presentation  of  the  head ;  3.  Besides, 
those  women  who  maintain  the  horizontal  position  during  gestation  on  account  of 
ill  health,  are  not  the  less  likely  to  exhibit  the  same  phenomenon  ;  4.  If  the  laws 
of  gravity  alone  determined  the  position,  the  head  being  more  voluminous  rela- 
tively to  the  trunk,  during  the  early  months,  the  foetus  should  present,  in  cases 
of  abortion,  by  the  cephalic  extremity  still  more  frequently  than  at  term;  but 
observation  establishes  the  contrary;  5.  Lastly,  in  animals,  the  lowest  part  of  the 
organ  does  not  correspond  with  the  neck,  but  rather  to  the  fundus,  of  the  womb; 
nevertheless,  the  foetus  is  much  oftener  delivered  by  the  head  than  the  pelvic 
extremity. 


OF    THE     FCETUS.  225 

After  having  tried  to  combat  the  generally-received  opinion  by  the  objec- 
tions just  given,  M.  Dubois  endeavors  to  prove  that  the  vertex  presentation  is 

a  consequence  of  the  instinctive  will  of  the  foetus  itself. The  child,  in 

its  mother's  womb,  has  the  faculties  of  perception  and  motion ;  for  the  regular 
and  nearly  constant  succession  of  the  perception  of  impressions,  and  the  move- 
ments which  follow,  sufficiently  indicate  the  same  connection  in  the  foetus,  be- 
tween these  two  functions,  that  should  exist  after  birth. 

Now,  the  objects  of  these  foetal  movements  are  partly  certain,  partly  presump- 
tive; consequently,  they  may  be  regarded  as  really  instinctive  determinations; 
again,  it  is  in  consequence  of  such  a  determination  that  the  head  in  the  mam- 
miferse  is  usually  found  at  that  part  of  the  uterus  nearest  to  the  pelvic  outlet. 

We  frankly  confess  that  M.  Dubois  seems  to  us  more  skilful  in  destroying  than 
in  building  up;  and  though  the  reasons  by  which  he  combats  the  doctrine 
hitherto  received  appear  very  strong,  yet  those  whereon  he  founds  his  opinion 
are  not  fully  convincing.  He  is  entitled  to  credit,  however,  for  having  sought, 
in  a  higher  order  of  ideas,  the  explanation  of  a  singular  fact,  which  does  not 
seem,  in  the  present  state  of  our  science,  capable  of  elucidation  by  the  material 
reasons  heretofore  given. 

If  we  might  be  permitted  to  hazard  an  opinion,  after  so  many  others,  we  should 
unhesitatingly  say  they  have  erred  by  seeking  only  in  the  foetus,  its  form  and 
structure,  for  the  cause  of  the  various  positions  which  it  assumes  in  the  uterine 
cavity. 

Already  have  several  authors  endeavored  to  account  for  the  rarity  of  trunk 
presentations,  by  the  vertical,  or  the  nearly  vertical  direction  of  the  long  diameter 
of  the  uterus,  which  would  naturally  force  the  greatest  foetal  diameter  in  the  same 
line ;  for  instance,  the  cause  of  trunk  presentations,  says  Wigand,  must  be  refer- 
red less  to  the  foetus  itself  than  to  a  change  in  the  ordinary  elliptic  form  of  the 
uterus.  Now,  by  advancing  a  step  further  in  the  path  they  have  marked  out, 
may  we  not  find  a  satisfactory  explanation  of  the  great  frequency  of  vertex  pre- 
sentations in  the  form  of  the  uterus,  and  especially  in  its  mode  of  development 
at  the  different  periods  of  pregnancy  ?  For,  when  we  reflect  that  the  uterus 
being  developed  during  the  first  six  months  at  the  expense  of  its  fundus,  is  spread 
out  superiorly,  but,  on  the  contrary,  is  much  contracted  below,  does  it  not  be- 
come evident  that  the  pelvic  extremity,  which,  from  the  folded  condition  of  the 
lower  limbs,  is  much  more  voluminous  than  the  head,  must  naturally  lie  in  the 
largest  cavity,  that  is,  towards  the  fundus ;  and,  consequently,  that  the  cranium 
will  descend  to  the  cervix  ?  There  can  be  no  doubt  that  the  inferior  part  spreads 
out  in  the  last  three  months  nearly  as  much  as  the  fundus;  but,  then,  the  foetal 
vertical  diameter  is  too  long  to  permit  it  to  traverse  the  transverse  diameter  of 
the  uterus ;  and  hence,  with  some  few  exceptions,  the  child  is  forcibly  retained 
in  the  position  it  first  assumed. 

Finally,  can  we  not  explain  by  this  circumstance  the  position  of  twins,  in  cases 
of  double  pregnancy,  where  it  frequently  happens  that  one  foetus  presents  by  the 
pelvic  extremity,  and  one  by  the  head  ?  In  a  word,  the  child,  shut  up  in  its 
close  sac,  and  constantly  subjected  to  movement,  must  assume,  not  instinctively 

15 


226  GENERATION. 

but  meclianically,  sucli  a  position  as  will  bring  its  largest  parts  into  correspond- 
ence with  the  most  spacious  portions  of  the  organ. 


ARTICLE   IV. 

FUNCTIONS   OF   THE   FCETUS. 

The  functions  of  the  child,  while  it  remains  in  the  uterine  cavity,  that  require 
our  particular  attention,  are  its  nutrition,  respiration,  and  circulation. 

§  1.  Op  Nutrition. 

Few  questions  in  physiology  have  given  rise  to  more  discussion  than  this  of 
foetal  nutrition.  However,  it  is  universally  admitted  that  the  nutritive  materials 
are  furnished  by  the  mother's  body ;  but  authors  are  not  as  unanimous  in  regard 
to  the  mode  of  their  introduction  into  the  interior  of  the  product  of  conception. 
For  instance,  some  think  that  the  liquids  secreted  by  the  internal  uterine  sur- 
face transude  through  the  membranes,  so  as  to  reach  the  amniotic  cavity,  to  be 
there  taken  up  by  the  foetus.  Others  regard  the  maternal  placenta  as  designed 
to  supply  the  child  with  nutritive  matter,  and  find  in  the  umbilical  cord  the  only 
means  of  conveying  it. 

It  is  necessary  to  admit  at  the  outset,  that  there  can  be  no  discussion  of  the 
question  until  after  the  placenta  is  developed,  or,  at  least,  until  after  connection 
is  established  between  the  mother  and  child  by  means  of  the  allantois.  Now,  as 
nothing  of  the  kind  exists  in  the  early  periods  of  pregnancy,  it  must  be  acknow- 
ledged that  during  this  time,  at  least,  the  maternal  fluids  must  reach  the  foetus 
by  endosmosis  through  the  membranes  of  the  ovum. 

The  nutritive  matters  cannot  all  be  derived  from  the  same  source  at  the 
various  periods  of  gestation.  Thus,  when  the  ovule  quits  the  ovarian  vesicle,  it 
carries  with  it  a  portion  of  the  granules  which  formed  the  proligerous  disk ; 
and  it  is  probable  that  these  may  subserve  its  nutrition  during  its  progress 
through  the  first  half  of  the  Fallopian  tube.  In  its  passage  through  the  other 
half,  an  albuminous  matter  secreted  by  the  walls  of  the  tube  envelopes  the  ovule, 
and  probably  also  penetrates  through  the  vitelline  membrane. 

An-ived  in  the  uterine  cavity,  the  ovule  comes  in  contact,  at  all  points,  with 
the  mucous  membrane  of  the  uterus.  The  villi  of  the  chorion  undergo  a  con- 
siderable development,  and  until  the  placenta  is  formed,  are  all  capable  of  im- 
bibing the  fluids  secreted  by  the  internal  surface  of  the  organ.  As  the  canal 
with  which  each  is  provided  opens  into  the  cavity  of  the  chorion,  they  are  won- 
derfully adapted  to  this  purpose ;  and  notwithstanding  the  closure  of  their  ex- 
tremities, the  uterine  secretions  pass  by  endosmosis  through  their  thin  walls; 
like  the  roots  of  a  tree,  they  serve  to  convey  the  nutritive  fluids  into  the  space 
separating  the  chorion  from  the  amnion.  These  fluids  are  in  fact  found  therein, 
where  they  constitute  what  we  have  described  as  the  reticulated  body  ;  they  also, 
probably,  furnish  the  fluid  of  the  vitellus.     From  thence,  the  nutritive  juices 


OF    THE    F(ETUS.  227 

transude  through  the  walls  of  the  amnion  into  its  cavity.  A  certain  portion  of 
them  is  conveyed  into  the  body  of  the  fojtus  through  the  canal  of  the  umbilical 
vesicle. 

But  as  soon  as  the  vascular  connections,  which,  as  we  have  learned,  are  esta- 
blished between  the  maternal  and  foetal  placentas,  begin  to  be  formed,  the  non- 
placental  villi  of  the  chorion  tend  gradually  to  waste  away;  the  development  of 
the  amnios  obliterates  the  cavity  which  separated  it  from  the  chorion,  and  along 
with  it  also  disappears  the  vitriform  body  and  the  umbilical  vesicle.  It  now 
becomes  a  question,  whether  the  nutritive  matters  supplied  by  the  mother  can 
penetrate  into  the  amniotic  cavity  through  the  two  membranes  of  the  ovum, 
without  collecting  to  an  appreciable  amount  during  the  passage  ?  Or,  on  the 
other  hand,  are  they  absorbed  by  the  vascular  radicles  of  the  foetal  placenta,  and 
introduced  into  the  body  of  the  embryo  by  means  of  the  umbilical  cord  'f 

The  partisans  of  the  former  opinion  have  endeavored  to  prove :  1,  that  the 
amniotic  fluid  is  derived  from  the  mother ;  2,  that  it  contains  nutritive  matter ; 
3,  that  it  may  enter  the  embryo  in  several  ways. 

A.  It  is  almost  certain  that  the  fluid  is  supplied  by  the  mother,  for  it  is  the 
more  abundant  as  the  child  is  less  developed,  and  its  quantity  diminishes  rela- 
tively to  the  foetus,  in  proportion  to  the  advancement  of  gestation.  Now,  the 
contrary  should  be  true,  were  it  a  product  of  the  foetus  itself.  Besides,  foreign 
matters  introduced  into  the  stomach  of  the  mother,  or  injected  into  her  veins, 
have  been  discovered  in  the  amniotic  cavity.  It  is  also  true,  that  they  have 
nearly  always  been  found  at  the  same  time  in  the  blood  of  the  embryo  and  in  the 
placenta.  So  that,  strictly  speaking,  it  is  diSicult  to  say  into  what  part  they 
were  first  distributed.  A'^ery  dissimilar  observations  having  reference  to  this 
subject  are  on  record.  Thus,  for  example,  in  the  case  of  an  embryo  of  five 
months,  the  mother  of  which  had  been  poisoned  by  sulphuric  acid,  Otto  found 
that  wherever  the  skin  had  come  in  contact  with  the  amniotic  fluid,  it  was  of  a 
reddish-brown  color,  and  as  hard  as  parchment.  On  the  other  hand,  in  the  case 
of  a  woman  four  months  pregnant,  who  had  been  poisoned  by  arsenic,  MM. 
Mareska  and  Lados  found,  by  analysis,  traces  of  the  poison  in  the  body  of  the 
foetus,  in  the  uterus,  and  in  the  placenta,  whilst  it  could  not  be  detected  in  the 
waters  of  the  amnion.  Mayer,  however,  injected  cyanide  of  potassium  into  the 
trachea  of  a  rabbit,  and  afterwards  discovered  it  in  the  amniotic  fluid,  the  pla- 
centa, and  the  organs  of  the  foetus. 

B.  The  amniotic  fluid  must  be  nutritive,  for  it  contains  albumen,  osmazome, 
and  some  salts;  in  fact,  young  calves  have  been  sustained  two  weeks  on  fresh 
amniotic  liquor.  Finally,  the  quantity  of  this  fluid,  and  more  especially  that  of 
the  animal  and  nutritive  substances  found  in  it,  is  much  diminished  towards  the 
end  of  pregnancy. 

c.  Supposing  it  to  be  furnished  by  the  mother,  and  to  possess  nutritive  pro- 
perties, it  remains  to  be  shown  how  it  is  enabled  to  enter  the  body  of  the  foetus. 
There  are  numerous  hypotheses  in  reference  to  this  point. 

The  liquor  amnii  may  reach  the  body  of  the  foetus  in  various  ways. 

1st.  By  cutaneous  absorption.     When  the  umbilical  vesicle  ceases  to  furnish 


228  GENERATION. 

nourishment  to  the  embryo,  the  skin  becomes  developed,  and,  very  probably, 
absorbs  the  surrounding  amniotic  liquid;  it  is  even  possible  that  the  lymphatic 
vessels,  which  are  highly  developed  in  the  foetus,  are  formed  as  a  consequence  of 
this  absorption,  just  as  bloodvessels  are  called  into  existence  by  the  circulation. 

Brugraans  proved  this  absorption  by  an  experiment :  thus,  after  having  ex- 
tracted several  living  embryos  of  animals  from  the  waters  of  the  amnios,  he 
noticed  that  the  cutaneous  lymphatics  were  filled,  and  that  those  of  the  intestines 
were  not  so ;  then  plunging  the  limbs,  previously  tied,  into  this  liquid,  he  found, 
after  the  lapse  of  some  time,  the  lymphatics  below  the  ligature  wore  filled  with 
lymph. 

The  epidermis  is  so  excessively  thin,  that  it  can  oflFer  no  obstacle  to  the  imbi- 
bition, and  the  liquor  amnii  itself  contains  a  large  proportion  of  water.  Again, 
the  sebaceous  matter  which  covers  the  fcetus  at  birth,  only  becomes  manifest  at 
an  advanced  stage  of  pregnancy;  and,  lastly,  this  absorption  has  been  directly 
proved  in  animals  both  by  experiments  and  dissection. 

2d.  By  the  tntesthud  canal.  Though  the  cutaneous  absorption  may  suffice  for 
the  nutrition  of  the  embryo,  as  is  sufficiently  proved  by  the  birth  of  monsters  and 
anencephalous  foetuses  with  closed  mouths,  nevertheless,  it  is  highly  probable 
that  the  child  makes  some  eff'orts  at  deglutition,  at  least  towards  the  termination 
of  pregnancy,  thereby  determining  the  introduction  of  fluids  into  the  intestinal 
canal.  Thus,  embryos  may  occasionally  be  observed  executing  motions  of  respi- 
ration with  their  jaws,  during  which  the  waters  would  necessarily  be  swallowed; 
indeed,  in  ova,  that  have  been  frozen  after  their  extraction  from  the  cow,  an  un- 
interrupted band  of  ice  has  been  found  extending  from  the  mouth  to  the  stomach. 
And  when  the  meconium  is  mixed  with  the  amniotic  liquid,  it  is  sometimes 
detected  in  the  throat,,pharynx,  and  stomach.  '  Lastly,  hair  is  occasionally  found 
there,  which  could  only  happen  as  a  result  of  deglutition. 

Besides  these  two  modes  of  absorption,  by  the  skin  and  the  intestinal  mucous 
membrane,  some  physiologists  have  supposed  this  fluid  might  be  taken  up  in 
other  ways ;  thus,  according  to  some,  the  mammary  glands  are  provided  with 
conduits  that  act  the  part  of  lymphatics,  absorbing  the  waters,  and  carrying  them 
to  the  thymus  gland,  to  be  there  elaborated.  Others  suppose  that  the  liquor 
amnii  may  enter  the  trachea  and  bronchia,  and  there  undergo  some  modification 
which  may  render  it  suitable  for  nutrition.  Lastly,  Lobstein  seems  to  think  it 
might  possibly  enter  through  the  genital  organs.  But  all  these  opinions  are 
merely  hypothetical. 

With  all  deference  to  their  ingenuity,  these  hypotheses  are  still  far  from  being 
satisfactory.  The  introduction  of  the  liquor  amnii  into  the  intestinal  canal  as  a 
regular  and  normal  occurrence,  is  by  no  means  proved  by  the  facts  cited  in  its 
support.  It  is,  indeed,  more  than  probable,  that  the  movements  of  deglutition 
which  the  child  has  been  seen  to  make,  were  really  respiratory  efi"orts  determined 
by  the  suspension  of  the  placental  respiration ;  also  that  the  icicles,  the  hairs,  and 
the  meconium,  found  in  the  stomach,  had  entered  it  but  a  short  time  before  the 
'death  of  the  child ;  ii)  short,  where  the  antecedent  death  of  the  mother,  the  com- 


OF    THE    F(ETUS.  229 

pression  of  the  cord  or  the  separation  of  the  placenta  had  begun  to  produce 
asphyxia. 

Supposing:  the  cutaneous  absorption  of  the  liquor  amnii  to  be  proved  by  the 
experiment  of  Brugmans,  it  would  still  seem  unequal  to  the  development  of  the 
foetus,  -which  must  have  some  additional  source  of  nutrition. 

Looking  beyond  the  membranes,  there  evidently  can  be  no  other  source  of 
supply  than  the  maternal  placenta,  and,  in  fact,  many  modern  authors  regard  the 
placental  circulation  as  the  principal  agent  in  the  nutrition  of  the  foetus.  It  is 
unnecessary  to  suppose  a  direct  communication  between  the  maternal  and  foetal 
vessels,  in  order  to  understand  how  that,  by  means  of  the  extensive  contact  exist- 
ing between  the  vascular  apparatus  of  the  two  placentas,  a  transudation  may  take 
place  of  the  more  fluid  parts  of  the  maternal  blood,  which  are  absorbed  and 
mingled  with  the  foetal  blood ;  also  that  this  transuded  fluid  being  charged  with 
oxygen  is  subservient  to  the  hfcmatosis  of  the  foetal  blood,  at  the  same  time  that 
it  supplies  it  with  nutritive  material.  (Van  Huevel.)  It  may,  perhaps,  be 
allowed,  that  all  of  the  villi  of  the  chorion,  in  the  midst  of  which  the  placenta  is 
developed,  may  not  be  applied  to  the  formation  of  the  radicles  of  the  umbilical 
vessels,  but  that  some  of  them  may  continue  to  exercise  their  primitive  functions, 
and  still  absorb  the  fluids  secreted  by  the  utricular  glands  of  the  utero-epichorial 
mucous  membrane. 

What  we  have  already  said  regarding  the  structure  of  the  chorial  villi  of  the 
placenta  lends  countenance  to  this  supposition ;  for  we  have  seen  (Fig.  55),  that 
beside  the  vascular  villi,  some  are  found  to  be  solid,  and  destitute  of  any  ramifi- 
cation of  the  umbilical  vessels,  although  still  adhering  by  their  pedicle,  and  com- 
municating with  a  larger  branch  of  the  villus.  This  fact  seems,  indeed,  to  have 
been  anticipated  by  some  authors ;  thus,  although  Eschricht  regarded  the  pla- 
centa proper  as  being  in  reality  the  respiratory  organ  of  the  foetus,  he  supposed 
that  the  utricular  glands  of  the  womb  secrete  a  fluid  designed  for  the  nourish- 
ment of  the  embryo,  which  fluid  is  taken  up  by  other  branches  of  the  umbilical 
vessels  than  those  by  which  the  placental  respiration  is  effected.  MM.  Prevost 
and  Morin  also  regard  the  placenta  as  the  organ  in  which  the  absorption  of  the 
plastic  matters  supplied  by  the  mother  is  accomplished  by  the  vessels  of  the 
foetus.  According  to  them,  this  fluid,  which  is  deposited  upon  the  internal  sur- 
face of  the  womb,  is  taken  up  by  the  vessels  of  the  cotyledons.  Thus,  in  the 
ruminantia,  if  the  ovum  with  its  cotyledons  be  extracted  from  the  womb  towards 
the  end  of  gestation,  by  which,  consequently,  the  foetal  and  maternal  placentas 
are  separated  from  each  other,  the  separation  being  easily  effected  without  lace- 
ration, a  whitish  fluid  is  discovered  in  the  uterine  caruncles,  and  a  similar  one 
can  be  expressed  from  the  vascular  brushes  of  the  cotyledons.  However  this  may 
be,  it  is  very  probable  that  the  nutritive  fluids  reach  the  foetus  through  the  um- 
bilical vessels  properly  so  called. 

When  mixed  with  the  foetal  blood,  the  nutritive  elements  supplied  by  the 
mother,  are,  like  the  chyle  in  the  adult,  devoted  to  the  development  of  the  organs. 
Lee  supposes,  however,  that  they  undergo  certain  changes,  first  in  the  liver,  and 
afterward  in  the  intestine.     When  thus  brought  by  the  umbilical  vein  into  the 


230  GENERATION. 

large  liver  of  the  foetus,  these  elements  experience  changes  which  result  in  the 
formation  of  a  new  albuminous  and  nutritive  compound,  which  is  poured  along 
with  the  bile  into  the  duodenum ;  there  the  mixture  is  separated  into  a  recre- 
mentitial  part,  which  is  taken  up  by  the  absorbents,  as  in  the  adult,  and  an 
excrementitial  part,  charged  with  carbon,  which  forms  the  meconium. 

In  fine,  until  the  placenta  is  formed,  the  nutritive  elements  reach  the  interior 
of  the  ovum  by  means  of  endosmosis ;  at  a  later  period  the  growth  of  the  foetus 
is  maintained  by  an  absorption  through  the  skin  of  some  of  the  nutritive  matters 
contained  in  the  liquor  amnii,  and  by  the  assimilation  of  those  which  the  radicles 
of  the  umbilical  vessels  take  up  in  the  placenta. 

§  2.  Respiration. 

Does  the  foetus  respire  in  the  amniotic  cavity  ? 

If  something  analogous  to  respiration  in  the  adult  be  sought  for  in  the  func- 
tions of  the  foetus,  this  question  will  doubtless  be  answered  negatively ;  because 
the  atmospheric  air,  having  no  access  to  it  whatever,  the  foetal  blood  could  not 
possibly  obtain  any  elements  from  it.  But  does  it,  therefore,  follow  that  the 
sanguineous  fluid  will  experience  no  similar  modification  at  any  part  of  the  cir- 
cuit ?     Most  physiologists  think  otherwise,  and  I  share  their  opinion. 

According  to  some,  the  liquor  amnii  is  the  modifying  agent  for  the  blood,  and 
Beclard  supposes  that  the  lungs  are  the  seat  of  such  changes,  the  amniotic  liquid 
reaching  them  through  the  air-passages.  Agreeably  to  M.  Geofi'roy  St.  Hilaire, 
the  whole  surface  of  the  child's  body  absorbs  air,  or  a  vivifying  gas,  like  insects, 
by  a  species  of  air-tubes,  or  by  minute  fissures  which  exist  on  the  lateral  parts  of 
the  neck  in  young  embryos.  The  resemblance  between  those  fissures  and  the 
branchial  apparatus  in  the  fish  has  given  rise  to  the  belief  of  an  analogous  func- 
tion; hence,  they  are  called  the  branchial  fissures. 

But,  says  BischoiF,  in  the  mammifera;  and  man,  these  arcs  never  have  an 
organization  justifying  in  the  least  the  supposition  of  their  being  intended  for 
respiration  :  they  never  have  internal  nor  external  branches;  nor  do  we  ever  see, 
as  in  the  hranchia,  vessels  distributed  either  on  their  surface  or  in  their  interior. 

Latterly,  M.  Serres  has  attempted  anew  to  explain  how  respiration  may  take 
place  in  the  embryo  before  the  placenta  is  fully  formed.  He  says  the  breathing 
apparatus  of  the  human  ovule  consists  of  the  chorion,  the  two  layers  of  the  de- 
cidua,  the  liquid  contained  between  the  latter,  and  of  a  particular  class  of  villi, 
called  by  him  the  branchial,  which,  after  having  traversed  the  reflected  decidua, 
come  into  contact  with  this  liquid.  On  the  one  hand,  the  reflected  decidua  is 
perforated  by  multitudes  of  foramina,  which  may  be  aptly  compared  to  those  on 
the  cribriform  plate  of  the  ethmoid  bone ;  and  on  the  other,  the  cliorial  villosities, 
the  branchial  villi,  entering  the  substance  of  this  membrane,  lodge  in  those 
openings,  and  thus  are  brought  into  immediate  apposition  with  the  liquid.  M. 
Serres  believes  that  this  arrangement  presents  all  tlio  conditions  of  a  branchial 
respiratory  apparatus ;  but  this  mode  of  respiration  only  lasts  during  the  first 
fifteen  or  twenty  days  of  the  intra-uterine  life ;  because,  as  the  embryo  is  deve- 


OF     THE     FCETUS.  231 

loped  and  grows,  one  part  of  the  villi  of  the  chorion  is  transformed  into  the  pla- 
centa, and  the  foetal  respiration  in  the  uterus  then  commences  the  second  time, 
as  the  placental  respiration.  Then  the  branchial  function  decreases,  the  appa- 
ratus atrophies  and  disappears ;  at  first,  the  branchial  villi  of  the  chorion  wither 
away ;  the  cavity  of  the  decidua  is  contracted ;  the  liquid  diminishes,  and  finally, 
the  two  laminas  of  the  decidua  being  brought  into  apposition,  unite  and  become 
confounded  with  each  other. 

This  hypothesis,  though  ingenious,  is  evidently  based  upon  badly-observed 
facts,  and  cannot  be  sustained  after  the  description  of  the  decidua  which  we  have 
given. 

After  the  allantois  is  developed,  the  villi  of  the  chorion,  which  have  then 
become  vascular,  are  in  immediate  contact  with  the  hypertrophied  vessels  of  the 
mucous  membrane,  and  from  this  moment  the  foetal  blood  derives  therefrom  the 
elements  necessary  to  hrematosis.  In  proportion  as  the  contact  becomes  more 
intimate  and  extensive,  the  organization  of  the  placenta  progresses,  and  soon 
forms  a  compact  mass,  which  is  the  seat  of  the  placental  respiration. 

In  fact,  this  body  is  formed  throughout  in  such  a  manner  as  to  establish  the 
greatest  possible  approximation  between  the  maternal  blood  and  that  of  the  em- 
bryo; and,  therefore,  whether  the  interlacement  we  have  described  from  the 
preparations  of  M.  Bonami  be  admitted,  or  the  disposition  pointed  out  by  Weber 
be  considered  as  an  ascertained  fact,  in  which  the  vascular  fasciculi  of  the  foetal 
placenta  dip  into  the  venous  sinuses  belonging  to  the  maternal  one;  in  either 
case,  we  say,  a  prolonged  contact  between  the  two  vascular  apparatuses  would 
necessarily  result.  And  this  mediate  union,  in  which  the  two  liquids  are  sepa- 
rated by  fixed  membranes,  establishes  between  the  foetal  and  the  maternal  blood 
the  same  relation  that  is  known  to  exist  in  the  lungs  of  the  adult,  betwixt  the 
venous  blood  and  the  atmospheric  air :  thus,  in  the  pulmonary  organs,  the  blood 
is  brought  within  the  influence  of  the  inspired  air ;  true,  there  is  none  of  the 
latter  in  the  after-birth,  but  the  maternal  vessels  are  found  there  in  great  abun- 
dance, whose  exceedingly  delicate  walls  remain  for  a  long  time  in  contact  with 
the  umbilical  radicles,  the  parietes  of  which  are  also  thin  and  transparent. 

Therefore,  if  nothing  but  thin,  transparent  membranes  divide  the  foetal  blood 
from  that  of  its  mother,  is  it  not  possible  for  the  first  to  communicate  some  of  its 
elements  to  the  second  ?  for,  does  not  the  air  act  through  the  walls  of  the  pulmonary 
vessels  on  the  blood  contained  therein  ?  And  further,  is  not  such  a  modification 
of  the  foetal  blood  in  the  placenta  sufficiently  proved  :  1st.  By  the  early  death  of 
the  child,  when  the  umbilical  cord  becomes  flattened  from  compression,  and  its 
circulation  thereby  arrested.  2d.  By  the  pathological  phenomena  of  asphyxia, 
which  are  always  revealed  by  the  autopsy  in  such  cases.  3d.  By  the  antago- 
nism known  to  exist  between  the  after-birth  and  the  lungs ;  in  fact,  the  new- 
born infant  may  dispense  with  the  pulmonary  respiration,  so  long  as  its  connection 
with  the  placenta  remains  uninterrupted,  and  this  communication  may  be  broken 
without  danger  as  soon  as  it  respires  through  the  lungs ;  if  it  breathes  freely,  the 
blood  no  longer  passes  along  the  cord,  and,  should  respiration  cease,  it  shortly 
flows  anew.     And  4th.  By  the  difi"erence  in  the  blood  circulating  in  the  umbili- 


232  GENERATION. 

cal  vein,  and  that  in  the  arteries, — a  distinction  not  very  manifest  upon  simple 
inspection,  but  wliicli  has  been  detected  by  physical  and  chemical  experiments. 
Now,  in  the  adult  pulmonary  respiration,  the  blood  not  only  absorbs  a  certain 
proportion  of  oxygen  from  the  air,  but  it  also  gives  off  some  carbonic  acid.  Thus 
far,  we  have  only  learned  that  the  foetal  blood  derives  from  the  placenta  a  vivify- 
ing principle ;  but  we  have  not  observed  the  separation  of  those  materials  from 
it,  which  may  be  unsuited  to  the  nutrition  of  the  child.  We  may  state,  how- 
ever, that  most  physiologists  believe  the  liver  is  destined  to  the  performance  of 
this  last  elaboration,  and  to  the  removal  of  its  superbundant  carbon  and  hydrogen, 
which  latter  are  employed  in  the  formation  of  the  bile,  and  contribute  to  the 
complete  development  of  the  organ.  "We  know,  in  fact,  the  growth  of  the  liver 
follows  that  of  the  placenta,  that  both  have  a  perfect  organization  at  the  same 
periods,  that  the  bile  is  a  highly  carbonized  fluid;  and  that  the  liver  has  a  similar 
chemical  composition. 

§  3.  Secretion. 

As  it  is  not  our  intention  to  treat  of  all  the  various  secretions  which  occur  in 
the  foetus,  we  shall  confine  our  remarks  to  those  of  the  bile,  meconium,  and 
urine. 

1.  Secretion  of  Bile. — The  liver  is  the  most  voluminous  of  all  the  foetal  organs. 
At  three  months  its  texture  is  soft  and  pulpy,  not  yet  having  the  granular  cha- 
racter visible  at  term  ;  the  gall-bladder  at  that  period  resembles  a  white  thread, 
its  inferior  extremity  being  the  largest,  and  its  cavity  exceedingly  contracted. 
At  five  months  the  volume  of  the  liver  is  much  greater,  the  texture  more  con- 
densed, and  the  gall-bladder  more  apparent;  the  secretion  of  bile  then  begins, 
and  continues  to  augment  thereafter  throughout  pregnancy.  We  have  just 
stated  what  appear  to  us  to  be  the  principal  elements  of  the  bile.  At  the  seventh 
month,  the  gall-bladder  is  filled  with  a  yellow  secretion,  and  a  considerable  quan- 
tity of  this  is  also  found  in  the  intestinal  canal. 

2.  Meconium. — During  the  early  periods  of  the  intra-uterine  life,  the  digestive 
canal  is  merely  moistened  by  a  little  fluid,  but  a  more  abundant  secretion  begins 
to  take  place  towards  the  third  month.  According  to  Lee,  the  stomach  then 
contains  a  clear,  acid,  and  non-albuminous  fluid ;  whilst  at  the  upper  part  of  the 
small  intestine  a  substance  similar  to  chyme  is  found,  consisting  of  pure  albumen, 
and  there  is  an  analogous  albuminous  liquid  in  the  biliary  duct.  The  meconium 
exists  in  the  small  intestine  only,  prior  to  the  fifth  month,  and  is  of  a  greenish- 
brown  color,  but  after  that  period  it  reaches  the  large  intestine,  becomes  of  a 
darker  hue,  and  finally  accumulates  in  the  rectum.  This  fluid  is  a  mixture  of 
bile  with  the  products  secreted  by  the  intestinal  mucous  membrane. 

3.  Urine. — The  urine  never  fills  the  bladder  entirely  in  the  human  embryo; 
now  as  the  kidneys  are  developed  early,  and  their  secretion  commences  at  once, 
the  urine  must  certainly  be  evacuated  by  some  outlet.  On  this  account,  certain 
enibryologists  have  supposed  that  the  bladder  communicated  originally  with  the 
allautois  by  means  of  the  urachus,  and  that  the  cavity  of  this  membrane  was  the 


OF    THE    FCETUS.  233 

ultimate  I'eservoir  of  the  urine.  However,  this  is  not  the  generally-received 
opinion,  for,  as  we  have  elsewhere  proved,  the  allantois  ceases  to  exist  in  the 
human  species  as  a  distinct  vesicle  long  before  the  development  of  the  kidneys ; 
and  the  urine  must  therefore  be  expelled  through  the  urethra  into  the  amniotic 
cavity. 

That  its  evacuation  is  necessary  is  proved  by  the  facts  already  cited,  in  which 
the  existence  of  an  imperforate  urethra  led  to  extreme  distension  and  even  rup- 
ture of  the  bladder. 

§  4.  Circulation. 

A.  The  foetal  vascular  apparatus  exhibits  certain  anatomical  peculiarities  that 
do  not  exist  in  the  adult,  and  which  must  be  noticed,  in  order  to  render  the 
account  of  the  circulation  comprehensible.  Now,  these  characteristics  evidently 
depend  on  the  absence  of  the  pulmonary  respiration,  for  they  disappear  as  soon 
as  it  is  established  ;  thus,  for  instance  : — 

1.  It  is  well  known  that  the  heart  in  the  adult  is  composed  of  four  cavities; 
namely,  a  right  and  left  auricle,  and  a  right  and  left  ventricle,  each  auricle  com- 
municating freely  with  the  corresponding  ventricle,  but  not  with  its  fellow,  being 
separated  from  it  by  a  complete  partition.  In  the  foetus  this  dividing  wall  ex- 
hibits an  opening,  called  the  foramen  of  Botal,  which  becomes  smaller  as  the 
pregnancy  advances,  and  is  wholly  obliterated  after  birth,  in  consequence  of  a 
valve  being  developed  on  its  inferior  margin,  which  gradually  diminishes  the 
freedom  of  the  passage,  and  is  large  enough  at  term  to  cover  the  orifice  entirely. 

2.  In  the  adult,  the  pulmonary  artery  divides  into  two  large  branches,  one  for 
each  lung :  these  ramify  throughout  its  ultimate  tissue,  distributing  therein  the 
venous  blood  derived  from  the  right  ventricle ;  the  blood  is  next  taken  up  by  the 
radicles  of  the  pulmonary  veins  and  carried  back  by  them  to  the  left  auricle. 
This  vascular  circle  is  interrupted  in  the  fcetus,  in  which  the  two  pulmonary 
arteries  are  veiy  small,  although  their  common  trunk  gives  origin  to  a  volumi- 
nous canal  which  opens  directly  into  the  arcus  aortse,  and  is  called  the  arterial 
canal  or  the  ductus  arteriosus. 

3.  The  abdominal  aorta  bifurcates,  so  as  to  form  the  primitive  iliac  arteries, 
and  each  of  these  again  divides  into  two  branches,  the  hypogastric  and  the  ex- 
ternal iliac.  In  the  foetus,  the  hypogastric  seems  to  be  continous  with  a  large 
vascular  trunk  called  the  umhilical  artery,  but  this  is  nearly  obliterated  in  after- 
life. The  two  umbilical  arteries  run  forwards  and  inwards  along  the  lateral  and 
superior  parts  of  the  bladder,  and  soon  curve  forwards  so  as  to  reach  the  inner 
surface  of  the  anterior  abdominal  wall,  along  which  they  ascend  to  the  umbilicus, 
then  pass  along  the  cord,  and  ultimately  ramify  in  the  placenta. 

4.  Lastly,  the  foetus  further  differs  from  the  adult  in  having  an  umbilical 
vein,  which,  commencing  by  numerous  ramifications  in  the  placental  tissue,  tra- 
verses the  whole  length  of  the  cord,  and  reaches  the  abdomen  by  passing  through 
the  umbilical  ring;  then,  running  upwards  and  to  the  right  in  the  substance  of 
the  suspensory  ligament  of  the  liver  immediately  behind  the  peritoneum,  it  gaina 


234  GENERATION. 

the  horizontal  or  umbilical  fissure  of  this  orpan  at  its  anterior  part,  where  it  gives 
off  a  few  branches  that  ramify  in  the  right  and  left  lobes.  Just  at  the  point 
where  the  two  fissures  of  this  viscus  intersect  each  other,  the  umbilical  vein 
becomes  enlarged,  and  then  divides  into  two  branches ;  the  posterior  of  which, 
called  the  venous  canal,  or  ductus  venosits,  is  a  continuation  of  the  primitive 
trunk,  and  goes  sometimes  to  the  vena  cava  inferior  above  the  diaphragm,  though 
at  others  it  joins  one  of  the  hepatic  veins,  and  the  common  trunk  thus  formed 
empties  into  the  vena  cava ;  the  other  branch  is  much  larger,  and  runs  to  the 
right ;  it  leaves  the  principal  trunk  lower  down  and  more  in  front  than  the  venous 
canal ;  then  it  unites  with  the  vena  portse,  producing  a  canal  whose  diameter  is 
double  its  own.  This  is  called  the  canal  of  reunion,  or  the  confluence  of  the 
portal  and  umbilical  veins.  After  a  short  course,  this  vessel  subdivides  and  rami- 
fies in  the  substance  of  the  liver,  anastomosing  with  the  hepatic  veins,  which  (as 
in  the  adult)  finally  reach  the  vena  cava  a  little  above  the  ductus  venosus. 

Plate  lY,  together  with  the  accompanying  explanation,  illustrates  the  whole 
vascular  apparatus  of  the"  foetus,  and  to  it  the  reader  is  referred. 

EXPLAXATIOX  OF  PLATE  IV, 

■WHICH    EXHIBITS    THE    WHOLE    VASCULAR    APPARATUS    OF    THE    FOETUS. 

A.  The  heart.  B  B.  The  lungs.  0.  The  spleen,  d.  The  liver,  n.  The  lobulus 
spigelii.  E  E.  The  kidneys,  f.  The  thymus  gland,  g.  The  upper  extremity  of  the 
rectum,  i.  The  bladder,  k.  The  ureters.  :H.  The  womb.  o.  The  umbilical  cord. 
1.  The  aorta.  2.  The  brachio-cephalic  trunk.  3.  The  left  primitive  carotid  artery. 
4.  The  left  subclavian  artery.  5.  The  pulmonary  artery.  6.  The  ductus  arteriosus. 
7.  The  vena  cava  superior.  8.  The  right  internal  jugular  and  the  right  subclavian 
veins.  9.  The  left  subclavian  vein.  10.  The  abdominal  aorta.  11.  The  primitive 
iliac  arteries.  12.  The  umbilical  arteries,  coming  off  from  the  bifurcation  of  the  primi- 
tive iliac.  13.  The  external  iliac  artery.  14.  The  umbilical  vein.  15.  The  ductus 
venosus.  16.  Vena  cava  inferior.  17.  The  vena  portarum.  18.  The  renal  artery  and 
veins.     19.  The  splenic  artery.     20.  The  ovarian  vessels. 


B.  Now,  having  acquired  these  anatomical  views,  let  us  see  what  is  the  course 
of  the  blood  in  the  footus.  A  part  of  this  fluid,  circulating  in  the  umbilical 
vein,  is,  therefore,  discharged  by  the  venous 'Canal  directly  into  the  vena  cava; 
another  part  is  distributed  to  the  liver,  where  it  probably  undergoes,  as  before 
'tated,  some  purification,  and  thence  is  brought  back  by  the  hepatic  veins  to  the 
vena  cava.  Consequently,  all  the  blood  from  the  umbilical  vein  reaches  the  vena 
.ava  inferior  either  directly  or  indirectly.  The  blood  contained  in  the  latter  is 
Lherefore  a  mixture  of  that  which  returns  from  the  inferior  extremities  of  the 
foetus  and  of  that  poured  into  the  liver  by  the  vena  portae,  with  the  addition  of 
the  portion  contributed  by  the  umbilical  vein.  This  compound  reaches  the  right 
auricle  through  the  ascending  vena  cava,  where  it  only  mixes  partially  with  the 
blood  of  the  upper  extremities,  which  has  been  brought  back  by  the  descending 
vena  cava,  because,  in  passing  into  the  auricle,  the  ascending  or  inferior  vena 


j'ln: 


OF    THE    FCETUS.  235 

cava  is  directed  towards  the  foramen  of  Botal,  and  hence  its  blood  passes  in  a 
great  measure  through  this  opening  into  the  left  auricle,  and  thence  into  the  left 
ventricle.  By  the  contractions  of  this  latter  the  fluid  is  then  forced  into  the 
aorta,  its  impetus  being  broken  against  the  great  curvature  of  this  artery ;  and  the 
blood  then  passes  into  the  vessels  which  arise  from  the  arch,  and  is  distributed 
through  them  to  the  head  and  superior  extremities,  a  very  small  portion  of  it 
only  reaching  the  descending  aorta  and  the  lower  parts  of  the  body. 

The  blood,  after  having  thus  supplied  the  upper  half  of  the  body  is  collected 
by  the  veins,  which,  by  their  successive  union,  form  the  superior  or  the  descend- 
ing vena  cava;  the  latter  empties  into  the  right  auricle,  where  a  small  quantity 
of  its  blood  probably  mixes  with  that  brought  by  the  ascending  cava ;  but  much 
the  largest  part  passes  directly  into  the  right  ventricle,  which  forces  it  into  the 
pulmonary  artery. 

This  vessel  sends  but  a  trifling  portion  to  the  lungs ;  the  rest  being  thrust  into 
the  ductus  arteriosus,  which  discharges  its  contents  into  the  aorta ;  that  is  to  say, 
the  blood  that  has  contributed  to  the  nutrition  of  the  superior  parts  of  the  body, 
and  has  traversed  the  descending  vena  cava,  the  right  au.ricle,  the  right  ventricle, 
and  pulmonary  artery,  and  then  has  passed  through  the  ductus  arteriosus,  finally 
mingles  with  the  remnant  of  blood  still  existing  in  the  descending  aorta.  The 
whole  now  descends  to  the  inferior  part  of  the  latter  vessel,  where  a  small  por- 
tion of  it  is  sent  through  the  arterial  trunks  to  supply  the  inferior  extremities, 
whilst  much  the  largest  quantity  is  driven  into  the  umbilical  arteries,  and  is  car- 
ried by  them  back  to  the  placenta ;  where,  after  having  undergone  the  modifica- 
tions produced  by  the  placental  respiration,  it  is  again  taken  up  by  the  radicles 
of  the  umbilical  vein  to  once  more  traverse  the  same  circuit. 

C.  Of  the  Changes  in  the  Circulation  after  Birth. — As  soon  as  the  respiration 
becomes  established*  the  sanguineous  current  takes  another  direction,  because,  on 
the  one  hand,  the  fluid  flows  towards  the  lungs  in  greater  quantity ;  and,  on  the 
other,  the  placental  circulation  is  forcibly  interrupted.  Below,  I  subjoin  the 
results  of  the  labors  of  Billard,  who  has  devoted  particular  attention  to  the  modi- 
fications then  observed  in  the  organs  of  circulation,  as  they  are  interesting  alike 
to  the  accoucheur  and  the  medical  jurist. 

1.  Period  of  Obliteration  of  the  Foetal  Openings. — The  foetal  openings  are 
generally  obliterated  in  the  course  of  a  week  after  birth,  still,  they  may  remain 

'  It  is  difficult  to  explain  the  cause  of  the  first  inspiration  ;  by  some,  it  has  been  attributed 
to  an  instinctive  movement  of  the  foetus,  from  the  "  bcsoin  de  respirer"  (necessity  of  respiring) 
experienced  by  it,  after  a  separation  from  the  placenta ;  but  these  reasons  are  not  satisfactory 
to  me,  for  the  air  is  only  introduced  into  the  lung  as  a  consequence  of  the  enlargement  of 
the  cavity  of  the  chest,  and  not,  as  some  imagine,  to  fill  a  vacuum  which  never  existed. 
Now  this  expansion  of  the  cheat  has  for  its  sole  cause  the  violent,  jerking,  spasmodic  con- 
traction of  the  diaphragm,  which  is  always  the  result  of  a  suffering  condition  of  the  fcctus, 
caused  by  the  suspension  of  the  utero-placental  circulation,  the  sudden  impression  of  cold,  or 
the  ditferent  characters  of  the  media  to  which  the  child  is  successively  and  rapidly  sub- 
jected. Finally,  also,  by  the  artificial  excitations  (friction  on  the  surface,  irritation  of  the 
mucous  membranes,  &c.)  resorted  to  when  the  infant  is  feeble. 


236  GENERATION. 

patulous  at  that  age ;  and,  I  may  add,  that  either  the  foramen  of  Botal  or  the 
arterial  canal  may  continue  pervious  at  two  or  even  three  weeks,  without  the 
child's  experiencing  any  particular  disadvantage  therefrom  during  after-life. 

The  umbilical  arteries  are  usually  closed  on  the  second  day ;  even  at  twenty- 
four  hours  they  have  already  become  smaller  in  the  vicinity  of  the  ring,  and  they 
are  obliterated  by  the  third  or  fourth  day  as  far  as  their  junction  with  the  hypo- 
gastrics, by  gradually  changing  into  a  fibrous  cord;  the  whole  process  being 
completed  in  three  weeks. 

The  umbilical  vein  is  never  obliterated  until  after  the  arteries  have  become 
impervious,  and  the  same  is  true  of  the  ductus  venosus ;  however,  both  are  quite 
empty,  and  considerably  contracted  on  the  fourth  day,  and  they  are  generally 
closed  up  by  the  sixth  or  seventh. 

The  arterial  canal  and  the  foramen  of  Botal  are  the  last  to  undergo  this  pro- 
cess; but  they  rarely  persist  beyond  the  eighth  or  ninth  day,  although  the  foramen 
sometimes  remains  open  much  longer,  being  only  effaced  completely  towards  the 
end  of  the  first  year. 

2.  Mode  of  Ohliferation. — If  the  ductus  arteriosus  and  the  umbilical  arteries 
be  examined  during  the  progress  of  obliteration,  their  parietes  will  be  found  to 
gi'ow  gradually  thicker;  this  hypertrophy  is  particularly  observable  in  the  arteries 
near  the  navel,  as  may  easily  be  verified  by  making  sections  of  them  at  this  point; 
but  the  thickness  gradually  diminishes  towards  their  origin  from  the  iliacs,  and 
their  canal  is  likewise  obliterated  precisely  in  the  same  order  of  progression.  Of 
course,  the  contractility  of  its  walls  will  also  contribute  towards  effecting  the 
occlusion. 

The  arterial  canal  undergoes  a  similar  hypertrophy  and  parietal  retraction, 
which  takes  place  in  such  a  manner  that,  whilst  the  absolute  size  of  the  vessel  does 
not  appear  diminished,  its  orifice  is  greatly  contracted,  resembling  a  pipe  whose 
fracture  is  quite  thick,  and  opening  at  its  centre  of  very  moderate  calibre.  The 
obliteration  is  therefore  the  immediate  result  of  the  retraction  and  concentric 
hypertrophy  of  the  walls ;  nevertheless,  it  must  not  be  supposed  that  this  is  the 
primitive  cause,  for  if  the  same  quantity  of  blood  flowed  into  those  vessels,  such 
a  retraction  evidently  could  not  take  place ;  but  from  the  very  first  inspiration, 
this  fluid  is  driven  by  the  contraction  of  the  right  ventricle  (see  hereafter)  almost 
entirely  into  the  pulmonary  arteries,  scarcely  any  of  it  passing  by  the  ductus 
arteriosus;  and,  on  the  other  hand,  the  very  oblique  angle  at  which  the  umbilical 
arteries  pass  off,  satisfactorily  explains  why  the  blood  that  flows  into  them  in 
such  great  abundance  when  it  has  no  other  outlet,  no  longer  enters  them  at  all, 
or  at  least  only  very  feebly,  when  the  establishment  of  respiration  has  completed 
the  vascular  circle  of  the  new-born  child. 

But  the  umbilical  vein,  and  the  ductus  venosus,  are  not  obliterated  in  this  way, 
and  their  walls  exhibit  no  remarkable  increase  of  thickness ;  for,  after  the  cord 
has  been  cut,  these  vessels  receive  no  more  blood,  excepting  in  those  cases  where 
it  regurgitates  from  the  vena  cava,  and  then  the  walls  fall  in  and  become  con- 
tiguous, just  like  any  other  canal,  when  the  liquids  that  habitually  traverse  it 
are  cut  off;  nevertheless,  the  umbilical  vein  and  the  ductus  venosus  retain  their 


OF    THE    F  (E  T  U  S.  257 

cavities  free  for  a  lonp;  time,  for  a  large  probe  may  easily  be  introduced  into  them  ; 
but  this  cannot  be  done  in  the  arteries  nor  in  the  ductus  arteriosus.' 

The  foramen  of  Botal  is  the  last  to  disappear,  although  an  effort  at  obliteration 
may  be  observed  there  sooner  than  in  any  other  of  the  fcetal  openings :  thus,  the 
two  auricles  are  nearly  confounded  in  one  in  the  early  stages  of  intra-uterine  life, 
and  the  diminution  of  the  foramen  ovale  only  begins  to  take  place  about  the  third 
month,  by  the  development  of  a  semilunar  valve  on  its  inferior  border.  This 
valve,  composed  of  a  double  membranous  layer,  containing  fleshy  fibres  in  its  sub- 
stance, gradually  rises  along  the  margins  of  the  opening  towards  the  left  auricle, 
by  contracting  adhesions  with  the  circumference  of  the  foramen,  and  it  ultimately 
forms  the  fundus  of  the  fossa  ovalis,  as  also  the  little  semilunar  fold  seen  in  the 
auricle.  In  this  way  the  partition  is  completed,  being  merely  perforated  by  an 
oblique  canal  occasionally  found  in  young  subjects,  which  also  disappears  after  a 
time.'' 

The  following  summary  will  enable  the  reader  to  appreciate  the  influence  of 
those  vascular  modifications  upon  the  circulation  : 

Immediately  after  the  first  inspiration,  and  from  the  sole  fact  of  the  distension 
of  the  pulmonary  cells,  the  branches  of  the  pulmonary  artery,  ramifying  in  the 
mucous  membrane,  and  contributing  to  the  formation  of  their  walls,  are  suddenly 
rendered  permeable  throughout  their  whole  extent,  and  a  vacuum  is  therefore 
produced,  into  which  the  blood  is  sent  from  the  right  ventricle ;  consequently, 
from  that  period,  the  route  travelled  by  this  fluid,  from  the  right  ventricle  to  the 
aorta,  is  much  longer  than  heretofore,  and  the  ductus  arteriosus,  being  thus 
emptied,  will  retract  at  once,  and  have  its  calibre  very  much  diminished. 

The  right  auricle,  which  could  scarcely  force  all  the  blood  that  it  received  from 
the  venae  cavte,  through  the  foramen  of  Botal,  now  sends  the  most  of  it  into  the 
right  ventricle. 

Prior  to  birth,  the  left  auricle  only  received  the  blood  by  the  foramen  ovale, 
but  it  is  henceforth  filled  with  that  brought  through  the  four  pulmonary  veins. 
Moreover,  the  relation  that  existed,  in  the  quantity  of  the  blood  deposited  in  each 
auricle,  is  changed  from  that  time ;  for  the  right,  which  was  distended  beyond 
measure,  now  relieves  itself  with  facility,  while  the  left,  that  scarcely  received 
any  before,  is  filled  with  the  blood  brought  by  the  pulmonary  veins ;  so  that  it 
would  flow  from  the  left  to  the  right  auricle,  through  the  foramen  ovale,  if  the 
semilunar  partition,  which  acts  as  a  valve,  did  not  prevent  such  a  movement. 

1  A  case  of  persistence  of  the  umbilical  vein  in  the  adult,  which  communicated  at  one 
extremity  with  the  vena  portas,  and  at  the  other  with  the  crural  vein  through  the  superficial 
abdominal  veins,  is  reported  by  M.  Cruveilhier,  in  the  IGth  number  of  his  Pathological 
Anatomy. 

^  According  to  Dr.  Tyler  Smith,  the  expansion  of  the  lungs  produces  a  compression  of  the 
ductus  arteriosus  by  the  left  bronchus,  and  thus  assists  in  its  obliteration.  The  change 
effected  in  the  position  of  the  heart,  also  aids  mechanically  the  occlusion  of  the  foramen 
ovale,  and,  finally,  the  depression  of  the  liver,  by  the  respiratory  act,  closes  the  umbilical  vein 
by  flattening  its  walls.  [The  Lancet,  Sept.  1848.)  None  of  these  assertions  appear  to  us  to 
be  sufficiently  well  proved,  and  therefore  demand  further  investigation. 


238  GENERATION. 

BOOK  IV. 

OF  ABNORMAL  PREGNANCIES. 

The  pregnant  condition  is  liable  to  present  varieties,  in  regard  both  to  the 
number  of  foetuses,  and  to  the  place  where  the  product  of  conception  undergoes 
its  development.  In  the  former  case  it  receives  the  name  of  multiple  pregnancy; 
in  the  latter,  it  is  termed  extra-uterine  pregnancy.  We  shall  describe  both  these 
varieties  under  the  head  of  abnormal  pregnancies.  The  hydatiform  mole  we 
regard  as  a  disease  of  the  ovum,  and  shall  speak  of  it  briefly  when  treating  of 
abortion. 


CHAPTER  I. 

OF   TWIN   PREGNANCY, 

The  tei'm,  compound  or  multiple  pregnancy,  has  been  applied  to  that  in  which 
two  or  more  foetuses  are  enclosed  in  the  uterine  cavity.  Certain  females  seem 
to  be  greatly  disposed  to  these  anomalies ;  thus,  cases  are  recorded  where  six, 
seven,  and  evea  eleven  children  have  been  born  at  three  successive  accouche- 
ments. 

Double  pregnancies  are  quite  frequent ;  that  is,  one  case  is  met  with  in  about 
seventy  or  eighty  labors.  Triplets,  on  the  contrary,  are  very  rare,  since  there 
were  but  five  in  the  records  of  87,441  accouchements  that  occurred  at  La  Mater- 
nite,  in  Paris.  Further,  we  cannot  call  in  question  those  instances  in  which 
there  were  said  to  be  four  at  a  birth ;  for  such  men  as  Viardel,  Mauriceau,  Hamil- 
ton, and  many  others,  furnish  examples  of  it.^     Both  Peu  and  Lauverjat  declare 

'  The  following  statistical  account  is  extracted  from  Chnrchiirs  work.  In  101,042  preg- 
nancies, there  were  2477  cases  of  twins,  or  1  in  69,  and  36  triplets  do.,  or  1  in  4473  (Eng- 
lish accoucheurs). 

In  36,570  pregnancies,  there  were  582  cases  of  twins,  or  1  in  110,  and  6  triplets,  or  1  in 
6095  (French  accoucheurs). 

In  251,386  pregnancies,  there  were  2967  cases  of  twins,  or  1  in  84,  and  35  triplets,  or  1 
in  7185  (German  accoucheurs). 

Total,  in  448,998  cases,  there  were  5776  instances  of  twins,  being  1  in  77|,  and  77  trip- 
lets, or  1  in  5831. 

The  same  author  furnishes  the  accompanying  information  as  to  the  sex  of  the  twins:  Dr. 
Joseph  Clarke  slates,  that  in  1S4  twin  cases,  both  children  were  boys  47  times,  girls  68  times, 
and  one  boy  and  one  girl  71  times. 

Dr.  Collins  reports  240  cases,  in  which  there  were  two  males  73  times,  two  females  67 
times,  and  male  and  female  97  times;  and  Dr.  Lever  33  cases,  two  males  11,  two  females 
11,  and  male  and  female  11. 


OF    TWIN    PREGNANCY.  239 

that  they  have  witnessed  cases  of  five  at  a  birth. i  And  lastly,  must  we  consider 
those  cases  of  six,  seven,  eight,  and  nine  children,  or  even  more,  at  once,  so 
many  examples  of  which  are  found  in  the  authors,  as  true  statements  or  as  fabu- 
lous tales  ? 

It  is  a  very  difl&cult  matter  to  point  out  the  causes  of  this  anomaly  in  the  pre- 
sent state  of  our  science ;  true,  numerous  explanations  have  been  oftered,  but  all 
are  nothing  more  than  pure  hypotheses ;  for  example,  it  is  said  that  a  single 
fecundation  may  aifect  both  ovaries,  or  two  of  the  Graafian  vesicles  in  the  same 
ovary ;  and  again,  that  several  impregnations  may  occur  successively  in  a  short 
period,  that  is,  before  the  first  fecundated  ovule  has  arrived  in  the  uterus.  Both 
take  it  for  granted  that  two  ovules  are  detached  either  at  the  same  time  or  suc- 
cessively, from  the  ovary,  and,  consequently,  that  two  corpora  lutea  are  deve- 
loped. Several  well-attested  facts  prove,  however,  that  a  different  state  of  things 
may  take  place ;  thus,  for  instance,  two  ovules  have  sometimes  been  found  in  the 
same  Graafian  vesicle,  and  it  is  evident  that  the  rupture  of  this  vesicle  alone,  in 
such  a  case,  might  produce  a  double  fecundation ;  at  other  times,  two  yolks  have 
been  seen  in  the  same  ovule ;  and  in  such  a  condition  a  twin  pregnancy  might 
certainly  occur,  although  but  one  ovule  be  fecundated. 

Hereafter  we  shall  see,  that  these  peculiarities  serve  to  explain  the  varied  dis- 
position exhibited  by  the  membranes  in  compound  gestations. 

It  is  frequently  possible  to  recognize  the  presence  of  twins  during  pregnancy; 
indeed,  the  abdomen  is  ordinarily  more  voluminous  then  than  at  other  times, 
and  the  belly  is  generally  flattened  on  the  median  line,  instead  of  presenting 
there  a  well-marked  protuberance ;  the  middle  is  depressed,  in  consequence  of 
the  two  children  lying  one  upon  each  side ;  nevertheless,  this  sign  may  fail  when 
one  child  happens  to  be  placed  before  the  other. 

'  M.  Pign6  informed  me  that  he  saw  a  single  placenta  at  Strasbourg,  from  which  five 
separate  cords  arose,  although  only  a  single  sac  existed,  which  was  composed  of  three  mem- 
branes, decidua,  chorion,  and  amnion,  in  which  the  five  embryos  were  enclosed. 

Dr.  Kennedy  (London  Med.  Gazette)  presented  to  the  Royal  Society  the  liistory  of  a  woman 
who  aborted  at  three  months  of  five  embryos.  Tiiere  were  three  ovums,  one  being  double, 
and  each  ovum  had  a  placenta  and  its  own  proper  membranes. 

M.  Boiirdois  (Gaz.  Med.,  p.  50 9,  1840}  describes  a  quadruple  pregnancy,  in  which  the  de- 
livery occurred  at  the  seventh  month.  The  second  child  was  born  twelve  hours  after  the 
first,  and  the  other  two  a  few  minutes  subsequently.  The  second  accouchement  was  attended 
by  a  new  discharge  of  waters;  there  were  two  placentas,  one  of  which  had  three  cords  and 
was  adherent,  and  some  portions  of  it  remained  behind  in  the  uterus. 

Dr.  Hull,  of  Manchester,  deposited  five  little  twin  foetuses  in  the  Museum  of  the  London 
College  of  Surgeons,  that  he  had  obtained  from  a  woman  who  aborted  at  the  fifth  month  of 
gestation. 

Cliambon  records  an  instance  of  quintuple  pregnancy,  where  the  children  survived  their 
baptism. 

A  woman  of  Naples  was  delivered  of  five  infants  at  seven  months.  (E7'itish  and  Foreign 
Med.  Review,  1839.) 

Dr  Kennedy  (Every)  states  (in  the  Dublin  Med.  Journal,  Jan.  1840),  that  a  woman  aborted 
of  five  embryos  between  the  second  and  third  months  of  gestation ;  and  finally,  Dr.  Francis 
Ramsbotham  has  collected  three  cases  of  quintuple  pregnancy  from  the  public  journals. 


240 


GENERATION. 


Fig.  64. 


The  form  of  the  uterus  varies  also  with  the  position  of  the  foetuses,  their  num- 
ber, and  the  amount  of  amniotic  fluid.  Thus,  when  the  head  of  one  is  above, 
and  that  of  the  other  below,  there  may  result  therefrom  two  correspondin"'  de- 
pressions and  projections,  as  M.  Ilergott  has  represented.  Should  both  present 
by  the  head,  the  fundus  of  the  womb  will  be  very  much  dilated,  and  the  con- 
trary is  the  case  when  they  present  by  the  pelvis.  In  a  case  which  occurred  at 
the  Clinic  of  Strasbourg,  the  shape  of  the  womb  was  irregular  and  oblique ;  the 

two  heads  occupied  the  angles  of  the  uterus, 
and  formed  two  tumors  separated  by  a  depres- 
sion; the  one  at  the  right  being  much  the 
higher.    The  twins  were  born  by  the  feet. 

The  slight  blows  perceived  by  the  mother 
are  sometimes  felt  at  one  and  the  same  time 
in  two  distant  parts  of  the  abdomen ;  and  the 
importance  of  auscultation  as  an  element  in 
this  diagnosis  has  already  been  pointed  out. 
(See  p.  i53.) 

The  bellows  murmur  can,  I  think,  rarely 
furnish  useful  information.  Still,  it  is  as- 
serted by  Holl,  that  in  sixteen  twin  preg- 
nancies, the  murmur  was  heard  seven  times 
on  both  the  right  and  left  sides  simultaneously, 
and  nine  times  on  one  side  only;  and  he  af- 
firms, that  when  the  latter  was  the  case,  there  was  a  common  placenta,  whilst  in 
the  other  instances  there  were  two.  He  is  also  of  the  opinion,  that  a  double 
souffle  is  diagnostic  of  a  double  pregnancy,  even  though  the  sound  of  the  heart 
be  heard  at  a  single  point  only.  We  caniiot  admit  the  last  conclusion,  since  we 
have  already  denied  the  very  relation  which  Holl  would  establish  between  the 
seat  of  the  murmur  and  the  insertion  of  the  placenta,  beside  which,  we  have 
often  heard  a  souffle  on  both  the  right  and  left  sides  in  single  pregnancies. 

Again,  as  the  two  foetuses  mutually  interfere  with  each  other,  neither  of  them 
presents  itself  to  the  vaginal  touch,  and  of  course  the  ballottement  is  then  ex- 
ceedingly difficult,  if  not  wholly  impossible ;  for,  even  if  the  finger  should  easily 
reach  the  presenting  part,  the  presence  of  another  child  would  interfere  with  the 
ascending  movement  of  the  first.  Desormeaux,  however,  cites  a  case  where  the 
ballottement  was  manifest  in  a  twin  gestation,  but  even  here  a  large  quantity  of 
water  was  present  at  the  same  time.  Whilst  in  charge  of  the  Clinic  of  the 
Faculty,  in  1845,  I  observed  on  two  occasions  the  same  fact  noticed  by  Desor- 
meaux; for  the  existence  of  dropsy  of  the  amnion  rendered  the  ballottement  very 
perceptible,  although  two  children  were  present. 

The  course  of  twin  pregnancies  is  sometimes  accompanied  by  peculiarities 
which  it  is  important  to  be  acquainted  with.  Thus,  the  two  foetuses  do  not 
always  attain  to  the  development  which  we  have  indicated.  One  of  them  may 
die,  and  yet  the  other  continue  to  grow.  In  such  cases,  which,  however,  are  rare, 
the  dead  body  may  either  remain  in  the  womb,  where  it  hardens,  withers,  and  is 


OF    TWIN    PREGNANCY.  241 

expelled  during  labor,  or,  by  irritating  the  uterus,  may  bring  on  the  contractions 
which  expel  it  from  its  cavity,  while  the  development  of  the  other  constantly 
progresses. 

In  my  course  of  1853, 1  exhibited  a  placenta  obtained  from  a  woman  who  was 
delivei-ed  at  term  of  a  living  and  well-developed  child.  It  was  provided  with 
two  amniotic  bags,  one  of  which  belonged  to  the  living  child,  and  presented  no 
unusual  appearance.  The  other,  which  was  much  smaller,  contained  barely  a 
trace  of  fluid,  but  enclosed  a  small  mummy-like  foetus,  about  the  size  of  one  of 
four  months'  development. 

Lastly,  the  twin  that  died  during  the  gestation  may  still  remain  in  the  womb, 
in  consequence  of  the  adherences  which  its  placenta  has  contracted  with  that 
organ,  for  a  long  period  after  the  expulsion  of  its  living  brother,  ihkt  occurs  at 
the  ordinary  term  of  gestation. 

Guillemot  furnishes  one  of  the  most  curious  observations  of  this  kind  (^Heiti-evx 
Ace,  livre  ii,  p.  225)  on  record,  in  which  the  artificial  extraction  of  the  dead 
body  did  not  take  place  until  two  years  after  the  accouchement.  But  what  is  the 
cause  which  thus  determines  the  death  of  one  foetus  ? 

Mauriceau  and  Peu  thought  it  might  be  attributed  to  the  fact  that  one  child, 
by  receiving  all  the  nourishment,  becomes  strong  and  vigorous  at  the  expense  of 
the  other,  thereby  rendering  it  feeble  and  languishing,  and  causing  its  early  death. 

M.  Guillemot  believes  that  one  child,  in  its  growth,  gradually  compresses  the 
second  against  the  uterine  wall,  and  the  latter  not  having  sufficient  space  for  its 
development  soon  after  dies.  Lastly,  M.  Cruveilhier  explains  the  atrophy  of  the 
foetus  by  a  gradual  separation  of  the  placenta,  founding  his  opinion  on  a  single 
case,  in  which  the  hemorrhage  was  great  enough  to  account  for  the  early  death  of 
one  of  the  twins;  but  in  the  greater  number  of  cases  that  have  been  recorded,  no 
mention  whatever  is  made  of  any  hemon-hage  during  the  pregnancy;  whence,  of 
course,  the  opinion  of  M.  Cruveilhier  would  not  be  applicable  to  thera.  For  my 
own  part,  I  believe  these  cases,  in  which  the  death  and  atrophy  of  one  foetus 
takes  place,  should  rather  be  attributed  to  some  disease  of  the  infant  or  placenta, 
or  of  some  parts  of  its  envelopes.  It  may  be  urged,  indeed,  that  these  altera- 
tions are  not  observed  at  the  time  of  the  accouchement,  which  is  not  to  be  won- 
dered at,  considering  the  state  of  degeneration  exhibited  by  all  parts  of  the  ovum  ; 
and,  although  no  positive  fact  sustains  this  opinion,  it  seems  to  me  more  admis- 
sible and  more  rational  than  the  others. 

It  not  unfrequently  happens  that  twin  pregnancies  terminate  before  full  term, 
owing,  doubtless,  to  the  great  distension  of  the  uterus,  which  is  often  as  large  at 
seven  or  eight  months  as  in  a  simple  pregnancy  at  nine  months.  The  same 
labor  generally  suffices  for  the  expulsion  of  both,  though  such  is  not  always  the 
case;  for,  after  the  first  child  is  born,  the  uterus  may  retract  upon  the  remaining 
twin,  and  leave  it  unexpelled  for  eighteen  or  twenty-four  hours.  A  still  longer 
interval,  several  months  even,  may  separate  the  two  parturitions;  and  it  is  upon 
such  facts  as  these,  that  some  persons  have  improperly  admitted  the  doctrine  of 
superfoetation  A  reference  to  the  latter  is,  however,  unnecessary  to  explain 
these  observations,  for  the  cause  of  premature  delivery  is  dependent  solely  on  the 

16 


242  GENERATION. 

enormous  distension  of  tte  uterus,  because  as  soon  as  one  infant  is  expelled  the 
womb  retracts,  the  cause  of  irritation  no  longer  exists,  and  we  can  readily  con- 
ceive that  the  gestation  may  continue  on  until  term.  A  child  born  at  seven 
months,  may  live  equally  well  with  one  delivered  at  the  end  of  pregnancy. 

The  peculiarities  just  studied  in  twin  pregnancies,  may  also  present  themselves 
in  cases  of  triplets,  kc.  Thus,  in  a  case  cited  by  Portal,  after  the  delivery  of 
the  first  child  and  its  placenta,  which  were  healthy,  he  was  obliged  to  extract 
two  others  that  had  apparently  been  dead  for  a  long  time,  and  were  thoroughly 
dried. 

Again,  the  membranes  are  not  always  disposed  in  the  same  manner  in  these 
pregnancies;  and  on  this  head  we  may  admit,  with  M.  Guillemot,  who  has  par- 
ticularly studied  the  subject,  four  distinct  varieties  :  thus,  in  the  first,  two  ovules 
are  fecundated,  and  each  embryo  becomes  developed,  and  is  surrounded  by  its 
own  proper  membranes;  in  the  second,  the  ovule  contains  two  germs,  though 
each  fuetus  has  but  a  single  envelope,  the  chorion  being  a  common  membrane ;  in 
the  third,  both  embryos  are  enclosed  in  a  single  cavity,  which  appears  never  to 
have  been  divided  by  any  membranous  diaphragm ;  and  finally,  the  last  variety 
is  met  with  when  the  ovule  contains  a  second  germ,  and  both  become  developed 
together,  which  gives  rise  to  what  are  called  monstrosities  by  inclusion  '  Adopt- 
ing this  classification  as  the  basis,  let  us  now  pi'oceed  to  the  difie*^,;M  modes  of 
termination  presented  by  these  pregnancies,  according  to  the  sfteifc^^to  which 
they  belong.  ■•*'>. 

1.  In  the  first  variety,  both  ovules  are  developed,  retainiEjg' theri  proper  mem- 
branes, the  chorion  and  amnion ;  at  first,  each  ovum  has  its  own  reflected  decidua, 
but  "•enerally  that  portion  of  the  latter  which  forms  the  partition  is  very  thin, 
and  becomes  absorbed  as  the  gestation  advances,  and  a  single  decidua  then  ap- 
pears to  envelope  both. 

The  two  chorions  repose  against  each  other,  being  only  separated  by  some  very 
fine  areolar  tissue,  so  that  the  children  are  divided  by  one  very  thick  partition  com- 
posed of  four  layers.  The  placentas  are  sometimes  separate,  though  usually  con- 
founded with  each  other,  or  else  are  united  by  a  kind  of  membranous  bridge  ;  but 
notwithstanding  this  continuity  of  tissue,  there  rarely  exists  any  vascular  com- 
munication between  them,  and  this  fact  is  so  uniform  that  the  exceptions  to  the 
law  are  very  rare  indeed.  From  all  which  it  must  therefore  be  evident  that  two 
distinct  ovules  have  been  fecundated,  whether  they  are  deposited  separately,  or 
are  contained  in  the  same  vesicle.     The  first  variety  is  the  most  frequent. 

2.  In  the  second  variety  of  compound  pregnancy,  the  chorion  is  common  to 
both  twins,  and  each  foetus  has  but  a  single  envelope  formed  of  the  amnion — the 
two  laminae  of  which,  resting  against  each  other,  constitute  the  median  partition. 
MM.  Dance  and  Mancel  have  furnished  an  example  of  this  variety  in  which 
there  were  but  two  children.  Brendelius  reports  that  a  woman  was  delivered  of 
two  girls  after  three  days  travail,  but  she  died  before  the  extraction  of  the  third 
infant,  which  was  found  dead  on  opening  her  body ;  the  placenta  was  single  and 
very  large,  and  the  chorion  had  been  common  to  all  three,  although  each  foetus 
had  a  distinct  amnion. 


OF    TWIN     PREGNANCY.  243 

There  is  therefore  only  a  single  placenta,  and  a  communication  nearly  always 
exists  between  the  rauiuscules  of  the  two  cords,  as  I  have  verified,  myself,  on  a 
placenta,  which  was  presented  by  one  of  my  former  pupils,  an  Interne  of  the 
Ursuline  Hospital,  where  he  obtained  it.  In  this,  as  in  the  preceding  variety, 
one  foetus  may  die,  the  other  continuing  to  live;  but  it  is  easily  foreseen  that  an 
expulsion  of  the  two  children  cannot  take  place  separately. 

3.  Further,  it  may  happen  that  the  foetuses  are  not  separated  by  any  parti- 
tion, and  are  all  shut  up  in  the  same  amniotic  cavity ;  and  to  the  examples  of 
this  kind,  already  cited,  I  may  add  a  case  observed  by  my  friend  and  colleague, 
Dr.  Fournier.  The  two  cords  arise,  most  frequently  at  least,  from  a  distinct 
point  of  the  placenta;  but  sometimes  they  are  observed  to  come  from  a  common 
trunk,  which  bifurcates  at  a  variable  distance  from  the  placental  surface.  In 
this  variety,  the  expulsion  of  one  foetus  must  evidently  be  followed  by  that  of  the 
other;  but  I  do  not  know  to  what  extent  we  can  justly  say  that  the  death  of  one 
necessarily  endangers  the  other's  life,  if  not  speedily  delivered  by  nature.  (Bau- 
delocque.)  This  inclusion  of  two  foetuses  in  the  same  amniotic  cavity,  is  often 
met  with  in  those  cases  where  one  of  them  is  destitute  of  an  important  part  of 
its  body ;  thus,  the  monstrosity  that  I  presented  to  the  Royal  Academy  of  Medi- 
cine \vt."  enclosed  in  the  same  sac  with  its  twin  brother. 

But  i  early  or  wholly  impossible,  in  the  present  state  of  ovohgical  know- 

ledge, ain  this  strange  anomaly,  the  existence  of  which,  however,  has 

sever:  3n  clearly  verified. 

Iv.  .  'th  what  we  have  said  respecting  the  formation  of  the  amnion 

(See  Art.  Ovology),  i,his  membrane  emanates  from  the  embryo  itself,  and  con- 
sequently the  amniotic  membranes  should  equal  the  foetuses  in  number;  but, 
without  admitting  the  theory  of  Pockels  and  Serres  on  the  development  of  the 
amnion,  a  theory  which,  notwithstanding  its  want  of  probability,  derives,  from  the 
facts  alluded  to,  a  certain  degree  of  support,  we  cannot  explain  them  but  by 
supposing  that  two  amniotic  membranes  existed  primitively,  and  that  the  parti- 
tion produced  by  their  contact  has  been  somehow  destroyed.  Most  generally, 
there  are  numerous  communications  existing  between  the  umbilical  ramifications, 
as  we  have  stated,  when  the  chorion,  and  especially  the  amnion,  are  common  to 
both,  which  is  not  always  the  case.  Thus,  Dodd  reports  a  case  of  triplets,  where 
the  placentas  were  consolidated  into  one,  two  of  the  children  being  enclosed  in  a 
common  chorion,  whilst  the  third  had  a  special  one;  the  umbilical  vessels  did 
not  communicate  with  each  other.  In  another  instance,  recorded  by  Davis,  the 
three  foetuses  had  a  common  decidua;  two  of  them  were  surrounded  by  the  same 
chorion  and  amnion,  but  the  third  had  its  chorion  and  amnion  distinct  from  the 
others;  the  placenta  formed  a  single  mass,  but  the  vessels  had  no  communication 
with  each  other.     (^London  Med.  Gazette,  1841.) 

4.  Finally,  the  fourth  variety  of  compound  pregnancy  that  we  have  admitted, 
along  with  M.  Guillemot,  constitutes  what  has  been  called  a  monstrosity  hy 
inclusion.  It  consists  of  the  con^plete  inclusion  of  the  elements,  whether  more 
or  less  numerous,  of  one  foetus  in  the  body  of  another  foetus,  which  is  otherwise 
well  formed. 


244  GENERATION. 

M.  Olliviev  (d' Angers),  who  has  published  a  very  interesting  article  on  this 
monstrosity,  admits  that  the  inclusion  may  take  place  in  two  different  ways;  for 
instance,  the  contained  foetus  is  sometimes  shut  up  in  the  abdominal  cavity  of  the 
other  child,  thereby  constituting  the  jyrofound,  or  ahdominal  inclusion.  At 
others,  it  is  merely  enveloped  by  the  integuments  of  the  latter,  which  form  an 
external  tumor,  without  any  communication  whatever  with  the  visceral  cavities 
of  the  foetus  that  carries  it;  this  is  the  cutaneous,  or  exterior  inclusion.  This 
latter  has  again  been  subdivided  into  two  varieties,  according  as  the  tumor  occu- 
pies the  scrotum  or  the  perineum ;  but  as  the  character  of  this  work  evidently 
prohibits  me  from  entering  into  a  discussion  of  the  various  opinions  put  forth  as 
to  the  nature  and  the  mode  of  formation  of  this  kind  of  monstrosity,  I  can  only 
allude  to  them  here ;  and  I  refer  for  more  complete  details  to  the  memoir  of  M. 
Ollivier  (^Archives,  1827),  as  well  as  to  that  of  M.  Lesauvage  de  Caen,  and  still 
more  especially  to  the  admirable  Traite  de  Teratologic,  by  M.  Isidore  Geoffroy 
St.  Hilaire. 


CHAPTER  II. 

OF   EXTRA-UTERINE    PREGNANCY.  '*■ 

The  fecundation,  as  elsewhere  stated,  most  frequently  takes  place  in  the  ovary, 
and  the  impregnated  ovule  is  then  received  by  the  fimbriated  extremity  of  the 
tube,  which  applies  itself  on  this  organ,  doubtless  by  a  kind  of  spasmodic  con- 
traction. Having  been  once  deposited  in  the  tubal  canal,  the  ovule  traverses  its 
whole  length,  and  falls  into  the  uterine  cavity,  where  its  development  continues 
until  term.  Such  is  the  course  observed  in  normal,  or  uterine  pregnancy  ;  but 
it  may  happen  that  the  ovule  is  arrested,  or  diverted,  in  the  route  it  thus  travels, 
and  engrafting  itself,  so  to  speak,  upon  the  point  of  stoppage,  is  there  developed ; 
in  the  latter  case,  the  pregnancy  is  called  an  alnormal,  or  an  extra-uterine  one. 

This  species  of  gestation  has  been  subdivided  into  several  varieties,  which 
have  received  different  names,  according  to  the  part  of  the  passage  where  the 
ovule  becomes  fixed.  Thus,  we  may  admit  with  M.  Dezeimeris  the  following 
divisions,  namely : — 

1.  The  ovarian  pregnancy. 

2.  The  sub-peritoneo-pelvic  pregnancy. 

3.  The  tubo-ovarian  pregnancy. 

4.  The  tubo-abdominal  pregnancy. 

5.  The  tubal  pregnancy. 

6.  The  tubo-uterine  interstitial  pregnancy. 

7.  The  utero-interstitial  pregnancy. 

8.  The  utero-tubal  pregnancy. 

9.  The  utero-tubo-abdominal  pregnancy. 
10.  And  the  abdominal  pregnancy. 


OF    EXTRA-UTERINE    PREGNANCY.  245 

1.  The  ovarian  pregnancy  is  that  variety  in  which  the  ovum  is  developed  in 
the  ovary  itself;  or  rather,  the  fecundated  ovule  is  found  on  the  interior  of  the 
envelope  or  ovarian  vesicle  that  contained  it  prior  to  fecundation;  or  else,  after 
having  ruptured  this  vesicle,  it  remains  adherent  to  the  surface  of  the  ovary, 
thus  constituting  two  varieties,  the  first  of  which  has  been  denominated  the  in- 
ternal ovarian  pregnancy.  Among  the  recorded  observations  of  our  science, 
bearing  on  this  point  (which,  however,  do  not  appear  very  satisfactory  to  M. 
Velpeau),  is  one  reported  by  Eoehmer,  about  which  it  would  be  useless  to  raise 
a  serious  doubt ;  for  the  author  carefully  describes  both  the  proper  membrane  of 
the  ovary  and  its  peritoneal  envelope ;  and,  unless  we  contest  the  accuracy  of  his 
details,  it  is  impossible  to  deny  that  the  foetus  was  really  in  the  substance  of  the 
ovary  itself 

But  M.  Velpeau,  who  rejects  this  variety  of  extra-uterine  pregnancy,  says, 
that  a  conception  cannot  occur  without  the  direct  contact  of  the  fecundating 
liquid  with  the  ovule;  and  as  this  junction  evidently  requires  the  previous  rup- 
ture of  the  ovarian  vesicle,  an  internal  ovarian  pregnancy,  properly  so  called,  that 
is,  where  the  ovule  is  developed  within  the  interior  of  the  vesicle,  is  wholly  im- 
possible. We  acknowledge  the  speciousness  of  the  argument,  but  shall  repl}'^, 
like  M.  Dezeimeris,  that,  in  the  present  state  of  our  science,  the  manner  in 
which  the  sperm  exercises  its  influence  upon  the  ovule  cannot  be  positively 
determined;  and  that,  between  a  simple  theoretical  view,  however  ingenious  it 
may  be,  and  a  well-observed  fact,  the  most  cautious  cannot  long  remain  undecided. 

The  second  variety  is  designated  under  the  term  of  the  external  ovarian, 
though  it  might  also  be  called  the  ovo-ahdoniinal,  because  the  ovule  is  partly 
developed  in  the  abdomen,  partly  in  the  substance  of  the  ovary  itself 

In  the  first  variety  of  ovarian  pregnancy,  the  product  of  conception  is  evi- 
dently exterior  to  the  peritoneal  cavity. 

2.  Sub-peritoneo-pelvic  Pregnancy. — Under  this  appellation,  M.  Dezeimeris 
designates  a  species  of  extra-uterine  pregnancy,  in  which  the  ovule,  after  havino- 
quitted  the  ovarian  vesicle,  is  unable  to  pass  into  the  external  opening  of  the 
Fallopian  tube,  but  gets  between  the  two  laminae  of  the  broad  ligament,  and  is 
there  developed.  Of  course,  the  ovule  is  situated  without  the  peritoneum,  and 
it  lodges  principally  in  the  pelvic  cavity. 

According  to  this  author,  this  species  is  not  very  rare,  and  from  the  situation 
of  the  ovule  it  is  one  of  the  least  consequence;  indeed,  its  situation  signally 
fixvors  the  spontaneous  expulsion  of  the  foetal  debris,  or  at  least  renders  them 
more  accessible,  in  case  their  extraction  should  at  any  time  become  necesgar3^  I 
am  inclined  to  believe  the  case  observed  by  M.  P.  Dubois,  at  the  obstetrical 
clinic  of  Paris,  in  1837,  the  details  of  which  are  furnished  by  M.  Voillemier,  in 
the  Archives  Generales  de  Medccine,  belonged  to  this  particular  variety. 

3.  Tuho-ovarian  Pregnancy. — In  this,  the  cyst,  which  surrounds  the  foetus, 
is  formed  partly  by  the  ovary,  and  partly  by  the  opening  of  the  dilated  tube, 
whose  extremities  have  conti-acted  some  adhesions  with  the  ovarian  tunic. 

The  following  case  of  Dr.  Jackson's  is  justly  quoted  by  M.  Dezeimeris  as 
serving  for  a  type.     A  woman,  aged  thirty-two  years,  was  seized,  in  consequence 


246  GENERATION. 

of  a  violent  blow  on  the  epigastrium,  •with  some  inflammatory  ?ymptomp,  to 
which  she  speedily  succumbed ;  at  the  autopsy,  a  large  quantity  of  blood  was 
found  diffused  in  the  abdomen,  and  a  fcetus  of  about  ten  weeks  was  found  enve- 
loped in  an  enormous  clot;  the  fundus  uteri  rested  against  the  pubis,  and  its 
cervix  near  the  middle  of  the  sacnim.  This  change  from  its  natural  position 
had  been  produced  by  a  tumor  situated  on  the  left  side  of  the  womb,  which  tumor 
was  formed  by  the  ovary,  the  Fallopian  tube,  and  the  broad  ligament,  that  had 
become  considerably  thickened  and  modified  in  their  structure ;  the  fringed  ex- 
tremity of  the  tube  adhered  intimately  to  the  ovarian  envelope,  and  a  cyst  was 
formed  by  these  two  organs,  whose  distension  by  the  body  contained  therein  had 
produced  the  rupture. 

In  another  case,  related  by  Bussieres,  which  seems  to  me  equally  conclusive, 
the  tube  on  the  right  side  was  extremely  dilated  at  the  extremity;  and  this  dila- 
tation, which  was  an  inch  in  its  largest  diameter,  extended  for  rather  more  than 
an  inch  and  a  half  in  length,  gradually  diminishing  as  it  approached  the  womb. 
The  portion  of  the  tube  thus  dilated  was  curved  on  itself,  and  embraced  nearly 
the  whole  ovary,  to  the  membrane  of  which  it  was  so  adherent  that  it  could  not 
be  separated  without  rupturing  the  attachments.  An  unctuous,  limpid  fluid 
escaped,  as  soon  as  it  was  opened,  and  then  the  ovum  appeared,  which  was  about 
the  size  of  a  hazelnut,  and  was  surrounded  by  the  liquid ;  three-fourths  of  it  had 
already  escaped  from  the  hole  made  in  the  ovary,  so  that  it  no  longer  seemed  to 
rest  there ;  yet,  on  attempting  its  removal,  it  was  found  attached  by  a  hard  pedicle 
covered  with  bloodvessels. 

4.  Tuho-ahdominal  Pregnancy. — It  is  evident  that,  if  the  tube  be  obliterated 
near  the  enlarged  extremity,  the  ovule  which  has  scarcely  entered  its  canal  will 
be  arrested ;  and  if  the  development  occurs  at  this  point,  the  tubal  walls  will 
necessarily  be  dilated,  and  one  portion  of  the  surface  of  the  ovum  be  free  in  the 
abdominal  cavity;  to  this  variety  the  name  of  tuho-ahdominal  is  applied.  The 
placenta  is  attached  in  the  interior  of  the  tube,  and  the  foetus  developed  in  the 
abdominal  cavity,  and  both  are  surrounded  by  a  cyst,  the  walls  of  which  are 
partly  made  up  by  the  parietes  of  the  tube. 

5.  Tuhal  Pregnancy. — This  is  the  most  frequent  of  all  the  varieties  of  extra- 
uterine pregnancy;  which  fact  is  readily  accounted  for  by  the  length  and  nar- 
rowness of  the  canal,  and  by  the  adhesions  and  morbid  obliterations  presented  by 
its  walls.  Under  such  circumstances,  the  ovule  is  arrested  and  developed  at 
some  point  between  its  {\bdominal  extremity  and  the  spot  where  it  enters  the 
uterine  parietes ;  and  by  its  continual  growth  distends  enormously  the  fibres  of 
the  tube  which  constitute  the  envelope  of  the  foetal  cyst.  To  the  numerous 
cases  of  this  kind  reported  by  Yelpeau  and  Dezeimeris,  I  might  add  another, 
already  published  by  me  in  the  Bulletin  de  la  Soci^te  Anaioinique,  but  so  many 
examples  are  everywhere  met  with  that  it  seems  useless  to  reiterate  their  details. 

6.  Interstitial  Tuho-^iterine  Pregnancy. — In  an  anatomical  point  of  view,  it  is 
important  to  distinguish  this  variety  from  the  succeeding  one,  with  which  most 
authors  have  confounded  it,  for  it  exhibits  the  peculiarity  of  the  ovule  being 
arrested  in  that  portion  of  the  tube  which  traverses  the  substance  of  the  uterine 


OF    EXTRA-UTERINE    PREGNANCY.  247 

walls.  At  this  point  the  parietes  undergo  a  considerable  distension,  and  press 
back  the  surrounding  proper  tissue  of  the  organ,  so  that  the  latter  always  forms 
the  most  internal  part  of  the  cyst  that  encloses  the  product  of  conception,  and 
consequently  the  uterine  extremity  of  the  tube  is  often  imperforate. 

7.  Interstitial  Uterine  Pregnancy. — Again,  the  ovule  reaches  that  part  of  the 
tube  which  traverses  the  uterine  walls ;  but  having  arrived  there,  it  opens  a  way 
through  the  tubal  parietes,  penetrates  into  the  midst  of  the  fibres  of  the  womb, 
and  thenceforth  has  no  further  relation  with  the  tube ;  hence,  the  surrouuding 
cyst  is  formed  by  the  muscular  fibres  of  the  womb  alone. 

This  anomaly  appears  wholly  inexplicable,  without  referring  it  to  the  canal 
previously  described  (p.  68),  the  existence  of  which  can  alone,  in  my  esti- 
mation, account  for  the  disposition  here  manifested.  After  having  been  once 
located  among  the  uterine  fibres,  the  ovum  may  either  take  an  inward  or  an  out- 
ward direction,  and  consequently  may  become  seated  near  to  the  mucous  layer, 
or  else  to  the  peritoneal  coat.  In  a  preparation  belonging  to  M.  Pinel  Grand- 
champ,  the  volume  of  the  uterus  was  about  the  same  as  at  six  weeks  or  two 
months  of  pregnancy ;  at  its  left  angle,  a  small  tumor,  slightly  ruptured  behind, 
constituted  the  cyst  containing  the  product  of  conception.  The  tube,  which 
passed  behind  it,  communicated  with  it  by  an  almost  microscopic  orifice,  and 
presented  nowhere  any  increase  of  calibre.  The  cyst  was  about  large  enough  to 
contain  an  almond. 

8.  Utero-tuhal  Pregnancy. — Notwithstanding  the  free  communication  existing 
between  the  tube  and  uterine  cavity,  there  is  no  absurdity  in  the  supposition  that 
the  ovule  may  become  deposited  in  a  little  depression  of  the  mucous  membrane, 
and  there  stop  and  engraft  itself,  just  at  the  internal  orifice  of  the  canal.  In 
this  case,  phenomena  similar  to  those  of  the  tubo-abdominal  gestations  will  arise  ; 
that  is,  the  ovule,  which  may  have  contracted  some  intimate  adhesions  with  this 
extremity,  may,  by  its  development,  encroach  upon  the  uterine  cavity  itself;  and 
I  do  not  hesitate,  therefore,  to  consider  this  variety  of  gestation  as  possible. 

9.  Utero-tuho-ahdominal  Pregnancy. — In  this  species,  examples  of  which  have 
been  furnished  by  Patuna,  Hunter,  and  Hoflfmeister,  the  foetus  is  found  in  the 
abdominal  cavity ;  the  cord  leaving  the  umbilicus  enters  the  Fallopian  tube,  tra- 
verses its  whole  length,  and  is  inserted  in  the  placenta,  which  itself  is  attached 
to  the  internal  surface  of  the  uterus.  However  extraordinary  these  facts  may 
appear,  I  think  that  no  one  can  doubt  them  after  reading  the  subjoined  case, 
taken  from  the  memoir  of  M.  Dezeimeris.' 

'  Helen  Zopp,  aged  35  years,  had  been  married  for  twelve  years,  and  had  given  birth  to 
eight  children,  two  being  twins. 

As  she  was  preparing  for  church  on  Sunday,  July  10th,  1763,  she  was  suddenly  attacked, 
after  a  violent  fit  of  anger,  with  a  profuse  flooding  and  the  pains  of  childbirth  (being  then  at 
term) ;  however,  she  did  not  pass  the  waters,  but  what  proved  to  be  pure  blood;  and  she 
felt  the  motions  of  her  child  up  to  the  last  moment.  The  midwife,  summoned  on  the  occa- 
sion, declared  at  once  that  the  accouchement  was  at  hand ;  but,  after  the  lapse  of  several 
hours,  as  the  loss  of  blood  continued  without  any  positive  signs  of  an  approaching  delivery, 
a  physician  and  a  surgeon  were  simultaneously  sent  for,  the  former  of  whom  soon  arrived, 
and  recognizing  at  onee  the  imminence  of  the  danger,  he  ordered  the  administration  of  the 


248  GENERATION. 

10.  AhJoniinal  Pregnancy. — The  long-contested  question  of  abdominal  gesta- 
tion is  now  established  by  so  many  facts,  observed  both  in  the  human  female  and 
in  animals,  that  we  can  no  longer  justly  deny  its  possibility.  No  doubt  the 
ovarian  or  other  pregnancies  have  often  been  confounded  with  it,  but  in  most  of 
the  published  cases  it  is  incontestable  that  the  ovum  had  no  relation  with  the 
internal  genital  organs  whatever. 

M.  Dezeimeris  has  divided  the  abdominal  gestation  into  primitive  and  secon- 
dary varieties;  in  the  former  of  which  the  product  of  conception  has  never  had 

sacraments,  at  the  same  time  prescribing  divers  remedies  for  the  discharge.  The  venesec- 
tion of  the  cephalic  vein  was  follovred  by  a  profound  syncope,  without  causing  the  least 
abatement  of  the  metrorrhagia,  and  the  sacraments  had  scarcely  been  administered,  when 
the  patient  died,  at  11  A.  M.  on  the  same  day. 

Patuna  and  his  father  (the  public  surgeon  to  the  city)  arrived  just  as  she  was  expiring. 
After  assuring  himself  of  her  death,  he  immediately  made  a  Caesarean  section  upon  the  right 
side,  where  the  abdomen  offered  the  most  resistance,  and,  as  soon  as  the  ventral  walls  were 
divided,  an  enormous  foetus,  resembling  a  child  nine  months  old,  presented  itself;  the  position 
was  such,  that  its  back  corresponded  with  the  abdominal  parietes  of  the  mother  ;  the  head 
was  somewhat  inclined,  was  directed  towards  the  vertebrae,  and  rested  immediately  under 
the  diaphragm  ;  the  knees  flexed  towards  the  head,  the  right  hand  upon  the  thighs,  and  the 
left  near  the  navel :  the  umbilical  cord  was  of  a  considerable  length ;  it  ascended  to  the 
right,  wound  around  the  neck,  and  then  entered  the  Fallopian  tube  on  the  right  side.  A  case 
of  extra-uterine  pregnancy  being  new  to  Patuna,  although  acquainted  with  most  of  the  pub- 
lished examples,  his  researches  were  made  in  the  most  careful  manner. 

Having  enlarged  the  opening  made  in  the  abdomen,  so  as  to  examine  its  cavity  to  better 
advantage,  he  sought  for  the  fcetal  envelopes  with  all  possible  attention,  but  in  vain  ;  for  he 
neither  found  the  amniotic  liquid,  nor  fluids  of  any  other  kind  in  this  cavity.  By  tracing  the 
umbilical  cord  with  his  hand,  he  found  that  it  penetrated  into  the  right  tube  at  the  distance 
of  a  finger's  breadth  from  the  uterus ;  the  uterine  portion  of  the  tube  was  more  voluminous 
than  that  part  which  ran  to  the  ovary,  whence  he  judged  that  the  cord  passed  through  the 
former  into  the  womb. 

This  organ  was  larger  than  the  fist,  and  had  the  natural  pyriform  shape,  but  not  the 
least  vestige  of  any  rupture ;  not  the  smallest  cicatrix  could  be  seen,  and  it  hardly  rose  above 
the  pelvis. 

These  observations  being  concluded,  Patuna  incised  the  tube  from  the  entrance  of  the  cord 
towards  the  uterus:  this  presented  nothing  peculiar,  excepting  the  adherence  to  the  cord 
where  the  latter  perforated  it.  The  uterus  was  then  opened,  and  exhibited  no  trace  in  the 
interior  of  any  previous  laceration  whatever;  the  walls  were  an  inch  and  a  half  in  thickness, 
and  their  substance  was  nearly  bloodless ;  the  placenta  was  found  within  adhering  to  a  nar- 
row space  at  the  fundus,  a  little  to  the  right;  it  extended  more  towards  the  left,  but  was  there 
detached.  It  was  about  two  fingers'  breadth  in  thickness,  and  four  inches  in  diameter,  and 
it  commenced  very  near  the  uterine  opening  of  the  right  tube,  and  adhered  more  strongly 
there  than  at  any  other  place.  The  extremities  of  some  vessels  were  evident  both  on 
its  convex  surface  and  at  the  fundus  uteri  upon  which  it  was  engrafted  ;  its  concave  face, 
from  the  middle  of  which  the  cord  arose,  was  covered  by  two  membranes,  one,  the  interior, 
being  thicker  and  vascular,  while  the  exterior  was  very  thin  and  translucent,  but  these  joined 
when  they  approached  the  border  of  the  placenta,  forming  there  a  more  solid  substance,  and 
having  some  very  delicate  vessels  ramifying  through  it.  The  internal  uterine  orifice  would 
hardly  admit  the  little  finger. 

Everything  else  remained  in  a  natural  state,  excepting  the  change  in  the  situation  of  the 
intestines.     (Barthelemy  Patuna.) 


OF    EXTRA-UTERINE    PREGNANCY.  249 

any  other  domicile  than  the  abdominal  cavity,  into  which  it  fell  immediately  on 
quitting  the  ovarian  vesicle ;  in  the  latter,  on  the  contrary,  the  ovule  was  first 
developed  in  the  ovary,  the  tube,  the  walls,  or  the  cavity  of  the  uterus ;  but  the 
excess  of  distension,  or  some  pathological  alteration  in  the  parietes  of  the  tumor, 
has  destroyed  its  attachments,  and  the  ovule,  being  driven  wholly  or  in  part  from 
the  containing  cyst,  escapes  into  the  abdominal  cavity,  where  it  is  subsequently 
found.  I  cannot,  however,  admit  any  such  distinction,  for  the  secondary  abdo- 
minal pregnancy  of  M.  Dezeimeris  seems  to  me  to  be  nothing  more  than  an  ova- 
rian, tubal,  or  interstitial  gestation,  which  is  terminated  by  the  rupture  of  the 
primitive  cyst  j  and  whether  this  rupture  takes  place  at  an  early  period  or  only 
at  the  regular  term  of  gestation,  it  can  only  be  considered  as  a  mere  anomaly,  and 
in  no  case  can  it  constitute  a  distinct  variety. 

We  shall  therefore  restrict  the  term  abdominal  gestation  to  that  species  in 
which  the  ovule,  at  the  commencement,  engrafts  itself  on  a  part  clearly  separated 
from  the  internal  genital  organs.  The  spot  where  this  may  take  place  varies 
almost  ad  infinitum,  the  placenta  being  sometimes  known  to  adhere  to  the  peri- 
toneum covering  the  right  or  the  left  iliac  fossa,  sometimes  to  the  mesentery,  or 
a  portion  of  the  large  or  the  small  intestines,  again  at  others  to  the  anterior 
abdominal  parietes. 

"We  have  not  been  able,  from  the  restricted  limits  of  this  chapter,  lo  bring 
forward  a  larger  number  of  cases,  but  sufficient  has  been  said  to  furnish  an  idea 
of  the  importance  that  ought  to  be  attached  to  the  different  varieties  of  extra- 
uterine pregnancy  admitted  by  us. 

The  reader  may  consult  with  benefit  the  article  of  Professor  Velpeau,  in  the 
fourteenth  volume  of  the  Dictionnaire  de  Medecine,  the  learned  memoir  pub- 
lished by  M.  Dezeimeris,  in  the  fourth  year  of  the  Journal  des  Connaissances 
Medico- Chirurgicales,  and  the  able  articles  of  Messrs.  Breschet,  Meniere,  and 
Guillemot. 

The  physiological  and  pathological  history  of  these  different  pregnancies  is  yet 
to  be  given,  and  we  shall  therefore  commence  with  their  pathological  anatomy. 

§  1.  Pathological  Changes. 

The  anatomo-pathological  examination  of  extra-uterine  gestations  evidently 
comprises  the  peculiarities  offered  both  by  the  product  of  conception  and  the 
parts  of  the  mother. 

a.  Product  of  Conception. — In  these  pregnancies  the  ovule  has  its  proper 
membranes,  the  chorion  and  the  amnion.  I  may  state  that  I  was  utterly  asto- 
nished to  hear  several  honorable  members  contend,  in  a  recent  discussion  before 
the  xVcademy  of  Medicine,  that  the  envelope  of  the  ovule,  in  abdominal  gesta- 
tions, was  only  composed  of  the  amnios,  and  that  no  chorion  existed ;  for  although, 
in  certain  very  old  pregnancies,  the  most  exterior  foetal  membrane  is  confounded 
with  the  walls  of  the  cyst,  it  is  not  fair  to  conclude,  from  thence,  that  it  did  not 
exist  at  the  commencement. 

Indeed,  it  is  only  necessary  to  recall  our  remarks  on  the  mode  of  development 


250  GENERATION. 

of  the  ovum,  to  comprehend  that  the  absence  of  the  chorion  supposes  that  of  the 
allantois,  and  without  the  h\tter  no  circulatory  relations  can  be  established  be- 
tween the  embryo  and  its  mother. 

The  structure  of  the  walls  of  the  cyst  varies  according  to  the  species  of  extra- 
uterine pregnancy.  In  the  tubal  variety,  they  are  formed  by  the  walls  of  the 
tube  itself,  and  in  the  ovarian,  by  the  integuments  of  the  ovary  and  its  peritoneal 
envelope. 

In  the  sub-peritoneo-pelvic  gestation,  or  whenever  the  ovule,  that  was  origi- 
ginally  located  in  the  ovary,  tube,  or  even  the  uterus,  is  transferred,  after  the 
rupture  of  the  cyst  which  enclosed  it,  to  some  part  of  the  abdominal  cavity,  there 
is  besides  a  pseudo-membranous  cyst,  representing  the  uterine  decidua,  produced 
by  the  inflammation  which  the  presence  of  the  ovule  determines  around  it  But 
this  enveloping  membrane,  the  cyst,  does  not  exist  in  primitive  abdominal  preg- 
nancies. M.  Dezeimeris  thus  explains  the  latter  circumstance  :  when  a  fecun- 
dated ovule  gets  into  the  abdominal  cavity  immediately  after  quitting  the  ovary, 
we  can  readily  believe  that  a  corpuscle  so  minute,  soft,  and  fragile  could  only 
produce  a  very  slight  irritation  at  the  point  of  arrestation,  and  that  the  extent  of 
this  excitation  will  not  pass  beyond  the  limits  of  contact  with  the  little  foreign 
body;  in  a  word,  it  cannot  produce  an  acute  inflammation,  or  extensive  adhe- 
sions, nor  an  exudation  of  plastic  lymph  sufficient  to  form  an  enveloping  cyst. 
Now,  if  it  has  not  primarily  caused  all  these  derangements,  the  neighboring 
organs  will  not  be  injured  by  its  ulterior  development,  because  they  become  gra- 
dually habituated  thereto ;  and  the  ovule,  having  obtained  a  right  of  possession, 
lives,  grows,  and  presents  to  the  smooth,  polished  surfaces  which  touch  it,  a  sur- 
face equally  smooth,  polished,  and  moistened  at  their  expense ;  and  not  having 
occasion  for  any  other  protecting  envelope,  no  cyst  is  formed.  But  when  a  volu- 
minous product  of  conception  suddenly  bursts,  and  its  contents,  placed  at  first 
like  it  in  the  tube  or  ovary,  are  transported  to  the  peritoneal  cavity,  the  ovule 
becomes  there  a  foreign  body,  wounding  and  irritating  the  abdominal  organs 
which  are  unaccustomed  to  its  vicinity,  and  determining  an  acute  inflammation 
around  it,  which  results  in  the  exudation  of  plastic  lymph ;  this,  by  coagulating, 
forms  a  cyst,  and  completely  isolates  the  foreign  body.  If,  under  these  circum- 
stances, the  displacement  of  the  foetus  is  such  that  it  completely  escapes  from 
the  amniotic  cavity,  and  suddenly  locates  itself  with  its  surrounding  liquid  in  the 
midst  of  the  intestinal  mass,  an  inflammation  occurs,  and  the  cyst  we  have  just 
described  forms  around  it ;  the  new  cyst  then  completely  environs  the  foetus. 
But  in  some  cases  the  displacement  is  not  so  complete — the  largest  part  of  the 
trunk  may  still  remain  in  the  amniotic  cavity  after  the  rupture,  a  portion  only 
being  displaced,  and  the  latter  alone  first  determines  an  inflammation  around  it, 
and  then  the  exudation,  which  is  transformed  into  a  false  membrane ;  this,  by 
uniting  with  the  lacerated  margins,  forms  only  a  part  of  the  foetal  cyst,  the  re- 
mainder being  constituted  by  the  old  foetal  envelope,  the  walls  of  the  Fallopian 
tube,  for  instance,  in  the  case  of  a  tubal  pregnancy.  The  same  relations  may  be 
established  with  the  membranes  of  the  ovule  when  the  chorion  and  amnion  are 
ruptured  at  an  advanced  period  in  a  case  of  primitive  abdominal  pregnancy. 


OF    EXTRA- UTERINE    PREGNANCY.  251 

For  instance,  in  a  case  cited  by  M.  Dubois,  the  cyst  that  enclosed  the  foetus  was 
formed  of  a  membrane  ■which  was  not  altogether  uniform  in  its  structure  and 
appearance  :  thus,  for  the  greater  part  of  its  extent,  the  internal  surface  was  of 
a  light  brown  color,  owing  perhaps  to  the  imbibition  of  the  adjacent  liquids,  and 
simulating,  both  to  the  touch  and  sight,  the  aspect  of  the  mucous  membrane  of 
the  small  intestines,  or,  still  better,  the  accidental  membranes  that  occasionally 
line  fistulous  canals ;  while  at  other  points,  those  for  instance  which  were  near 
the  circumference  of  the  placenta,  and  on  the  largest  part  of  this  surface  itself, 
the  cyst  was  more  smooth  and  polished ;  presenting,  in  fact,  the  ordinary  appear- 
ance of  the  amnion. 

The  cyst  was  simple,  and  about  a  fourth  of  a  line  in  thickness  at  the  part 
where  it  exhibited  the  brown  and  villous  character  above  alluded  to ;  but  on  the 
contrary,  where  the  surface  was  smooth  and  polished,  it  evidently  conuisted  of 
two  membranes  (the  chorion  and  the  amnion). 

When  an  extra-uterine  pregnancy  is  somewhat  prolonged,  these  envelopes  are 
sometimes  destroyed,  being  perforated  with  fistulous  canals,  conJmunicating  di- 
rectly with  the  intestinal  canal,  vagina,  bladder,  uterus,  or  an  external  abscess. 
At  times,  the  destruction  of  the  cyst  is  partial,  at  others  complete ;  so  much  so, 
indeed,  as  to  leave  in  certain  cases  no  vestiges  of  its  former  existence;  on  the 
other  hand,  the  envelopes  sometimes  undergo  osseous  or  cretaceous  transforma- 
tions, which  may  convert  them  into  solid  shells.  As  a  general  rule,  the  foetus 
exhibits  nothing  peculiar  in  its  development;  for  example,  in  several  cases 
studied  anatomically  a  Jong  time  after  the  term  of  pregnancy,  the  osseous  system 
appeared  to  have  a  better  development  than  in  the  ordinary  child  of  nine  months. 
The  existence  of  several  teeth  has  frequently  been  noticed,  or  else  traces  of  the 
eruption  of  these  little  bones,  which  would  seem  to  aflford  an  indication  that  the 
foetus  continued  to  live  and  grow  beyond  the  ordinary  term  of  gestation. 

The  most  common  of  the  numerous  alterations  which  it  may  undergo,  is  the 
putrescent  dissolution  of  its  soft  parts,  from  macerating  in  a  compound  of  am- 
niotic liquor,  blood,  and  pus;  the  separation  of  the  various  pieces  of  its  skeleton, 
and  their  discharge  through  the  divers  routes  just  mentioned.  At  other  times, 
it  seems  to  have  undergone  a  kind  of  mummification,  a  complete  drying  up. 
Again,  in  other  cases,  all  the  tissues  appear  to  be  transformed  into  an  osseous  or 
cretaceous  substance,  or  into  one  resembling  the  fat  of  a  dead  body — and  here, 
it  is  doubtless  unnecessary  to  add,  it  is  no  longer  possible  to  discover  any  trace 
of  the  foetal  membranes. 

B.  Tissues  of  the  Mother. — Some  very  large  vascular  canals  are  seen  to  deve- 
lope  themselves  in  those  parts  where  the  ovum  is  attached,  however  devoid  of 
bloodvessels  they  might  have  been  previously ;  and  several  great  veins  are  found 
to  ramify  under  the  peritoneum  towards  the  circumference  of  the  placental  at- 
tachment ;  and  where  the  ovary  or  the  tube  happens  to  be  the  seat  of  pregnancy, 
it  presents  a  soft  tissue,  apparently  fungous  in  character,  and  impregnated  with 
blood. 

The  womb  does  not  continue  so  indifferent  to  the  advancement  of  the  extra- 
uterine pregnancy  as  might  be  supposed ;  for  its  volume  increases  in  a  remark- 


252  GENERATION. 

able  degree,  the  tissues  become  softer,  and  the  mucous  membrane  hypertrophied 
and  more  vascular,  so  as  to  form  from  the  outset  a  true  decidua.  M.  Yelpeau, 
however,  disputes  this  last  assertion ;  but  I  have  endeavored  to  refute  his  opinion 
in  the  Bulletin  de  la  SocUte  Anatomique  (Sept.  1836),  to  which  the  reader  is 
referred. 

This  hypertrophy  of  the  uterine  mucous  membrane  is  of  short  duration.  For, 
as  the  ovum  does  not  enter  the  uterus,  it  has  no  office  to  perform,  and  therefore, 
like  every  other  useless  organ,  becomes  atrophied,  loses  its  vascularity,  and  in  a 
few  months  has  returned  to  its  usual  condition.  A  gelatinous  substance,  a  kind 
of  thick,  ropy  mucus,  is  also  frequently  found  in  the  neck  of  the  uterus ;  but 
w^hen  the  pregnancy  has  advanced  beyond  term,  the  womb  gradually  regains  its 
natural  condition.  Finally,  in  certain  cases,  the  calibre  of  the  Fallopian  tube  has 
been  found  obliterated  at  some  part  of  its  length.     (See  page  266,  et  seq.) 

§  2.  Progress  of  Extra-uterine  Pregnancy. 

During  the  early  months,  it  is  exceedingly  difficult  to  recognize  the  existence 
of  an  extra-uterine  pregnancy;  for  the  modifications  which  then  occur  in  the 
size,  form,  and  consistence  of  the  body  and  neck  of  the  uterus,  will  certainly  lead 
to  error,  and  give  rise  to  the  belief  of  a  true  gestation.  With  regard  to  the 
menstruation  and  the  lacteal  secretion,  no  constant  rule  is  observed.  Sometimes 
the  menses  continue  to  appear ;  at  others,  they  do  not.  In  some  instances  this 
function  is  not  re-established,  even  after  the  period  when  the  accouchement 
should  have  taken  place  j  and  similar  variations  are  met  with  in  the  secretion  of 
milk.  Again,  menstruation  has  been  known  never  to  appear  during  an  extra- 
uterine pregnancy,  which  lasted  more  than  thirty  years,  while  the  lacteal  flow 
continued  throughout  the  whole  of  that  time. 

There  are,  likewise,  some  abdominal  pains,  at  an  epoch  not  very  distant  from 
the  date  of  conception,  more  or  less  analogous  to  the  uterine  pains,  and  at  times 
a  constant,  fixed,  circumscribed  one  in  the  pelvis,  groin,  or  umbilical  region. 
(The  woman  whose  preparation  I  presented  to  the  Anatomical  Society,  had  on 
this  account  been  treated  for  a  partial  peritonitis.)  Not  unfrequently,  there  is 
an  inability  to  lie  upon  one  side.  When  the  tumor,  whilst  still  small,  falls  into 
the  lesser  pelvis,  it  pushes  the  uterus  forward,  the  neck  being  directed  in  front 
and  quite  high  behind  the  pubis.  This  displacement  of  the  neck  of  the  womb, 
together  with  the  presence  of  a  large  tumor  occupying  the  excavation  posteriorly, 
and  the  dysuria  occasioned  by  the  pressure  made  upon  the  neck  of  the  bladder, 
has  been  mistaken  for  retroversion.  Several  examples  of  this  error  are  men- 
tioned by  Burns. 

At  a  later  period  the  tumor  rises  above  the  superior  strait.  The  motions  of 
the  child  are  felt  at  the  usual  time,  but  they  appear  to  be  more  superficial,  and 
are  generally  felt  on  one  side  only. 

The  labor-pains  come  on  at  the  natural  term,  or  at  the  seventh  month,  or  even 
sooner,  generally  lasting  for  three  or  four  days,  but  occasionally  much  longer ; 
and,  should  the  pregnancy  be  unusually  prolonged,  they  are  apt  to  return  at 
varied  intervals,  and  again  pass  oflf. 


OF    EXTRA-UTERINE    PREGNANCY.  253 

Schmidt  reports  a  case  where  the  gestation  lasted  three  years,  within  which 
period  the  labor-pains  were  renewed  eight  times,  and  on  each  occasion  continued 
for  several  weeks. 

In  another  gestation,  of  ten  years'  duration,  the  pains  returned  annually  at  the 
period  corresponding  to  the  term  of  pregnancy. 

These  pains  are  not  produced  by  contraction  of  the  walls  of  the  cyst,  as  many 
have  stated ;  because,  excepting  the  cases  of  tubal  and  interstitial  pregnancy, 
they  never  contain  any  muscular  fibres,  and  hence  we  must  search  for  the  caxise 
in  the  uterus  itself;  for  the  great  development  exhibited  by  this  organ,  and  the 
mucous  and  albuminous  matters  enclosed  in  its  cavity,  the  expulsion  of  which 
requires  some  contractions,  sufficiently  account  for  the  pains  experienced  by  the 
patients.  But  it  is  exceedingly  difficult  to  explain  in  a  satisfactory  manner  their 
frequent  coincidence  with  the  usual  term  of  gestation. 

The  physical  signs  which  require  our  notice,  are  the  changes  in  the  uterine 
body  and  neck,  just  indicated,  the  more  or  less  irregular  development  of  the  belly, 
and  the  possibility,  in  some  cases,  of  distinguishing  two  tumors,  one  being  the 
uterus,  while  the  other  is  formed  by  the  abnormal  cyst. 

In  the  sub-peritoneo-pelvic  variety,  the  product  of  conception,  by  occupying 
the  pelvic  excavation,  displaces  and  compresses  the  organs  there  situated,  the 
vagina  and  rectum,  for  instance,  and  pushes  them  to  one  side.  Frequently,  the 
different  parts  of  the  foetus  may  be  detected  by  the  vaginal  touch. 

The  foetus  seems  to  be  much  nearer  the  surface  in  the  abdominal  pregnancy 
than  in  either  of  the  other  varieties,  hence  its  motions  are  more  easily  perceived, 
and  are  more  distressing  to  the  mother,  and  the  forms  of  the  diffiirent  parts  more 
clearly  distinguishable.  Besides,  the  rounded  and  regularly  circumscribed  tumor 
formed  by  the  uterus  in  a  normal  gestation  is  not  present. 

In  the  tubal  and  ovarian  varieties,  says  Baudelocque,  the  foetal  movements 
should  be  less  vague,  and  its  limbs  more  retracted.  The  body  of  the  uterus  is 
associated  with  the  tumor  formed  by  the  foetal  cyst,  and  can  neither  be  separated 
nor  readily  distinguished  from  it. 

I  have  thus  brought  forward  the  various  signs  by  which  authors  endeavor  to 
detect  the  different  species  of  extra-uterine  gestation,  although  they  have,  in  my 
estimation,  but  little  practical  importance ;  nor  do  I  see  that  auscultation  itself 
could  render  us  much  service  in  determining  the  diagnosis. 

I  ought  to  observe  that  the  possibility  of  a  fresh  fecundation  is  a  feature  com- 
mon to  all  the  varieties  of  extra-uterine  pregnancy. 

Perhaps  it  may  be  serviceable  to  note  that  the  vacuity  of  the  uterus  might  be 
detected  by  the  touch.  Very  frequently  its  habitual  position  will  be  changed  by 
the  pressure  of  the  tumor,  more  especially  when  the  latter  occupies  the  excava- 
tion, and  urges  it  against  some  part  of  the  pelvic  walls. 

Terminations. — It  is  but  rarely  that  an  extra-uterine  pregnancy  is  prolonged 
beyond  the  fourth  or  fifth  month;  for  generally  the  walls  of  the  cyst  give  way, 
in  consequence  of  their  distension,  before  it  has  had  time  to  become  very  large. 
Sometimes,  however,  the  foetal  envelopes  resist  the  pressure  to  which  they  are 
subjected,  and  if  the  foetus  itself  do  not  perish  through  want  of  nourishment,  or 


254  GENERATION. 

by  some  accidental  disease,  its  development  may  progress  until  term,  and  it  may 
even  live  for  some  time  after  the  expiration  of  the  ninth  month.  Such  is  re- 
ported by  Dr.  Grossi  to  have  been  the  case  with  a  lady,  who,  in  all  probability, 
carried  an  extra-uterine  foetus,  whose  motions  were  perceived  clearly  by  himself 
and  several  consulting  physicians,  through  a  space  of  fourteen  months.  Usually, 
the  child  perishes  either  before,  or  shortly  after  the  term  of  pregnancy;  and  we 
shall  now  proceed  to  point  out  the  possible  consequences  of  its  retention. 

A.  Rupture  of  the  Cyst. — When  left  to  itself,  an  extra-uterine  pregnancy  will 
generally  terminate  in  a  rupture  of  the  cyst;  but  the  time  and  consequences 
thereof  are  very  variable.  Were  we  to  class  these  pregnancies  according  to  the 
frequency  of  the  rupture,  and  the  early  period  of  its  occurrence,  they  would 
stand  as  follows  :  the  interstitial,  tubo-interstitial,  tubal,  ovarian,  sub-peritoneo- 
pelvic,  and  the  abdominal. 

It  is  very  rare  for  the  period  of  the  rupture  to  extend  beyond  the  middle  term 
of  pregnancy  except  in  the  latter  varieties. 

This  rupture,  which  is  usually  spontaneous,  always  gives  rise  to  exceedingly 
grave  phenomena,  which  may  be  described  as  the  primitive  and  secondary  conse- 
quences. Thus,  the  patient  at  first  suffers  from  violent  pains  for  several  hours, 
then,  after  a  pain  which  is  much  stronger  than  all  the  others,  a  perfect  calm 
comes  on.  The  abdomen  sinks,  or  becomes  flattened,  and  the  former  tumor  dis- 
appears; a  gentle  and  equal  heat  spreads  over  the  abdominal  cavity,  and,  if  the 
pregnancy  is  well  advanced,  the  patient  feels  as  though  a  voluminous  body  had 
been  suddenly  displaced ;  the  skin  loses  its  natural  hue,  faintings  come  on,  the 
pulse  is  small  and  contracted,  a  cold  sweat  covers  the  whole  body,  and  death  fre- 
quently follows,  because  the  rupture  of  the  cyst  is  often  the  immediate  cause  of 
a  hemorrhage  that  speedily  proves  fatal.  Should  any  circumstance  whatever 
arrest  the  hemorrhage,  the  first  symptoms  that  follow  the  displacement  of  the 
product  of  conception,  and  the  transference  of  the  waters,  blood,  or  even  the 
foetus  itself,  to  parts  not  accustomed  to  such  contact,  are  those  of  a  very  violent 
peritonitis.  The  patient  generally  dies,  though  sometimes  she  is  able  to  resist 
the  violence  of  the  first  inflammatory  symptoms,  in  which  case,  the  course  of  the 
disease  diS"ers  from  that  time,  according  to  whether  the  debris  of  the  pregnancy 
are  to  be  enclosed  in  a  cyst  of  new  formation  for  the  remainder  of  the  patient's 
life,  or  whether  they  are  to  be  eliminated  in  various  ways.  In  the  first  case,  the 
foetus  may  undergo  all  the  transformations  described  under  the  head  of  the 
pathological  anatomy ;  and  in  the  second,  the  symptoms  vary  with  the  manner  in 
which  the  elimination  is  effected. 

B.  Prolonged  retention  of  the  Cyst. — As  we  have  already  stated  the  pecu- 
liarities of  extra-uterine  pregnancy,  when  the  integrity  of  the  cyst  allows  the 
development  of  the  foetus  to  proceed  until  term,  and  even  somewhat  beyond  it, 
we  shall  not  reconsider  it.  We  would,  however,  add,  that  in  some  cases  the  dis- 
orders of  the  general  health,  produced  by  the  development  of  these  abnormal 
pregnancies,  have  been  so  great  as  to  prove  fatal,  without  there  being  any  dis- 
coverable lesion  to  account  therefor.  Thus,  says  M.  Jacquemier,  the  autopsy 
reveals  neither  rupture  of  the  cyst,  nor  a  trace  of  hemorrhage,  peritonitis,  nor 


OF    EXTRA-UTERINE    PREGNANCY.  255 

process  of  elimination  going  on  in  the  cyst ;  the  unfortunate  sufferers  appearing 
to  have  succumbed  under  a  kind  of  exhaustion  of  vital  power. 

The  development  of  the  cyst  ceases  with  the  life  of  the  foetus,  the  circulation 
in  its  walls  becomes  feebler,  the  vessels  which  maintain  the  connections  necessary 
to  the  support  of  the  foetal  life,  gradually  become  atrophied,  and  even  in  great 
part  obliterated;  so  that  the  foetus  and  its  envelopes  are  thenceforth  a  foreign 
body  within  the  organism  of  the  mother.  Occasionally,  the  latter  becomes  accus- 
tomed to  their  presence ;  for  some  women  carry  a  foetal  cyst  for  many  years  with- 
out their  health  appearing  to  be  much  injured  thereby:  we  have  mentioned  what 
transformations  the  foetus  and  its  envelopes  are  liable  to  undergo  in  such  cases. 
Sometimes,  however,  the  weight  of  the  tumor,  and  the  pressure  which  it  exerts 
upon  the  neighboring  parts,  disturb  the  general  functions  so  seriously,  as  to  make 
the  female  demand  earnestly  to  be  relieved  of  the  cause  of  her  suffering  by  an 
operation. 

Whether  the  tumor  be  the  cause  of  acute  pain  to  the  woman  or  not,  it  is 
likely,  after  the  lapse  of  an  indeterminate  period,  to  become  the  seat  of  an  in- 
flammation, which  extends  rapidly  to  the  neighboring  parts.  In  consequence  of 
this  inflammation,  which  may  progress  with  greater  or  less  rapidity,  adhesions 
are  contracted  between  the  walls  of  the  cyst  and  the  parts  adjacent;  ulceration 
begins  at  the  points  of  adhesion,  perforation  follows  with  the  formation  of  com- 
munications between  the  cavity  of  the  cyst  and  that  of  one  of  the  neighborino- 
organs,  or  with  the  exterior,  in  case  the  abdominal  walls  be  invaded  by  the 
ulceration. 

The  foetal  debris  find  their  way  to  the  exterior,  at  times  by  the  bladder,  rec- 
tum, vagina,  and  even  the  stomach,  at  others  by  means  of  an  abscess  opening 
into  the  perineum,  or  through  the  anterior  abdominal  parietes.  Furthermore, 
since  these  latter  communications  are  common  to  all  kinds  of  extra-uterine  preg- 
nancies, we  can  understand  that  the  situation  of  the  foetus  in  the  sub-pei-itoneo- 
pelvic  variety,  which,  as  before  stated,  is  the  most  deeply  engaged  in  the  exca- 
vation, will  render  its  expulsion  by  the  vagina  or  rectum  more  frequent  than  in 
the  others. 

Most  generally,  some  one  of  the  above-mentioned  organs  serves  as  an  excre- 
tory canal,  but  in  certain  cases  several  of  them  are  simultaneously  attacked  by 
the  adhesive  inflammation;  of  course,  ulceration  and  perforation  soon  follow; 
and  the  wreck  of  the  foetus  escapes  at  once  by  the  anus,  the  vagina,  and  throu"-h 
a  fistulous  opening  in  the  abdominal  walls. 

This  expulsion  greatly  endangers  the  mother's  life — for  very  often  the  inflam- 
mation and  suppuration  of  the  cyst,  by  spreading  to  neighboring  parts,  exhausts 
the  patient,  and  sooner  or  later  she  succumbs.  In  the  more  fortunate  cases,  the 
sac  is  gradually  emptied,  cleansed,  and  contracted,  the  suppuration  ceases,  and 
the  wound  cicatrizes,  or  at  least  becomes  a  simple  fistulous  ulcer. 

§  3.  Causes. 

Nothing  can  be  more  obscure  than  the  causes  of  extra-uterine  pregnancy, 
although  numerous  facts  would  seem  to  prove  that  the  effects  of  terror,  coincidino- 


256  GENERATION. 

with  the  time  of  fecundation,  may  produce  such  an  effect  as  to  prevent  the  im- 
pregnated ovule  from  being  ulteriorly  transported  into  the  uterus ;  but  notwith- 
standing the  high  authority  of  those  who  have  adopted  this  doctrine,  it  does  not 
appear  to  me  admissible,  since  the  ovule  does  not  abandon  the  ovary  at  the  mo- 
ment of  conception,  but  several  days  after  or  even  several  days  before  this  event. 
M.  Dezeimeris  brings  forward  one  case  that  seems  to  prove  that  a  blow  on  the 
hypogastrium  a  short  time  after  a  fruitful  coition  may  be  the  cause  of  this 
anomaly,  though  I  should  rather  refer  it  to  a  particular  disposition  of  the  mother's 
organs.  When,  indeed,  we  consider  the  narrowness  of  the  tubal  canal,  we  can 
readily  conceive  that  any  deviations,  even  slight  ones  of  the  Fallopian  tube,  any 
paralysis  or  spasm,  an  excess  or  defect  of  length,  an  engorgement,  the  swelling 
and  ulceration  of  the  mucous  membrane,  or  hardening  of  its  pavilion,  or  any 
retraction  at  the  external  orifice ;  in  one  word,  all  the  anomalies  and  alterations 
described  by  authors  may  take  place  thei'e,  and  give  rise  to  it.  I  myself  have 
had  an  opportunity  of  observing  two  cases  (reported  in  the  Bulletin  de  la  Societe 
Anatomique)  in  which  the  tube  was  obliterated  between  the  point  where  the 
ovule  was  developed  and  the  internal  orifice  of  this  canal.* 

'  The  obliteration  of  the  tube  in  the  case  referred  to  is  so  remarkable  an  occurrence,  that 
I  endeavored  to  learn,  by  referring  to  various  authors,  whether  similar  cases  had  been  re- 
ported; most  of  them  have  not  observed  the  state  of  permeability  or  impermeability  of  the 
tube ;  others,  on  the  contrary,  have  given  their  attention  to  this  point.  Thus,  Smellie  (t.  ii, 
p.  77)  quotes  an  observation  of  Dr.  Fern,  in  which  an  obliteration,  or  rather  an  excessive 
retraction  of  the  tube  was  described.  In  the  memoir  of  M.  Breschet,  on  interstitial  preg- 
nancy, I  found  several  instances  where  the  obliteration  of  the  uterine  orifice  was  also  noted. 
M  Mayer  communicated  a  case  to  M.  Breschet,  where  the  fcEtus  was  developed  in  that  part 
of  the  tube  which  traversed  the  substance  of  the  uterine  walls;  M.  Mayer  further  remarks, 
that  the  right  tube  was  dilated  at  its  fringed  extremity,  contracted  in  the  uterine  portion,  and 
was  completely  obliterated  at  about  three  lines  from  the  uterus;  the  left  one,  in  which  the 
ovule  was  developed,  was  permeable  as  far  as  the  morbid  mass,  but  from  this  point  to  the 
uterus  the  canal  ceased.  He  adds:  it  is  very  probable  that  an  induration  of  the  uterine  sub- 
stance formerly  existed  at  the  insertion  of  the  left  tube,  which  caused  the  occlusion  of  its 
orifice,  and  furnished  an  obstacle  to  the  passage  of  the  ovule. 

M.  Schmidt  reports  that  in  an  example  of  interstitial  pregnancy,  of  six  weeks,  the  internal 
orifice  of  the  right  tube  was  completely  closed.  (The  ovule  was  developed  on  the  right 
side  of  the  womb.) 

M.  Meniere  {Archives,  June,  1826)  furnishes  a  case  of  interstitial  pregnancy  located  in  the 
left  cornua,  and  he  says  the  left  tube  was  impermeable  at  its  internal  part. 

M.  Gaide,  in  a  similar  instance  {Journal  Hebdomedaire,  t.  i),  ascertained  that  the  right  tube 
had  no  uterine  orifice. 

Another  case  is  reported  in  the  Jrchivcs  of  a  mortal  liemorrhage  produced  by  tubal  preg- 
nancy. The  author  adds:  "The  left  tube  (the  ruptured  one)  formed  a  consistent  membra- 
nous sac,  and  its  free  extremity  embraced  the  whole  ovary;  below  the  dilatation,  and  in  the 
uterine  portion,  the  canal  was  completely  obliterated,  in  such  a  manner  that  it  was  wholly 
impossible  to  reach  the  uterus  through  it." 

I  might  cite  a  greater  number  of  examples,  but  I  think  these  will  suffice  to  prove  that  an 
obliteration  of  the  tube  is  sometimes  inet  with  in  extra-uterine  pregnancies ;  for  whenever 
we  find  the  canal  efiaced  between  the  ovule  and  uterus  in  a  tubal  gestation,  it  seems  natural 
to  suppose  that,  if  the  product  of  conception  has  been  arrested  in  the  course  it  has  to  travel 
in  order  to  reach  the  uterus,  some  mechanical  obstacle  has  opposed  its  passage,  and  that  the 


OF    EXTRA-UTERINE     PREGNANCY.  257 

Finally,  if  we  take  into  consideration  the  singular  anomaly  described  by  M.  Gr. 
Richard  (see  page  GG),  we  may  suppose  that  the  fecundated  ovule  might,  in  its 

effacement  is  the  cause  of  such  hindrance  in  the  progress  of  the  ovule ;  consequently,  the 
cause  of  this  variety  of  gestation,  at  least,  seems  to  me  clearly  indicated.  But  how  long  has 
the  eflacement  existed  ?  Was  it  prior  or  subsequent  to  the  conception  ?  In  reply,  it  may  be 
said  that,  according  to  the  ideas  generally  admitted  by  physiologists,  an  obliteration  of  the 
tubes  is  an  infallible  ground  of  sterility,  and  when  met  with  in  a  pregnant  woman  it  would 
be  absurd  to  suppose  that  such  an  obstacle  was  in  existence  before  impregnation.  In  this 
case,  the  seminal  fluid  could  not  reach  the  ovule,  for  its  only  way  is  closed  up,  and  the  fecun- 
dation cannot  occur. 

Let  us  examine,  however,  whether  this  is  the  only  admissible  opinion;  it  is  well  known 
that  the  obliteration  of  a  canal,  lined  internally  by  a  mucous  membrane,  can  only  result 
either  from  the  coagulation  of  a  secreted  liquid,  the  chronic  engorgement  of  its  walls,  or  from 
their  adherence  to  each  other:  and  in  either  of  these  cases  it  is  necessary  to  suppose  the 
existence  of  a  previous  inflammation ;  but  in  neither  of  the  instances  mentioned  have  I  no- 
ticed that  the  females  exhibited  any  peculiar  phenomena  during  the  early  periods,  those  im- 
mediately following  the  fruitful  coition.  Again,  even  supposing  the  inflammation  is  latent, 
and  too  feeble  to  produce  any  sensible  etfects,  we  must  admit  that  its  progress  has  then  been 
very  slow,  and  that  it  could  not  determine  an  obliteration  of  the  walls  (whatever  be  the  mode 
of  its  action)  until  after  the  lapse  of  a  considerable  time;  now  the  ovule,  at  the  earliest, 
arrives  in  the  womb  about  the  tenth  day,  and  therefore  the  inflammation  and  the  subsequent 
eflacement  must  take  place  within  that  short  period  ;  but,  even  admitting  this  hypothesis  to 
be  true,  soine  cause  for  this  phlegmasia  in  the  tube  must  be  assigned,  and  the  partisans  of 
that  opinion  have  not  hesitated  to  assert  that  it  is  either  produced  by  the  irritation,  and  the 
sanguineous  congestion,  experienced  by  all  the  genital  apparatus  at  this  period,  or  by  a  spas- 
modic condition  of  the  tubal  walls,  or,  further,  by  the  presence  of  the  ovule  itself. 

I  shall  reply  to  this  perfectly  hypothetical  explanation,  by  simply  presenting  a  single  fact. 
It  is  this.  In  some  of  the  cases  related  in  the  memoir  of  M.  Breschet,  and  in  several  others 
from  different  writers,  not  only  was  the  tube  that  served  as  the  seat  of  gestation  obliterated, 
but  also  the  one  on  the  opposite  side ;  and  consequently  in  these  instances,  at  least,  we  can- 
not admit  that  a  spasm  of  the  walls,  or  any  irritation  from  the  ovule's  passage  was  the  cause 
of  eii'acement,  and  therefore  we  have  to  believe  that  it  existed  previously. 

From  all  which  it  follows,  as  a  natural  consequence,  that,  contrary  to  the  opinion  generally 
received,  it  is  not  necessary  for  the  sperm  to  pass  successively  through  the  uterus  and  the 
Fallopian  tube,  so  as  to  approach  and  fecundate  the  ovule;  and  further,  this  conclusion  per- 
mits the  adoption  of  certain  facts  which  have  been  rejected  as  improbable ;  for  we  can  ex- 
plain by  it  how,  in  some  females,  there  may  happen  to  be  a  complete  occlusion  of  the  os 
tinctp  at  the  period  of  labor;  how,  in  others,  the  fecundation  has  taken  place  without  a 
proper  introduction  of  the  membrum  virile,  the  physical  proofs  of  virginity  even  remaining 
at  the  time  of  labor. 

But  how,  then,  can  conception  be  explained  ?  Without  adopting  the  theory  of  the  at«ra 
seminalis,  Chaussier,  Mad.  Boivin,  and  M.  Duges  thought  it  was  only  necessary  for  the  sper- 
matic fluid  to  be  deposited  at  the  entrance  of  the  vagina,  so  that,  by  absorption,  it  might  be 
taken  into  the  circulation,  and  then  be  brought  back  through  the  bloodvessels  to  the  ovary, 
where  the  fecundation  occurred.  This  hypothesis  would  indeed  explain  all  the  anomalies; 
but  it  is  not  founded  on  a  single  anatomical  fact,  nor  yet  upon  any  direct  experiment,  and 
further,  it  is  at  variance  with  the  researches  of  modern  ovologists;  so  of  course  I  shall  not 
dwell  further  upon  it. 

Perhaps  comparative  anatomy  might  throw  some  light  on  the  question  before  us:  thus,  in 
certain  mammiferte,  such  as  the  hog,  cow,  &c.,  the  Fallopian  tube  is  not  the  only  canal  that 
affords  a  passage  to  the  sperm ;  for  M.  Gartner,  of  Copenhagen,  has  announced  the  existence 

17 


258  GENERATION. 

progress  alonp;  the  tube  towards  the  uterus,  escape  through  one  of  those  accidental 
openings,  and  so  fall  into  the  abdominal  cavity. 

of  a  particular  duct  in  these  animals,  which  extends  from  the  external  parts  through  the  sub- 
stance of  the  broad  ligaments.  In  182G,  he  came  to  Paris,  and,  conjointly  with  M.  de  Blain- 
ville,  made  some  new  researches  on  this  point,  the  results  of  which  the  French  naturalist  has 
communicated  to  the  public  in  the  Bidletin  de  la  Societe  Philomatique,X.  9,  p.  109,  1826.  The 
latter  says,  that  if  the  vagina  of  a  young  sow  be  carefully  examined,  a  particular  canal  will 
be  discovered,  having  its  external  orifices  on  each  side  of  the  meatus  urinarius,  and  running 
through  the  muscular  fibres  of  the  vagina;  it  becomes  contracted  near  the  neck  of  the  uterus, 
but  does  not  the  less  continue  in  the  uterine  tissue.  This  canal  at  first  follows  the  body  of 
the  womb,  then  abandons  it,  and  runs  in  the  substance  of  the  broad  ligament  parallel  to  the 
corresponding  cornua  and  close  to  the  origin  of  the  Fallopian  tube,  where  it  is  lost  by  seem- 
ing to  spread  out,  or  to  subdivide  in  two  or  three  filaments,  which  can  scarcely  be  distin- 
guished from  the  vessels,  and  more  especially  from  the  proper  tissue  of  the  broad  ligament. 

M.  de  Blainville  says  he  has  searched  in  vain  for  similar  canals  in  women,  but  he  has  not 
met  with  anything  of  the  kind.  Analogy,  however,  renders  their  existence  probable  in  the 
human  species ;  and  this  probability  becomes  still  stronger  from  the  account  of  a  case  com- 
municated by  M.  Baudelocque  to  the  Academic  de  Mddecine  [Jirch.  de  Med.,  1826),  as  an 
unique  anomaly  in  the  science;  although  it  is  a  very  singular  fact  that  Dulaurens,  according 
to  the  report  of  Mauriceau  (Traite  des  Maladies  des  Femmes  Grosses,  p.  12,  t.  1),  had  several 
times  observed  that  the  tube,  after  arriving  at  the  angle  of  the  uterus,  separated  into  two 
distinct  canals,  the  larger  and  shorter  of  which  was  inserted  in  the  fundus  uteri,  while  the 
other,  being  narrower  and  longer,  terminated  at  the  neck,  near  its  internal  orifice. 

De  Graaf  (Opera  Omnia,  p.  212)  thought  he  had  found  canals  in  women  similar  to  those 
described  by  M.  Gartner  as  existing  in  certain  mammiferoe. 

Lastly,  Mad.  Boivin  declares  she  has  met  with  cases  analogous  to  the  bifurcated  canal  of 
M.  Baudelocque.  Hence,  in  these  examples,  at  least,  there  is  good  ground  for  supposing 
that  a  conception  may  occur,  even  when  the  internal  orifice  of  the  tube  is  wholly  obliterated. 

Now,  if,  as  Mauriceau  and  Dulaurens  say  (whose  researches  the  modern  authors  seem  to 
have  entirely  overlooked),  such  anomalies  were  found  at  a  period  when  dissections  were 
much  more  rare  than  at  the  present  time,  we  may  conclude  that,  if  the  writers  of  our  own 
day  have  not  realized  that  disposition,  it  is  because  their  eiforts  are  not  directed  to  the  same 
end. 

I  shall  close  these  remarks  by  bringing  forward  a  case,  reported  by  M.  Reynaud,  in  the  2d 
volume  of  the  Journal  Hebdomedaire,  An.  1829,  as  follows:  A  young  woman,  aged  21  years, 
died  at  La  Charlie  in  consequence  of  a  vertebral  caries.  At  the  autopsy,  the  uterus  was 
found  as  large  as  the  pregnant  organ  at  six  weeks,  and  its  enlarged  cavity  was  occupied  by 
a  false  membrane  having  just  the  same  shape,  but  in  which  no  opening  was  discovered. 
The  adhesions  to  the  walls  were  easily  broken  up,  and  three  or  four  ounces  of  a  yellowish 
liquid  were  found  enclosed  within.  No  trace  of  the  internal  orifice  of  the  tubes  existed,  and 
they  were  equally  obliterated  at  the  free  extremity.  The  long  diameter  of  the  ovaries  ex- 
ceeded an  inch  in  lengdi,  and  their  surfaces  exhibited  evident  traces  of  numerous  cicatrices. 
Both  of  them  contained  in  their  interior  a  rounded  body  of  a  brownish-red  color  (a  true 
corpus  luteum),  and  small  fibrous  pouches  were  detected  in  several  places,  with  wrinkled 
and  retracted  walls.  Numerous  little  ovoidal  bodies,  about  the  size  of  hemp-seed,  resem- 
bling the  ovules,  existed  along  the  course  of  the  tubes  and  in  the  thickness  of  the  broad 
ligament. 

It  was  very  remarkable  in  this  case  that,  notwithstanding  a  complete  obliteration  of  the 
tubes,  the  organs  of  generation  were  found  in  a  condition  similar  to  what  is  observed  at  the 
commencement  of  the  generative  action.  However,  I  shall  deduct  no  direct  conclusion 
therefrom;  but  I  would  ask  your  attention  to  the  confirmation  it  affords  of  the  ideas  pro- 
mulgated in  this  report  (Report  of  M.  Cazeaux,  extracted  from  the  Bulletin  de  la  Societe 
Anatomique). 


OF    EXTRA-UTERINE    PREaNANCY.  259 

§  4.  Treatment. 

It  is  evident  that  no  operation  could  be  attempted  in  the  earlier  months  of 
pregnancy,  even  if  we  should  be  fortunate  enough  to  ascertain  with  certainty 
that  the  ovule  was  not  developed  in  the  uterus. 

It  is  my  opinion,  however,  that  frequent  copious  bleedings  should  be  resorted 
to  in  such  cases,  for  the  double  purpose  of  causing  the  death  of  the  foetus,  and 
of  preventing  (possibly)  a  congestion,  or  rather  too  great  a  determination  of  blood 
towards  the  point  at  which  the  ovum  is  being  developed. 

Indeed,  it  seems  clear  to  me,  that  not  only  does  the  constantly-increasing  weak- 
ness of  the  walls  of  the  cyst,  but  also  the  local  congestions  so  common  during 
pregnancy,  contribute  to  render  rupture  of  the  cyst  more  frequent. 

Venesection,  practised  within  the  limits  authorized  by  the  general  health  of 
the  patient,  will  be  the  more  indicated  here,  as  its  unfavorable  influence  on  the 
child's  life  is  not  to  be  dreaded,  since  its  death  is  the  most  fortunate  event  that 
could  occur.  Might  this  latter  result  be  obtained  by  passing  electric  shocks 
through  the  cyst  ?  Still,  if  no  obstacle  can  be  opposed  to  the  constant  develop- 
ment of  the  foetus,  every  operation  must  be  proscribed  at  this  period  for  extract- 
ing the  foetus  from  its  mother's  body,  because  an  operation  would  be  as  dangerous 
as  the  anticipated  accident.  Even  when  the  spontaneous  rupture  of  the  cyst, 
during  the  early  stages,  occasions  a  just  fear  of  mortal  hemorrhage,  we  can  only 
employ  those  general  means  which  are  the  best  calculated  to  prevent  profuse 
discharges,  such  as  rest,  refrigerants,  &c.  Again,  supposing  that  a  well-marked 
case  of  estra-uterine  pregnancy  has  advanced  almost  to  term,  or  that  the  labor 
has  actually  commenced,  we  may  still  justly  dread  the  laceration  of  the  cyst  as  a 
consequence  of  the  expulsive  efforts ;  and  the  question  then  arises  whether  gas- 
trotomy,  which  has  been  successfully  practised  in  similar  cases,  ought  to  be 
resorted  to.  If  the  child's  safety  be  alone  considered,  this  question  is  easily 
resolved.  But  is  not  the  life  of  the  mother  almost  necessarily  compromised  by 
such  an  operation  ? 

How  shall  we  persuade  the  patient,  when  the  proper  period  for  operating  has 
arrived,  if  she  herself  does  not  suspect  the  danger  she  encounters  by  refusing  ? 
Or  how,  indeed,  can  we  ourselves  decide,  when  the  possible  consequences  are 
foreseen,  the  whole  difficulties  of  a  delivery  appreciated,  and  the  necessity  staring 
us  in  the  face  of  leaving  open  in  the  abdomen  a  vast  cyst,  the  inflammation  and 
suppuration  of  which  are  so  difficult  to  dry  up,  and  are  of  themselves  sufficient  to 
endanger  the  sufferer's  life  ? 

In  such  cases,  who  can  doubt,  says  M.  Dezeimeris,  that,  if  there  was  any 
measure  at  all  that  could  suspend  the  commencing  labor,  the  ties  of  humanity 
alone  would  render  its  employment  a  duty  ?  And  I  fully  embrace  the  same 
opinion. 

Now  among  the  means  calculated  to  restrain  the  ordinary  uterine  contractions, 
I  know  of  nothing  more  serviceable  than  opium,  when  exhibited  in  large  doses 
per  anum,  and  I  certainly  should  not  hesitate  to  employ  it  under  these  circum- 
stances ;  but  if  the  labor  continues,  notwithstanding  its  use,  gastrotomy  may  then 
be  authorized. 


260  GENERATION.  . 

The  cyst  is  generally  opened  through  the  abdominal  parietes,  the  place  of 
selection  being  the  same  as  in  the  common  Caesarean  operation,  though  in  case 
the  head  be  felt  through  the  vagina  during  the  expulsive  efforts,  less  danger 
would  certainly  accompany  an  incision  through  the  walls  of  the  latter.  The  child 
may  be  extracted  by  turning,  or  by  the  forceps,  if  necessary.  In  two  cases,  one 
of  which  is  attributed  to  Lauverjat,  both  mother  and  child  were  saved  by  an  ope- 
ration of  the  kind.  In  three  other  cases,  collected  by  Burns,  the  child  was 
extracted  alive,  but  the  mother  perished. 

Finally,  it  is  evident  that  if  a  prolonged  labor  has  produced  a  rupture  of  the 
cyst,  no  operation  would  be  permissible. 

The  first  efforts  should  be  directed  towards  moderating  the  hemorrhage,  and 
when  the  first  dangers  have  been  removed,  every  means  of  preventing  and  op- 
posing consecutive  inflammation  should  be  energetically  employed. 

But  the  primitive  phenomena  once  calmed,  whether  there  be  a  rupture  or  not, 
our  art  may  evidently  interpose  to  prevent  the  consecutive  accidents  that  have 
been  enumerated,  and  which  compromise  to  so  great  an  extent  the  health  and 
even  the  life  of  the  patient.  When  the  inflammatory  symptoms  have  ceased,  it 
is  proper  to  wait;  and  especially  after  the  cyst  is  ruptured,  hasty  action  becomes 
unnecessary. 

In  fiict,  a  considerable  period  is  requisite  in  such  cases  for  the  development  of 
a  new  cyst  around  the  displaced  parts,  and  a  certain  length  of  time  is  necessary 
for  the  adhesions  to  form  between  them  and  the  adjacent  parts,  and  it  would  be 
exceedingly  rash  to  interfere  with  this  salutary  action  by  any  inopportune  opera- 
tion on  our  part.  In  old  abnormal  pregnancies,  the  resources  of  art  vary  with 
the  particular  case.  Sometimes,  indeed,  an  eliminatory  efibrt  has  already  com- 
menced by  an  inflammation  of  the  integuments  placed  just  in  front  of  the  tumor, 
whereby  an  abscess  is  formed;  and  the  only  question  then  is,  whether  to  open  it, 
or  by  suitable  incisions  to  enlarge  the  spontaneous  solutions  of  continuity ;  in 
either  case  we  encounter  a  vast  abscess,  which  must  be  emptied  and  cleansed  by 
the  usual  methods. 

When  some  portions  of  the  foetus  get  into  the  bladder,  and  we  are  assured  of 
that  fact  by  the  use  of  the  catheter,  the  operation  for  stone  may  be  practised 
either  through- the  vagina  or  by  the  hypogastrium.  Again,  a  woman  may  pre- 
sent herself  with  an  extra-uterine  foetus  of  one  or  several  years'  standing.  Can 
the  resources  of  art  afford  her  any  relief?  We  reply,  that  if  the  gestation  is  a 
source  of  severe  suffering,  and  it  renders  her  incapable  of  discharging  her  duties; 
and  if,  besides,  the  tumor  may  be  reached  through  the  vagina  without  difiiculty, 
the  vaginal  incision  should  doubtless  be  performed.  But  if  she  is  otherwise  in 
good  health,  would  it  be  prudent  to  interfere  for  the  mere  purpose  of  anticipating 
the  accidents  to  which  she  will  probably  be  afterwards  exposed  ?  Or  is  there 
any  ground  for  hoping  to  extract  the  foetus  en  masse,  by  a  prudent  and  metho- 
dical operation  ?  This  last  question  is  far  more  difiicult  to  solve.  In  a  case  of 
this  kind,  where  the  head  of  the  foetus,  from  being  wedged  at  the  superior  strait, 
could  readily  be  felt  through  the  posterior  superior  part  of  the  vaginal  parietes, 
I  knew  Professor  P.  Dubois  (notwithstanding  sharp  opposition  from  several  of 


DISEASES     OF    PREGNANCY.  261 

his  brethren  in  consultation)  to  resolve  upon  incising  freely  the  vaginal  wall,  as 
well  as  the  cystic  envelopes,  intending  to  apply  the  forceps  on  the  head,  and  thus 
extract  the  footus  bodily ;  but  the  walls  of  the  cyst  and  vagina  having  been  cut 
through,  an  intimate  adhesion  was  discovered  between  the  former  and  the  foetal 
head,  which  caused  the  operation  to  be  abandoned.  It  was  not  without  benefit, 
however,  for  in  the  course  of  a  few  days  it  was  followed  by  the  discharge  of  a 
putrid  mass,  comprising  all  the  soft  parts  of  the  foetus ;  the  detached  bones  of  the 
skeleton  were  gradually  extracted  by  the  aid  of  long  pincers,  and  frequently  re- 
peated injections ;  the  cystic  walls  contracted  slowly;  and  when,  at  length,  nothing 
remained,  and  the  parietes  were  cleansed,  the  opening  gradually  closed  up,  and 
by  the  end  of  two  months  the  patient  was  completely  cured.  At  the  time  of 
operating  she  had  been  pregnant  twenty-two  months. 

This  plan,  I  think,  ought  to  be  followed  up  in  similar  cases,  more  especially  if 
the  female's  health  is  visibly  affected. 

Incision  by  the  rectum  has  been  practised  in  some  few  instances  where  the 
vulva  was  obliterated. 

Finally,  gastrotomy  alone  would  be  practicable  when  the  foetus,  from  its  high 
situation  in  the  abdomen,  is  inaccessible  by  the  vagina  or  rectum  ',  but  this  ope- 
ration must  be  regarded  as  the  last  resource,  and  only  to  be  resorted  to  where 
the  patient's  life  is  seriously  endangered. 


BOOK  V. 

PATHOLOGY  OF  GESTATION. 

The  pathology  of  gestation  properly  comprises  all  the  functional  derangements 
that  may  occur  in  the  pregnant  female,  and  all  the  spontaneous  or  accidental 
lesions  of  the  ovum,  sufficient  to  compromise  the  life  of  the  foetus ;  but  we  shall 
pass  over  the  latter,  as  they  most  generally  happen  unperceived,  or  are  not  re- 
vealed to  the  physician  until  it  is  too  late  to  remedy  them ;  in  fact,  all  we  could 
say,  would  be  limited  to  a  few  general  considerations  of  pathological  anatomy, 
altogether  foreign  to  the  object  of  this  work. 


CHAPTER   I. 

DISEASES    OF   PREGNANCY. 

Those  who  have  studied  the  various  affections  of  the  womb,  are  well  aware 
that  its  diseases  excite  numerous  sympathetic  disorders.  The  commencement  of 
the  physiological  acts  which  devolve  upon  it,  and  their  periodical  fulfilment,  exert 
upon  the  functions  of  the  alimentary  canal,  and  upon  those  of  the  nervous  system, 


262  GENERATION. 

an  influence  which  has  for  a  long  time  attracted  the  attention  of  practitioners. 
It  were  useless  to  mention  all  the  morbid  phenomena  which  so  often  precede, 
accompany,  and  follow  the  first  menstruation.  These  are  more  strikinsc  when 
the  latter  is  postponed  or  difficult.  In  some  individuals  they  appear  at  each 
menstrual  epoch  for  a  long  time,  thus  seeming  to  show  an  impossibility  on  the 
part  of  the  organ  to  perform  its  functions,  without  occasioning  extensive  disturb- 
ances of  the  economy ;  and  it  is  only,  so  to  speak,  when  the  sensibility  of  the 
womb  has  been  blunted  by  habit,  that  the  return  of  the  menses  ceases  to  produce 
the  general  disorders  which  accompanied  it  previously. 

If  the  diseases  of  the  organ,  and  even  the  simple  monthly  congestion,  are 
capable  of  giving  rise  to  such  troubles,  it  is  easy  to  foresee  that  pregnancy,  which 
changes  simultaneously  the  form,  size,  and  even  the  structure  of  the  uterus,  can 
hardly  pass  through  its  various  periods  without  deeply  afi"ecting  all  the  functions. 

The  effects  produced  by  the  pregnant  condition  vary  greatly,  as  regards  both 
the  degree  and  the  nature  of  the  symptoms;  all  of  them  being  influenced  by  the 
constitution  of  the  female.  Occasionally,  it  results  in  a  salutary  change  in  the 
entire  system,  better  health  being  then  enjoyed  than  at  any  other  period.  In 
the  majority  of  cases,  however,  tiresome,  or  at  least,  very  disagreeable  symptoms 
are  experienced,  which  are  the  expression  of  the  unpleasant  influence  exerted  by 
the  uterus  upon  important  functions.  These  troubles,  which  are  so  slight  in 
some  individuals  as  to  amount  merely  to  discomforts,  are,  in  others,  so  great  as 
to  injure  their  health,  and  even  to  excite  fears  for  their  existence. 

These  accidents  may  appear  at  almost  any  time;  for  though  some  persons 
begin  to  suffer  at  the  very  outset,  and  are  relieved  by  the  third,  fourth,  or  fifth 
month,  others  are  attacked  only  in  the  latter  half  of  gestation. 

The  pregnant  condition  operates  differently  at  the  different  periods  of  gestation, 
in  the  production  of  the  accompanying  discomforts  or  diseases;  this  fact,  which 
is  important  in  a  therapeutical  point  of  view,  was  felt  vaguely  to  be  so  by  Burns, 
but  clearly  expressed  by  M.  Beau,  who,  I  think,  has  thrown  much  light  upon 
the  pathology  of  pregnancy. 

Most  of  the  functional  disturbances  may  occur  in  the  early,  as  well  as  in  the 
latter  months.  At  first  they  were  regarded  as  the  result  of  the  numerous  sympa- 
thies existing  between  the  uterus  and  the  digestive  apparatus,  and  at  a  later 
period,  the  purely  mechanical  difficulties  produced  in  the  neighboring  organs  by 
the  pressure  of  the  uterine  tumor  were  thought  to  assist  in  their  production. 
Now,  the  pressure  of  the  womb  is  of  quite  secondary  importance,  if,  indeed,  it 
be  of  any  whatever ;  for,  according  to  M.  Beau,  the  following  is  what  usually 
occurs.  The  womb,  as  modified  by  pregnancy,  affects  the  digestive  functions 
through  sympathy,  giving  rise  to  the  dyspeptic  symptoms  described  hereafter. 
The  disturbance  of  these,  results  necessarily,  if  prolonged,  in  deficient  nutrition, 
which,  in  a  woman  who  is  obliged  to  furnish  the  material  for  the  development  of 
the  child,  must  soon  occasion  a  greater  or  less  diminution  of  the  blood  corpuscles, 
and  a  considerable  increase  of  the  serum ;  in  short,  to  all  the  anatomical  charac- 
teristics of  chlorosis  or  polyasmia. 

Now,  this  impoverishment  of  the  blood  soon  occasions  new  morbid  symptoms 


DISEASES     OF    PREGNANCY.  263 

in  the  pregnant  woman,  as  well  as  in  tbe  young  clilorotic  female ;  and  so  serves 
to  explain  the  reappearance  of  the  disorders  of  digestion,  vertigoes,  headaches, 
congestions  of  the  face,  palpitations,  and  difficult  respiration,  so  frequently  ob- 
served at  an  advanced  period  of  pregnancy.  We  thus  see  that  the  functional 
disorders,  which  at  the  outset  are  purely  sympathetic,  become  afterward  inti- 
mately connected  with  the  chlorosis  which  themselves  helped  to  produce.  (See 
Disorders  of  the  Circulation.)  Though  we  shall  have  occasion  to  treat  hereafter 
of  this  latter  etiological  peculiarity,  we  cannot  help  calling  attention,  at  present, 
to  the  importance  of  taking  it  into  consideration  in  the  choice  of  remedial  mea- 
sures. For,  though  it  be  proper  at  the  commencement  to  reduce  the  over-excite- 
ment of  the  uterus,  and  the  sympathetic  irritation  produced  by  it  in  other  organs, 
by  soothing  remedies,  as  baths,  mild  laxatives,  antispasmodics,  and  sometimes 
even  by  moderate  bloodletting,  an  entirely  different  course  should  be  pursued 
toward  the  end  of  gestation.  All  the  restorative  agents,  as  iron,  animal  food, 
and  tonic  wines,  are  here  the  surest  means  of  opposing  the  plethora  and  remov- 
ing the  disorders  which  it  occasions.  Still,  it  is  right  to  observe,  that  beside  the 
chlorosis,  which  plays  the  principal  part  in  the  production  of  the  disorders  of  the 
latter  months,  the  uterus  still  retains  its  sympathetic  influence,  and  is  subject  at 
all  times  to  congestions,  which  increase  its  irritability,  and  cause  it  to  react  upon 
other  organs;  of  all  which,  account  should  be  taken  in  the  treatment.  The  sub- 
ject will  claim  attention  hereafter. 

Finally,  the  connection  which  we  have  endeavored  to  demonstrate  as  existing 
between  the  sympathetic  troubles  of  the  beginning  of  pregnancy  and  the  chlorosis 
of  the  latter  months,  cannot  always  be  readily  discovered.  The  sympathetic  in- 
fluence of  the  uterus  upon  the  digestive  functions,  is  not  always  manifested  by 
vomitings,  nausea,  and  strange  and  depraved  appetites.  All  these  symptoms 
may  be  wanting,  and  yet  the  stomach  fail  to  perform  its  functions  with  its  normal 
regularity.  Nutrition  may  be  disordered,  giving  rise  to  a  dyspepsia,  which  M. 
Beau  proposes  to  distinguish  as  latent;  a  dyspepsia  which  cannot  fail  to  occasion 
eventually  a  general  deterioration  of  the  blood.  Exactly  the  same  thing  occurs 
in  young  girls  whose  menstruation  is  either  difficult,  irregular,  or  imperfect. 
Confirmed  chlorosis  is  always  preceded  in  them  by  sympathetic  disorders  of 
digestion ;  though  sometimes  the  deranged  function  is  evinced  by  very  marked 
symptoms,  at  others,  it  is  hardly  a  cause  of  discomfort. 

Desormeaux,  in  his  excellent  article  on  this  subject,  ranges  all  the  diseases  of 
pregnancy  under  the  following  heads,  viz.,  lesions  of  digestion,  of  circulation,  of 
respiration,  of  the  secretions  and  excretions,  of  locomotion,  and  of  the  sensorial 
and  intellectual  functions.  And  we  propose  to  adopt  the  same  order  in  our  de- 
scription. 

ARTICLE    I. 

lesions  of  digestion. 
§  1.  Anorexia. 

The  want  of  appetite,  or  the  disgust  for  aliments,  which  pregnant  women  are 


264  GENERATION. 

SO  often  affected  with  towards  the  end  of  gestation,  and  still  more  frequently  at 
its  comuiencement,  may  be  referred  to  various  causes,  and  consequently  will  pre- 
sent different  indications  for  treatment.  When  it  seems  to  result  merely  from 
the  sympathetic  relations  existing  between  the  uterus  and  the  organs  of  digestion, 
there  is  little  or  nothing  to  be  done,  for  it  would  be  in  vain  to  attempt  removing 
the  disgust  which  some  patients  have  to  certain  articles  of  food.  In  general, 
they  dislike  all  meats,  and  this  is  an  indication,  or  rather  an  obligation,  to  permit 
the  use  of  vegetables  in  such  cases.  Again,  if  at  an  advanced  stage,  the  anorexia 
be  accompanied  or  preceded  by  the  phenomena  of  general  plethoi'a,  venesection, 
proportioned  to  the  general  condition  of  the  female  and  the  stage  of  pregnancy, 
may  relieve  it.  Care,  however,  should  be  observed  not  to  mistake  the  symptoms 
produced  by  anaemia  for  the  indications  of  plethora ;  the  former  being  far  more 
effectually  treated  by  ferruginous  preparations.  (See  Disorders  of  the  Circulation.) 
In  those  cases  which  exhibit  evident  signs  of  an  overloaded  condition  of  the 
alimentary  canal,  some  purgative,  such  as  rhubarb,  or  even  the  neutral  salts,  may 
be  administered.  Indeed,  certain  authors  have  recommended  an  emetic,  when 
there  is  any  gastric  distress ;  but  I  think  practitioners  ought  to  be  very  reserved 
in  the  employment  of  this  last  measure,  since  the  shock  of  vomiting  has  often 
produced  abortion. 

§  2.  Pica,  or  Malacia. 

Pica,  or  malacia,  frequently  accompanies  the  affection  just  described.  Preg- 
nant women,  like  chlorotic  girls,  often  have  irregular  and  depraved  longings  for 
the  most  absurd  or  disgusting  articles.  For  instance,  I  have  known  a  young 
female  to  eat  pepper  grains  almost  continually.  Another,  at  La  Clinique,  scraped 
the  walls  to  appease  her  cravings  for  chalk ;  and  M.  Dubois  often  relates  in  his 
lectures,  the  history  of  a  young  pregnant  woman  whose  greatest  pleasure  con- 
sisted in  eating  small  bits  of  well-charred  wood.  Again,  they  have  been  observed 
eating  greedily  substances  that  are  still  more  disgusting.  Unfortunately,  all  our 
persuasions  are  useless  with  such  monomaniacs  in  the  majority  of  instances,  and 
consequently  we  must,  as  a  general  rule,  grant  them  an  indulgence,  and  avoid 
too  strong  an  opposition,  unless  the  coveted  articles  would  evidently  be  injurious 
to  their  health. 

I  have  but  little  to  say  of  the  acidity  of  stomach,  of  the  spasmodic  pains  of 
that  organ,  and  of  the  pyrosis  and  other  symptoms  of  gastralgia,  which  are  also 
quite  frequent  during  pregnancy.  The  treatment  of  the  symptom  is  here  the 
same  as  under  ordinary  circumstances.  Thus,  for  sour  eructations  and  acidity  of 
the  primse  viaj,  magnesia  and  the  absorbents,  bicarbonate  of  soda,  the  water  and 
pastilles  of  Vichy,  may  be  administered.  Pyrosis  and  cramps  of  the  stomach  are 
usually  treated  successfully  by  powdered  columbo,  and  most  of  the  antispasmodics, 
in  connection  with  small  doses  of  opiates.  The  latter  may  also  be  used  after  the 
endermic  method. 

If,  however,  it  be  desired  to  attack  the  first  cause  of  these  gastralgic  symp- 
toms, it  is  important  to  remember  that  this  is  different  for  the  first  and  second 
half  of  gestation,  and  that  the  measures  employed  should  vary  accordingly. 


DISEASES     OF    PREGNANCY.  265 

§  3.  Vomiting. 

This  symptom  is  so  common  that  most  females  are  affected  with  it ;  in  fact, 
vomiting  frequently  commences  in  the  very  earliest  stages  :  whence  many  women, 
taught  by  their  former  pi'egnancies,  recognize  it  as  an  almost  certain  sign  of  a 
new  gestation.  At  other  times  it  does  not  appear  until  towards  the  third  or 
fourth  month,  though  seldom  later  than  that ;  but,  it  is  not  at  all  uncommon  to 
see  it  reappear  near  the  end  of  pregnancy  in  some  who  had  been  previously  tor- 
mented in  this  way  at  its  beginning.  As  an  ordinary  rule,  the  vomiting  only 
lasts  six  weeks  or  two  months,  sometimes,  however,  it  extends  over  four  or  five 
months,  rarely  persisting  throughout  the  whole  term.  Some  females  have  the 
unenviable  privilege  of  vomiting  every  time  they  are  pregnant  j  others,  more  for- 
tunate, pass  through  several  gestations  without  feeling  any  digestive  disorders 
whatever.  It  is  a  very  remarkable  fact,  if  we  may  rely  on  the  testimony  of 
numerous  mothers,  that  the  sex  of  the  child  is  not  wholly  irrelevant  to  the  pro- 
duction of  this  symptom,  and,  however  ridiculous  this  may  appear  at  first  sight, 
I  have  heard  it  repeated  by  so  many  women,  that  I  cannot  refrain  from  believing 
that  it,  like  most  other  popular  prejudices,  has  some  foundation. 

But  what  is  the  cause  of  such  vomitings  ?  When  they  occur  near  term,  we 
may  justly  attribute  them  to  the  pressure,  to  the  mechanical  constraint  which  the 
uterus,  whose  fundus  reaches  the  epigastric  region,  exercises  upon  the  stomach ; 
but  in  the  early  stages  it  is  much  more  difficult  to  explain  this  phenomenon, 
unless  we  content  ourselves  by  referring  it  to  the  numerous  sympathies  existing 
between  the  uterus  and  the  stomach ;  sympathies  so  intimate  that  they  are  mani- 
fested in  certain  women  at  every  menstrual  period,  and  even  in  nearly  all  those 
afilicted  with  a  disease  of  the  womb. 

Although  the  intimate  nature  of  these  sympathies  is  very  obscure,  we  can 
admit  them  more  readily  in  the  etiology  of  vomiting  than  the  influence  of  most 
of  the  anatomical  causes  adduced  by  some  authors.  In  endeavoring  to  trace  a 
relation  of  causality  between  the  vomiting  and  an  inflammation  of  the  uterus, 
placenta,  and  membranes,  like  Dance ;  softening  of  the  stomach  and  fatty  dege- 
neration of  the  liver,  like  Chomel ;  or,  finally,  to  the  existence  of  organic  lesions 
of  parts  in  the  neighborhood  of  the  uterus,  observers  have  merely  noticed  simple 
coincidences,  without  throwing  the  least  light  upon  the  question  of  etiology. 
IIow  often,  indeed,  is  nothing  of  the  kind  discoverable. 

I  am  persuaded,  says  Dr.  Bennett,  that  those  gastric  disorders  and  obstinate 
vomitings,  which  so  often  bring  women  to  the  portals  of  the  tomb,  are  almost 
always  caused  by  inflammatory  ulcerations  of  the  neck  of  the  womb.  For  my 
own  part,  he  adds,  since  my  attention  has  been  directed  to  this  subject,  I  have 
almost  invarinhly  found  ulceration  of  the  neck  in  cases  of  this  kind. 

I  cannot  receive  this  opinion  of  the  English  accoucheur,  at  least  as  relating  to 
the  majority  of  cases,  for  I  have  frequently  examined  with  the  speculum  each  of 
four  primiparous  women  affected  with  incorrigible  vomiting,  and  in  whom  I  as- 
certained the  cervix  to  be  perfectly  healthy. 

It  has  been  said  that  primiparous  women  are  more  subject  to  vomiting  than 


26d  GENERATION. 

others,  on  account  of  the  uterus  yielding  less  readily  to  distension  in  first  preg- 
nancies.   . 

Although  this  opinion  is  quite  conformable  to  the  theoretical  views  already 
given,  the  fact  is,  that  it  is  liable  to  very  frequent  exceptions.  Some  multiparge 
who  suffered  vei'y  slight  disorders  of  the  stomach  in  their  first  pregnancies,  have 
vomited  almost  constantly  in  later  ones.  The  rigidity  of  the  uterus  is  not,  there- 
fore, the  only  cause  which  is  capable  of  sustaining  an  irritability  of  the  organ 
which  reacts  sympathetically  upon  the  stomach. 

I  do  not  think  that  an  epidemic  influence  can  be  admitted  as  a  cause  of  these 
vomitings. 

Some  persons  have  been  inclined  to  refer  the  vomitings  and  most  of  the  other 
gastric  disorders  also,  to  albuminuria,  or  at  least  to  the  disease  of  which  it  is  the 
symptom.  I  am  not  prepared  to  disprove  this  opinion,  which  I  think  few  will  be 
disposed  to  adopt,  provided  they  remember  that  these  disorders  of  the  stomach 
are  most  frequent  at  the  beginning  of  pregnancy,  whilst  albuminuria  has  hitherto 
hardly  ever  been  observed  before  its  latter  stages. 

The  vomitings  vary  much  as  regards  their  frequency,  intensity,  and  the  greater 
or  less  ease  with  which  they  are  accomplished. 

Thus,  some  women  vomit  only  upon  awakening  or  rising  in  the  morning. 
They  then  throw  up  some  viscid  or  glairy  matters,  which  are  generally  colored 
with  a  little  bile,  especially  if  the  retchings  have  been  very  severe.  Others  vomit 
only  after  eating ;  occasionally  after  only  one  of  the  daily  meals,  but  sometimes 
after  all  of  them.  Again,  in  some  unfortunate  cases  they  continue  even  in  the 
intervals  of  the  repasts ;  everything  taken  into  the  stomach,  whether  liquid  or 
solid,  being  immediately  rejected.  There  are  cases,  finally,  in  which  the  mere 
theught  of  food,  or  the  sight  or  smell  of  it,  are  sufficient  to  provoke  them. 

The  vomiting  is  sometimes  easy,  and  causes  little  pain ;  it  is  indeed  not  un- 
common to  find  ladies  suddenly  interrupted  at  their  meals,  who  can  return  in  a 
few  minutes,  and  sit  down  and  eat  with  a  good  appetite  and  pleasure. 

In  other  cases,  however,  the  ingestion  of  food  is  pi'oductive  of  pain  in  the 
stomach  or  an  inexpressible  uneasiness  of  variable  duration,  and  it  is  only  after 
five  or  six  hours  of  suffering,  that  the  food  is  vomited  and  then  found  to  be 
almost  .unchanged,  notwithstanding  its  long  retention  in  the  stomach.  In  such 
cases  the  vomiting  is  preceded  by  such  prolonged  and  violent  retchings  as  to 
reduce  the  patient  to  a  state  of  extreme  sufiering  and  agitation. 

It  is  occasionally  followed  by  considerable  epigastric  pain,  which  is  increased 
by  pressure,  and  might  for  a  moment  be  taken  as  a  sign  of  inflammation  of  the 
stomach ;  it  gradually  diminishes,  however,  and  disappears  entirely  after  a  time. 
The  shocks  and  violent  eff^orts  sometimes  extend  their  influence  to  the  hypogas- 
trium,  and  give  rise  to  abdominal  pains  and  even  uterine  contractions,  which  may 
be  active  enough  to  produce  abortion. 

But  it  must  not  be  supposed  that  vomitings,  even  when  prolonged  and  oft- 
repeated,  are  necessarily  disastrous.  No  doubt  many  women  waste  away,  but  I 
have  often  satisfied  myself  that  the  leanness  is  not  apt  to  be  excessive,  by  examin- 
ing females,  who,  according  to  their  own  expression,  could  retain  nothing  at  all ; 


DISEASES     OF     PREGNANCY.  267 

and  hence  it  is  exceedingly  probable  that  all  the  food  taken  by  them  is  not  re- 
jected. 

Burns  states  that  he  has  never  known  vomiting  dependent  on  pregnancy  alone 
to  have  a  flUal  termination.  I  might  cite,  says  Desormeaux,  examples  of  emesis 
accompanied  by  cruel  pains  and  violent  general  spasms,  yet  the  gestation  has 
happily  gone  on  to  full  term.  At  this  time,  I  have  myself  under  care,  a  lady 
who  has  been  vomiting  throughout  the  whole  period  of  gestation,  and  who  has 
just  been  delivered  of  a  daughter  weighing  seven  pounds  and  three  quarters. 

Finally,  it  must  not  be  forgotten  that  in  some  cases  which  even  appear  serious, 
the  vomiting  may  cease  abruptly,  either  spontaneously,  or  because  the  sympa- 
thetic irritation  of  the  uterus  has  been  translated  to  some  other  organ,  or  again, 
as  a  consequence  of  a  violent  mental  emotion.  A  remarkable  instance  of  the 
latter  has  quite  recently  come  under  my  notice.  A  young  lady,  two  months  and 
a  half  advanced  in  her  pregnancy,  had  been  tormented  for  three  weeks  with  such 
obstinate  vomiting,  that,  according  to  her  own  statement,  the  smallest  mouthful 
of  fluid  excited  it,  and  that  she  was  unable  to  retain  anything  whatever  in 
her  stomach.  All  the  remedies  employed  against  it  had  proved  useless.  At 
this  juncture,  her  husband  fell  suddenly  and  dangerously  ill  with  symptoms  of 
strangulation  of  the  bowels,  and  from  this  time  her  vomiting  ceased,  nor  did  she 
suffer  the  least  disturbance  of  her  digestive  functions  afterwards. 

I  have  been  induced  thus  to  hold  forth  from  the  outset  a  favorable  prognosis, 
which  indeed  is  true  for  the  vast  majority  of  cases,  in  order  to  relieve  young 
practitioners  from  the  anxiety  which  some  recently-published  articles  on  the 
gravity  of  this  affection  are  calculated  to  produce. 

The  vomiting  is  not,  generally,  serious,  but  only  painful  and  fatiguing  to  the 
mother;  it  must,  however,  be  acknowledged  that  in  some  very  rare  cases  it 
is  so  violent  and  constant  as  to  exhaust  the  strength  of  the  patient  in  a  few 
weeks,  and  after  producing  extreme  emaciation  terminate  in  death. 

The  display  of  symptoms  given  by  M.  Chomel  in  one  of  his  clinical  lessons, 
applies  to  these  exceptional  cases  only.  The  disease,  he  says,  is  characterized 
by  frequent  bilious  vomiting,  an  acid,  foetid  breath,  and  fever ;  then  the  brain 
becomes  involved,  and  we  have  delirium,  coma,  and  death. 

The  views  of  M.  Dubois  correspond  closely  with  those  of  M.  Chomel,  and,  like 
him,  he  describes  three  stages.  In  the  first  stage,  the  vomiting  is  very  frequent, 
and  occurs  at  all  times  of  the  day.  It  is  very  obstinate,  and  causes  all,  or 
nearly  all  of  the  food  to  be  rejected,  even  liquids  not  being  retained.  This  is 
soon  followed  by  serious  symptoms,  arising  from  deficient  nutrition,  as  debility, 
emaciation,  and  alteration  of  the  features. 

To  these  symptoms  I  would  add  an  extreme  disgust  and  aversion  for  food  of 
any  kind, — a  repugnance  so  invincible  as  to  defy  the  entreaties  of  the  family,  and 
the  repeated  urgent  solicitations  of  the  physician. 

Shortly  after,  the  symptoms  peculiar  to  the  second  stage  begin  to  appear. 
They  are,  frequency  of  pulse,  great  thirst,  and  a  remarkably  acid  breath.  The 
foetidity  and  acidity  of  the  breath,  says  M.  Chomel,  are  so  great  as  to  strike  the 
attention  immediately  upon  entering  the  chamber.     The  smell  is  comparable  to 


268  GENERATION. 

that  of  vinea'fir.  In  three  cases,  however,  two  of  which  proved  fatal,  I  was  unable 
to  perceive  this  odor. 

This  state,  which  is  of  variable  duration,  is  generally  followed  in  a  short  time 
by  a  third  period,  marked  by  cerebral  symptoms.  The  patient  suffers  hallucina- 
tions, intolerable  neuralgic  pains,  and  disordered  vision.  The  vomiting  lessens 
or  stops,  a  comatose  sleep  comes  on,  and  the  scene  soon  ends  in  death,  (ia- 
borie,  Lerons  de  M.  Dubois.^ 

In  moderate  cases,  the  diagnosis  is  quite  easy.  Here,  the  absence  of  acute 
symptoms,  such  as  redness  of  the  tongue,  and  pain  upon  pressure  on  the  epigas- 
trium, would  settle  the  question,  even  were  pregnancy  doubtful.  But  if,  in  the 
cases  just  spoken  of,  the  nature  of  the  epigastric  pain  be  misunderstood,  the 
practitioner  would  be  more  liable  to  error,  therefore  he  should  be  very  careful  in 
his  proceedings.  For  example,  I  have  known  a  case  of  vomiting,  which  the 
autopsy  proved  to  have  been  dependent  upon  tubercular  peritonitis,  attributed  to 
a  pregnancy  which  did  not  exist.  In  the  case  of  another  female,  who  had  actu- 
ally been  pregnant  for  two  months  and  a  half,  the  examination  after  death  disco- 
vered a  serious  disease  of  the  stomach,  amply  sufficient  to  account  for  the  vomiting. 
In  the  latter  case,  it  is  true,  that  an  admixture  of  blood  with  the  matters  vomited, 
had,  during  life,  excited  suspicion  of  organic  disease.  This  very  case  has,  how- 
ever, been  quoted  to  me  by  some  persons  as  one  of  incurable  vomiting  occasioned 
by  pregnancy. 

Generally  speaking,  even  when  the  vomiting  is  not  so  great  as  to  compromise 
the  life  and  health  of  the  mother,  it  has  but  an  indirect  influence  upon  the  life 
of  the  child,  nor  do  I  know  of  a  single  well-attested  case  of  death  of  the  foetus 
from  inanition  through  defective  nutrition  of  the  mother. 

Still,  we  may  understand  how  the  violent  efforts  of  the  female  may  sometimes 
communicate  such  shocks  to  the  uterus  as  to  bring  on  premature  contractions  and 
even  abortion.  We  can  also  comprehend  how  the  same  efforts  may  produce  vas- 
cular congestion  of  the  womb,  giving  rise  to  rupture  of  some  of  the  utero-placental 
vessels  and  detachment  of  the  placenta ;  sv;ch  accidents  are,  however,  rare.  In 
grave  cases,  results  of  the  kind  are  rather  to  be  desired  than  deprecated,  for 
vomiting  generally  ceases  upon  the  death  of  the  foetus,  and  the  mother  escapes 
the  threatened  danger. 

Treatment. — There  are  but  few  medicines  that  have  not  been  proposed,  atone 
time  or  another,  for  this  affection  of  pregnant  women  :  however,  I  shall  merely 
bring  forward  those  which  appear  to  me  the  most  efficacious. 

When  the  emesis  is  slight,  and  only  occurring  in  the  morning,  we  may  recom- 
mend an  aromatic  infusion  of  the  lime-tree,  orange-flower,  common  tea,  &c.  &c. 
Where  it  comes  on  after  a  meal  during  the  day,  it  is  advisable  to  change  the 
order  of  the  repasts;  for  example,  if  it  be  generally  more  distressing  after  supper, 
the  patient  should  sup  sparingly  and  eat  more  breakfast.  Cold  aliments  are 
sometimes  retained  when  others  are  rejected.  Iced  drinks,  mineral  waters,  and 
swallowing  small  pieces  of  ice,  have  arrested  some  cases  of  obstinate  vomiting, 
that  set  at  defiance  the  whole  series  of  antispasmodics.  The  subnitrate  of  bis- 
muth, in  doses  of  from  four  to  eight  grains,  before  each  meal,  has  appeared  to 


DISEASES    OF    PREGNANCY.  269 

me  of  late  to  be  of  some  service.  I  have  also  directed  two  or  three  spoonfuls  of 
kirsch  to  be  taken  after  meals,  and  I  think  with  some  success.  Should  it  persist, 
notwithstanding  these  measures,  a  resort  may  be  had  to  a  remedy,  which  has 
often  succeeded  perfectly  in  my  hands, — I  allude  to  the  narcotics.  About  an  hour 
before  the  meal,  let  her  take  one-third  or  one-half  a  grain  of  the  aqueous  extract 
of  opium  made  into  a  pill ;  but  when  she  is  constipated,  it  will  be  necessary  to 
administer  some  mild  purgative  to  counteract  any  action  the  opium  may  have  on 
the  large  intestine. 

Whenever  the  emesis  is  attended  with  pain  and  stricture  at  the  epigastrium, 
leeches  have  been  recommended  over  this  part,  though  I  have  rarely  seen 
their  application  followed  by  any  benefit.  I  should  prefer  laudanum  lotions,  or 
the  application  of  a  cataplasm  well  tinctured  with  this  fluid.  Sometimes  I 
have  successfully  applied  a  small  blister  to  the  epigastrium,  and  subsequently 
sprinkled  the  sixth  or  the  third  of  a  grain  of  the  muriate  or  acetate  of  morphia 
over  it. 

If  the  vomiting  occasions  pains  in  the  loins,  or  hypogastrium,  in  a  word,  if  it 
threatens  an  abortion,  or  if  the  patient  be  plethoric,  and  this  condition  is  mani- 
fested by  local  or  general  phenomena,  venesection  in  the  arm  should  be  resorted 
to,  as  this  is  one  of  the  best  measures  I  am  acquainted  with,  especially  during 
•the  last  half  of  gestation.  Enemata  containing  laudanum  are  also  very  useful 
for  the  prevention  of  abortion,  as  well  as  for  alleviating  the  vomiting,  and  calm- 
ing the  irritability  of  the  uterus.  General  bathing  may  be  added  to  these  mea- 
sures with  advantage. 

With  regai-d  to  the  regimen,  doubtless  a  mild  liquid  diet,  composed  of  aliments 
that  are  easily  digested,  seems  at  first  to  possess  decided  advantages  over  all 
others ;  but  how  many  exceptions  !  how  many  women  reject  the  mildest  articles — 
even  liquids,  and  yet  readily  digest  less  suitable  substances  !  How  often,  indeed, 
have  I  not  seen  women  eat  ham,  liver,  pie,  &c.,  who  could  not  digest  a  piece  of 
sole,  or  the  white  meat  of  fowl.  Of  course,  we  must  respect  these  peculiarities 
of  the  stomach. 

Among  the  various  measures  recommended,  but  which  I  have  rarely  had 
occasion  to  resort  to,  may  be  mentioned  the  application  of  cups  to  the  pit  of  the 
stomach  (Mauriceau) ;  of  a  plaster  of  theriaea  (Sydenham) ;  a  few  spoonfuls  of 
Sherry  wine,  or  even  some  brandy,  ether,  peppermint-water,  the  potion  of  Eiviere, 
and  the  Colombo  root. 

In  those  cases  in  which  there  was  some  degree  of  regularity  in  the  return  of 
the  pains,  and  febrile  action,  Desormeaux  has  given  two  or  three  grains  of  the 
dry  extract  of  cinchona  with  success.  Lastly,  Walter  and  Blundell  have  highly 
extolled  the  use  of  hydrocyanic  acid  in  the  dose  of  one  or  two  drops,  in  some 
mucilaginous  drink,  several  times  a  day. 

To  overcome  the  acidity  of  the  primas  vise,  M.  Chomel  recommends  the  use 
of  alkalies,  as  the  water  from  the  springs  of  Vichy  and  Bussang,  also  dilute  solu- 
tions of  potash  and  soda,  magnesia  with  milk,  but  never  milk  alone,  and  an 
avoidance  of  acids. 

M.  Bretonueau,  being  induced  to  try  belladonna,  in  the  idea  that  possibly  the 


270  GENERATION. 

vomiting  might  be  occasioned  by  rigidity  of  the  uterus,  succeeded  in  quieting 
it,  even  in  very  grave  cases,  by  rubbing  the  abdomen  with  a  concentrated  solu- 
tion of  that  medicament. 

In  one  very  serious  case,  in  which  the  vomiting  had  resisted  every  effort,  even 
Bretonneau's  measure,  and  in  which  the  poor  patient  seemed  doomed  to  a  speedy 
death,  I  conceived  the  idea  of  applying  the  belladonna  to  the  neck  of  the  uterus ; 
this  was  done  by  means  of  the  speculum.  A  brash,  laden  with  the  soft  extract, 
was  introduced,  and  the  neck,  together  with  the  inferior  segment  of  the  uterus 
and  the  walls  of  the  vagina,  were  besmeared  with  it.  From  this  moment,  a 
marked  change  for  the  better  was  manifest,  and  after  the  same  unctions  had 
been  repeated  on  four  successive  days,  I  had  the  satisfaclfon  of  finding  my  pa- 
tient cured.  It  is  my  duty  to  add,  that  in  another  case,  the  same  means  failed 
completely.  The  unctions  are  made  with  difficulty,  and  on  this  account  too 
small  a  quantity  of  the  preparation  is  left  behind.  Would  it  not,  in  such  cases, 
be  better  to  cover  a  tampon  of  charpie  or  wadding  with  the  extract,  and  after 
placing  it  in  contact  with  the  cervix  by  means  of  the  speculum,  withdraw  the 
instrument,  and  leave  it  there  ?  In  this  case,  it  would  be  necessary  to  watch  the 
patient  attentively,  and  withdraw  the  tampon,  if,  as  I  have  seen  in  several  cases, 
signs  of  intoxication  should  appear. 

M.  Stackler  overcame  the  vomiting  in  two  cases  by  the  black  oxide  of  mer- 
cury, in  the  dose  of  one  grain  daily.  The  prolonged  use  of  the  remedy  was  un- 
accompanied by  salivation. 

Success  has  sometimes  followed  the  use  of  emetics,  and  especially  of  drastic 
pur^^atives.  But  the  first  cause  great  suffering  to  the  female,  and  I  think  that 
in  most  cases,  such  purgatives  as  scammony,  or  calomel  and  jalap,  given  in  pow- 
der or  pills,  would  be  sufficient.  I  have  twice  employed  them  successfully.  In 
one  of  these  cases,  two  grains  of  tartar  emetic  had  been  administered  the  day 
preceding. 

Finally,  alcoholic  liquors  given  to  the  extent  of  intoxication,  have  met  with 
real  success.  M.  Rayer  tells  me  that  he  has  used  them  with  great  advantage, 
and  champagne  wine,  recommended  by  M.  Moreau  in  a  case  so  obstinate  as  to 
cause  o^reat  frequency  of  pulse  and  delirium,  put  an  end  at  once  to  the  symp- 
toms. M.  Jacquemier,  who  related  the  case  to  me,  considered  the  patient  as 
lost,  and  had  only  called  the  professor  in  consultation,  in  order  to  obtain  his 
opinion  in  regard  to  the  propriety  of  producing  abortion. 

Dance  reports  two  cases,  from  which  he  feels  authorized  to  conclude  that  these 
vomitinirs  are  often  an  evidence  of  a  morbid  activity  in  the  uterine  system,  of  an 
inflammation  of  the  membranes;  and  consequently  he  advises  direct  antiphlo- 
gistic measures,  especially  in  the  neighborhood  of  the  womb ;  but,  as  his  opinion 
is  founded  on  two  cases  only,  which,  after  all,  are  not  conclusive,  it  seems  to  me 
that  it  cannot  be  admitted  as  the  rule  of  practice. 

I  have  thus  enumerated  all  these  remedies,  because  they  may  be  successively 
employed  in  this  affection.  In  fact,  the  same  medicine  may  act  on  one  female 
and  have  no  effect  on  another.  And  it  must  be  confessed  that  sometimes  all  will 
fail,  and  we  can  scarcely  succeed  in  moderating  the  patient's  sufferings.     The 


DISEASES     OF    PREGNANCY.  271 

change  of  medicine  is,  however,  useful,  either  by  really  calming  her  distress  in 
a  measure,  or  by  sustaining  her  spirits,  not  seeming  to  abandon  her,  but  holding 
out  the  idea  that  each  new  remedy  may  effect  some  amelioration.  In  this  way 
she  gradually  approaches  towards  term,  or  at  least  to  a  period  of  gestation  when 
these  symptoms  often  disappear  of  themselves. 

But  where  the  vomitings  continue,  notwithstanding  all  the  rational  measures 
resorted  to,  the  woman  absolutely  throwing  up  everything  she  takes,  and  the  pri- 
vation from  food  has  reduced  her  to  such  a  state  of  emaciation  as  to  endanger 
life,  and  the  symptoms  which  we  have  described  as  belonging  to  the  second  and 
third  stages  appear,  some  accoucheurs  have  advised  (if  her  term  is  still  remote) 
the  production  of  premature  labor.  This  operation  has  already  been  practised, 
in  similar  cases,  by  several  English  and  Grerman  accoucheurs,  with  full  success, 
both  for  the  mother  and  child.     (jMerriman,  Blundell,  and  Churchill.) 

It  seems  to  me  that  it  cannot  be  improper  to  resort  to  this  measure  after  the 
seventh  month  of  gestation,  for  it  then  appears  to  be  fully  justified  both  by  the 
dangers  to  which  the  mother  is  exposed,  and  by  the  possibility  of  the  child  living 
after  its  expulsion. 

But  is  the  case  the  same  before  the  sixth  month,  when  the  sudden  termination 
of  pregnancy  must  necessarily  lead  to  the  death  of  the  foetus?  This  is  one  of 
■the  gravest  questions  which  can  come  up  in  practice.  Although  fully  disposed 
to  sacrifice  the  child  whenever  that  sacrifice  will  siircli/  save  the  life  of  the 
mother,  as  in  cases  of  extreme  narrowing  of  the  pelvis,  I  make  no  hesitation  in 
declaring  myself  against  the  production  of  abortion  under  the  circumstances  in 
question. 

I  shall  proceed  to  justify  this  proscription,  as  I  know  that  several  distinguished 
accoucheurs  have  boldly  decided  in  the  affirmative. 

When  a  woman  having  a  contracted  pelvis  presents  herself  to  a  physician,  he 
knows  very  well  that  if  the  pregnancy  be  allowed  to  go  on  until  term,  he  will 
have  to  choose  between  embryotomy  and  the  Csesarean  operation ;  also,  that  in 
some  cases  the  latter  operation  will  be  the  only  resource.  If,  after  mature  con- 
sideration of  the  inevitable  consequences  of  the  one  and  the  probable  conse- 
quences of  the  other,  he  decides  upon  the  mutilation  of  the  child,  it  will  doubt- 
less appear  to  him  reasonable  not  to  wait  until  the  increased  size  of  the  foetus  at 
term  shall  add  to  the  difficulties  and  dangers  of  embryotomy;  therefore,  the  pro- 
duction of  abortion  within  the  first  four  months  of  gestation  will  seem  to  be  fully 
justifiable. 

But  the  conditions  are  different  when  the  life  of  the  mother  is  compromised 
by  vomiting,  however  severe  it  may  be. 

In  the  first  case,  the  danger  is  inevitable;  and  unless  abortion  occurs  sponta- 
neously, the  CfBsarean  operation  is  the  only  resource,  and  we  are  aware  of  the 
usual  consequence  of  the  latter.  But  however  intense  the  vomitings  may  be, 
and  notwithstanding  the  state  of  exhaustion  to  which  they  reduce  the  female, 
still  they  are  not  inevitably  fatal.  Patients,  whose  condition  justly  excited  the 
greatest  solicitude,  have  been  known  to  resist  until  the  latter  months,  and  even 
until  the  term  of  their  pregnancy,  and  then  give  birth  to  strong  and  healthy 


272  GENERATION. 

children.  Others,  whom  the  vomiting  had  reduced  to  a  hopeless  condition,  have 
been  suddenly  restored  to  the  most  complete  health.  A  case  of  this  kind  has 
fliUen  under  my  own  notice,  and  the  following  was  related  to  me  (June,  1849) 
by  M.  P.  Dubois. 

A  young  German  lady,  two  months  and  a  half  pregnant,  had  been  troubled 
with  the  most  obstinate  vomiting  from  the  first  two  weeks  after  conception.  For. 
the  last  sis  weeks,  especially,  she  vomited  almost  without  intermission ;  the 
smallest  spoonful  of  fluid  exciting  violent  contractions  of  the  stomach.  She  was 
extremely  emaciated  and  feeble,  and  her  breath  was  disgustingly  foetid ;  in  short, 
her  symptoms  were  so  serious,  that  M.  Dubois,  who  was  called  in  consultation, 
requested  the  additional  advice  of  M.  Choniel.  Both  of  these  gentlemen  came 
to  a  most  unfavorable  prognosis,  and  left  the  patient,  under  the  impression  that 
she  had  but  a  few  days  to  live.  Some  cold  applications  were  the  only  remedies 
advised,  but  the  attending  physician,  being  alarmed  at  her  extreme  weakness, 
limited  them  to  slight  aspersions.  On  the  second  day  after  the  consultation  the 
patient  was  attacked  with  violent  purging,  and  from  that  time  the  vomiting 
ceased  and  never  returned.  The  poor  sufferer  was  at  once  able  to  take  and  retain 
some  nourishment,  which,  being  gradually  increased  in  amount,  soon  restored 
her  strength.  Now,  this  woman,  who  had  been  so  greatly  reduced  that  two 
eminent  men  regarded  her  fate  as  sealed,  is  in  the  enjoyment  of  perfect  health, 
and  has  almost  reached  the  middle  of  her  pregnancy  with  every  prospect  of  a 
happy  termination. 

In  two  other  cases,  which  the  professor  related  with  commendable  frankness, 
he  had  deemed  it  his  duty  to  propose  the  induction  of  premature  labor.  The 
women  declined  submitting  to  the  operation,  and  reached  the  end  of  their  preg- 
nancies in  good  health. 

2.  When  abortion  is  produced  in  cases  of  extreme  contraction  of  the  pelvis, 
there  is  a  certainty  that  when  once  accomplished,  all  the  dangers  which  threat- 
ened the  termination  of  the  pregnancy  are  at  an  end,  and  that  only  the  usual 
consequences  of  miscarriages  can  follow  from  the  operation.  Even  supposing 
that  the  artificial  means  should  add  to  the  ordinary  risks  of  spontaneous  abor- 
tions, the  object  is  nevertheless  certainly  attained  in  terminating  a  pregnancy 
whose  progress  so  greatly  endangered  the  mother's  life. 

The  conditions  are  very  different  in  cases  of  spontaneous  vomiting,  for  if  all 
the  instances  on  record  be  referred  to,  it  will  be  found  that  the  operation  is  far 
from  removing  the  danger.  I  am  well  aware  that  four  or  five  fortunate  cases 
have  been  cited  from  the  practice  of  English  accoucheurs,  but  we  are  not  told 
how  often  it  has  been  followed  by  death. 

We  have  a  personal  knowledge  of  seven  cases,  in  two  of  which  we  declined 
the  operation,  which  was  afterwards  performed  by  skilful  hands.  Of  these,  but 
one  woman  survived ;  all  the  others  perished,  one  of  the  latter  dying  only  fifteen 
days  after  the  first  attempts,  and  ten  days  after  the  abortion  was  accomplished. 
The  vomiting  ceased,  it  is  true,  and  she  was  able  to  take  some  food ;  but  the 
fever  continued,  abscesses  appeared  in  several  parts  of  the  body,  and  though  no 
autop.sy  could  be  made,  it  is  very  likely  that  they  originated  in  a  deep-seated 


DISEASES    OF    PKEGNANCY.  273 

suppuration  of  the  genital  organs.  However  this  may  be,  the  fact  of  the  patient 
having  lived  for  fifteen  days  after  the  first  attempts  to  procure  the  abortion, 
makes  it  difficult  to  say  that  the  operation  had  been  postponed  too  loyg. 

The  failure  of  the  other  operations  was,  nevertheless,  accounted  for  in  this 
manner.  The  operation  was  performed  too  late,  say  they,  when  the  prolonged 
defective  nutrition  of  the  mother  had  exhausted  the  vital  powers;  and  had  the 
uterus  been  emptied  sooner,  the  chances  of  success  had  certainly  been  greater. 

I  believe  this  fully;  but  here  it  is  that  the  most  difficult  question  arises. 
When  is  the  operation  proper  ?  If  you  act  too  soon,  may  it  not  be  said,  whilst 
instancing  the  cases  of  spontaneous  cessation  of  the  vomiting,  as  in  those  which 
have  been  quoted,  that  you  have  destroyed  the  foetus  without  advantage  ?  If 
you  act  too  late,  may  you  not  be  equally  reproached,  in  view  of  the  failure  of  all 
known  operations,  with  an  attempt  which  may  have  hastened  the  fatal  termi- 
nation ? 

Where  will  the  prudent  practitioner  place  the  limit  of  expectancy  ?  If  it 
be  remembered  that  the  ancient  accoucheurs  declared,  as  do  Mauriceau  and  De- 
lamotte,  that  the  vomitings  may  possibly  produce  abortion,  yet  are  not  dangerous 
for  the  mother ;  also  that  many  moderns  assert  with  Burns  and  Desormeaux, 
that  they  have  never  known  them  to  terminate  fatally,  there  would  certainly  be 
small  temptation  to  operate  before  all  hope  had  been  dissipated  by  the  gravity  of 
the  symptoms.  Our  hopes,  indeed !  But  does  not  nature  sometimes  mock  at 
our  expectations  ?  Did  not  the  patient  of  MM.  Dubois  and  Chomel  seem  doomed 
to  certain  death  ? 

I  know  it  may  be  answered  that  it  must  be  left  to  the  tact  and  skill  of  the 
practitioner  to  think  deeply,  and  choose  conscientiously,  between  the  dangers  of 
expectation  and  the  chances  of  an  operation ;  that  the  difficulties  which  I  raise, 
present  in  a  host  of  surgical  cases;  that  there  is  barely  an  amputation  which  may 
not  be  authorized  by  affirming,  dogmatically ^  that  a  spontaneous  cure  is  impos- 
sible ;  that  the  exceptional  preservation  of  a  limb  proves  nothing  against  the  pro- 
priety of  amputation  in  a  majority  of  similar  cases. 

All  this  is  doubtless  true ;  but  let  us  not  decide  too  quickly,  for  the  comparison 
is  far  from  being  strictly  just. 

When  the  surgeon  has  to  deal  with  a  serious  traumatic  lesion,  he  regards 
nothing  but  the  interest  of  his  patient ;  and  after  explaining  to  him  the  grounds 
of  his  conclusion,  may,  in  cases  of  difficulty,  consult  his  wishes,  and  then  leave 
his  life  at  his  own  disposal.  The  accoucheur  has  the  serious  interests  of  two 
beings  to  care  for ;  and  though  the  instinct  of  self-preservation  may  silence  in 
the  female  the  voice  of  maternal  feeling,  it  is  nevertheless  his  duty  to  protect  the 
foetus,  with  whose  welfare  he  is  equally  intrusted. 

In  a  given  traumatic  lesion,  all  experience  shows  that  spontaneous  recovery  is 
a  rare  exception.  On  the  other  hand,  the  experience  of  all  accoucheurs  goes  to 
prove  that  the  spontaneous  cessation  of  vomiting  is  of  almost  universal  occurrence. 
Finally,  when  the  surgeon  decides  upon  a  grave  operation,  he  is  not  only  con- 
vinced that  he  affijrds  his  patient  a  much  greater  chance  than  by  expectation, 
but  is  emboldened  by  the  results  which  it  has  already  afibrded. 

18 


274  GENERATION. 

Hitherto,  when  abortion  has  been  induced  in  order  to  stop  the  vomiting,  it  has 
not  generally  prolonged  the  mother's  life  to  a  sensible  degree,  though  it  has  in- 
variably destroyed  the  foetus ;  and  even  in  the  gravest  cases,  if  the  results  of 
induced  abortion  be  compared  with  those  afforded  by  expectation,  conjoined  with 
the  use  of  rational  therapeutic  measures,  the  advantage  will  be  found  to  remain 
with  the  latter. 

We  thus  see  that  the  surgeon  and  the  accoucheur  stand  on  a  different  footing, 
and  that  the  difl&culty  which  I  have  suggested  is  not  removed  by  the  comparison 
which  has  been  made  between  them  with  that  object. 

The  impossibility  of  deciding  rationally  upon  the  proper  moment  for  producing 
abortion,  still  continues,  we  observe,  in  its  fullest  extent.  Therefore,  so  long  as 
in  any  given  case,  it  is  impossible  to  say  that  the  patient  presents  an  assemblage 
of  symptoms  which,  if  left  to  themselves,  will,  in  all  probability,  prove  fatal,  and 
these  symptoms  existing,  it  \^  jjrohahle  that  the  procuring  of  abortion  will  put  an 
end  to  them,  and  restore  the  patient, — I  think  that  the  operation  should  be  re- 
jected as  irrational. 

§  4.  Constipation.    Diarrhcea. 

Constipation  is  a  very  common  affection  in  pregnant  women,  and  it  is  usually 
attributed  to  the  pressure  of  the  developed  uterus  on  the  upper  part  of  the  rec- 
tum, by  which  not  only  is  the  calibre  diminished,  but  its  action  is  also  paralyzed. 
Would  it  not  be  more  reasonable  to  attribute  it  in  many  cases  to  a  commencing 
chlorosis  ?  We  know,  indeed,  that  constipation  is  so  common  in  the  latter  dis- 
ease, that  Hamilton  regarded  it  as  one  of  its  causes.  When  carried  too  far,  it 
often  produces  anorexia,  and  disordered  digestion,  and  becomes  a  cause  of  agita- 
tion and  loss  of  sleep.  Whatever  be  its  cause,  the  strainings  necessary  to  expel 
the  hardened  fseces  that  have  accumulated  in  the  intestine,  may  give  rise  to 
hemorrhage  and  abortion. 

The  best  measures  for  preventing  and  remedying  this  state  are  nearly  identical 
with  those  used  at  other  periods  of  life. 

The  same  remarks  apply  to  the  diarrhoea  with  which  women  are  often  tor- 
mented. 

ARTICLE   IL 
lesions  of  respiration. 

Cough  and  dyspncea  are  about  the  only  affections  claiming  our  examination 
under  this  title. 

The  dyspnoea  that  supervenes  towards  the  end  of  pregnancy  is  evidently  pro- 
duced by  the  crowding  of  the  lungs  from  the  excessive  uterine  development,  and 
the  delivery  alone  can  cure  it;  but  sometimes  it  is  sooner  manifested  in  conse- 
quence of  a  pulmonary  congestion,  which  must  be  remedied  by  general  blood- 
letting, a  light  regimen,  repose  in  a  suitable  position,  and  loose  clothing. 

The  same  may  be  said  of  such  palpitations  as  are  not  due  to  organic  disease 


DISEASES    OF    PREGNANCY.  275 

which  existed  before  the  pregnancy;  but  it  must  not  be  forgotten  that  though 
bleeding  is  useful  when  the  dyspnoea  or  palpitations  are  very  severe,  by  diminish- 
ing the  local  congestion  for  the  time,  the  latter  is  much  more  frequently  due  to 
hydra;mia  than  to  a  true  plethora,  and  that  the  best  means  for  preventing  its 
return  is  to  follow  the  bleeding  by  tonic  remedies.     (See  the  following  article.) 

As  to  the  cough,  it  is  only  dangerous  as  regards  the  pregnancy,  by  the  violent 
jars  sometimes  given,  which  may  produce  an  abortion.  Indeed,  all  the  observers 
who  have  written  on  the  influenza,  have  carefully  noted  the  frequency  of  this 
accident  in  women  who  were  affected  with  it. 

When  the  cough  is  the  effect  of  pregnancy,  it  may  sometimes  be  attributed  to 
local  plethora,  and  then  we  should  bleed.  But  at  other  times  it  has  a  spasmodic 
character  resembling  hooping-cough,  with  the  exception  of  the  alteration  of 
the  voice.  In  such  cases,  I  have  derived  much  advantage  from  baths,  repeated 
for  several  days  in  succession. 

When  it  is  the  symptom  of  a  chronic  malady,  existing  prior  to  gestation,  the 
treatment  will  vary  with  the  disease  that  produced  the  cough.  Whatever  may 
be  its  origin,  the  accoucheur  should  always  resort  to  such  demulcents  and  pecto- 
rals as  are  calculated  to  diminish  its  intensity. 


AKTICLE  III. 

lesions  of  the  circulation. 

§  1.  Alterations  of  the  Blood.    Plethora  and  Hydremia. 

The  general  circulation  is  more  active  in  pregnant  women  than  in  others,  and 
this  increased  activity  manifests  itself  by  a  greater  frequency  of  pulse,  which  is 
often  harder  and  fuller  than  in  the  non-gravid  state.  Though  all  this  may  be 
regarded  as  normal,  it  sometimes  becomes  exaggerated  and  gives  rise  to  a  slightly 
morbid  condition.  Thus,  some  women  experience  at  the  same  time,  vertigo, 
dimness  of  vision,  ringing  of  the  ears,  sudden  flushings  of  the  face,  spontaneous 
heats  over  the  body,  but  more  especially  of  the  head.  If  bleeding  be  practised 
under  these  circumstances,  the  blood  will  sometimes  afford  a  large  and  consistent 
clot  with  but  little  serum ;  though  much  more  frequently  there  is  much  serum, 
and  a  small  clot,  covered  with  a  distinct  whitish  coat,  resembling  that  observed 
in  inflammatory  diseases. 

The  differences  in  the  appearance  of  the  blood  drawn  by  venesection  ought  to 
have  excited  the  suspicion  that,  notwithstanding  their  identity,  these  functional 
disturbances  might  be  produced  by  different  causes ;  and  although  some  scattering 
therapeutic  measures  induce  the  supposition  that  the  idea  had  suggested  itself  to 
some  good  minds,  it  is  also  evident  that  it  was  almost  immediately  stifled ;  for 
the  majority  of  authors,  even  the  most  recent,  do  not  hesitate  to  refer  them  to 
plethora,  and  making  the  treatment  correspond  with  the  etiology,  recommend 
bloodletting  as  the  best  means  of  overcoming  it. 

The  little  advantage  which  I  had  derived  from  this  practice,  had  for  several 


276  GENERATION. 

years  excited  doubts  in  my  mind  as  to  the  value  of  the  theory ;  which  doubts 
were  especially  increased  by  reading  the  admirable  investigations  by  M.  Andral 
on  the  blood.  Therefore,  in  treating,  in  1844,  in  the  second  edition  of  this  work, 
of  the  plethora  of  pregnant  females,  I  wrote  as  follows  :  "  After  having  read  the 
curious  statements  just  given  (a7ial^sis  of  the  blood  by  M.  Andral),  the  reader 
will  perhaps  find  them  to  disagree  with  the  title  of  this  paragraph,  and  possibly 
also  with  the  therapeutic  measures  hereafter  recommended  j  for  how,  indeed,  can 
we  reconcile  this  denomination  of  plethora,  applied  to  the  totality  of  the  pheno- 
mena observed  in  most  gravid  females,  with  the  evidences  of  anaemia  furnished 
by  the  analysis  of  the  blood  ?  7s  it  not  probable  that  the  profession  has  hereto- 
fore been  in  error,  in  attributing  to  this  cause  what  in  fact  is  only  due  to  an  im- 
poverishment of  the  blood?  Because,  if  to  these  results  we  add  the  beating  of 
the  carotids,  the  caprices  of  the  stomach,  the  digestive  disorders,  and  the  varied 
nervous  phenomena  that  occur  during  pregnancy,  and  which  closely  resemble 
those  so  often  observed  in  chlorotic  patients,  are  we  not  irresistibly  brought  to 
the  conclusion,  that  the  chlorosis  which  produces  them  in  the  one  case  also  does 
in  the  other?  and  consequently,  that  the  bleeding  generally  recommended  is 
more  likely  to  augment  than  to  diminish  such  disorders  ?  A  sufficient  number  of 
facts  are  still  wanting  to  decide  the  question  satisfactorily ;  but,  while  presenting 
in  this  work  the  views  most  generally  received,  we  cannot  conceal  the  eiFects 
produced  on  our  mind  by  the  experiments  of  Andral  and  Gravarret." 

From  that  time,  we  have  endeavored  to  test  by  facts,  the  inferences  which  we 
had  drawn  from  the  documents  furnished  by  the  experiments  of  these  two  learned 
professors ;  and  we  have  to  say,  that  the  theory  is  confirmed  by  practice.  There- 
fore, we  now  assert  boldly,  what  we  before  expressed  timidly  in  a  simple  note : 
That  hydremia  is  the  most  frequent  cause  of  those  functional  disorders  of  preg- 
nant women  which  have  hitherto  been  attributed  to  plethora. 

However  strange  this  proposition  may  at  first  appear,  it  seems  to  us  to  be 
proved  by  the  results  of  the  chemical  analysis  of  the  blood,  by  the  symptoms 
presented  by  the  patients,  and  by  the  happy  effects  of  a  tonic  treatment. 

1.  It  is  now  well  proved  that  the  essential  character  of  plethora  is  based  upon 
a  great  increase  in  the  proportion  of  the  blood  corpuscles,  as  their  diminution  is 
the  distinctive  fact  in  anaemia.  Now,  if  we  admit  with  MM.  Andral  and  Gavar- 
ret,  that  the  mean  normal  proportion  of  corpuscles  is  127,  or  with  MM.  Bec- 
querel  and  Rodier,  that  it  is  141  for  men  and  125  for  women,  it  will  be  seen 
that  all  the  analyses  made  up  to  the  present  time  give  a  much  lower  mean  for  a 
woman  at  an  advanced  stage  of  her  pregnancy.  Thus,  of  34  bleedings  examined 
by  Andral  and  Gavarret,  but  one  specimen  exhibited,  at  the  end  of  the  second 
month,  a  proportion  of  corpuscles  greater  than  the  physiological  mean,  namely, 
145.  In  one  only,  pregnant  between  one  and  two  months,  did  the  corpuscles 
reach  the  physiological  standard  of  128.  In  all  the  remaining  32  cases  the  cor- 
puscles were  below  this  point,  ranging  in  6  cases  from  125  to  120,  and  in  the 
other  26,  from  120  to  95. 

The  34  bleedings  gave  different  results  as  regards  the  fibrine,  the  mean  physio- 
logical proportion  of  which  is  3,  according  to  the  period  of  pregnancy  at  which 


DISEASES     OF     PREGNANCY.  277 

the  blood  was  drawn.  Thus,  from  the  first  month  to  the  end  of  the  sixth,  the 
amount  of  fibrine  was  always  below  the  average;  the  mean  being  2-5,  the  mini- 
mum 1-9,  and  the  maximum  only  2-9.  During  the  three  last  months,  on  the 
contrary,  the  proportion  of  fibrine  exceeded  the  physiological  average ;  it  was 
about  4,  the  maximum  reaching  4-8.  Toward  the  end  of  the  last  month,  the 
average  is  4-3. 

MM.  Becquerel  and  Rodier  analyzed  the  blood  of  nine  pregnant  women,  two 
of  whom  were  20  years  of  age,  two  22,  one  25,  one  27,  one  29,  one  34,  and 
one  41. 

Five  of  these  were  of  robust  constitution,  two  were  about  the  average  in  this 
respect,  whilst  the  other  two  were  weak  and  apparently  lymphatic. 

Six  enjoyed  excellent  health,  two  were  not  so  well,  and  one  was  in  the  hospital 
on  account  of  indefinite  pains  in  the  abdomen,  and  a  cough  of  rather  long  stand- 
ing, though  not  serious  in  character. 

One  was  4  months  pregnant,  four  5,  one  5  J,  one  6,  and  two  7. 

None  of  them  were  hied  except  when  they  felt  it  to  he  necessary,  and  in  pre- 
sence of  an  actual  plethoric  condition  tchich  positively  indicated  venesection. 

The  carotid  murmur  was  heard  in  three  cases  only,  one  of  them  being  5  months 
and  the  other  7  months  pregnant. 

The  following  represents  the  average  composition  of  the  blood,  at  least,  as  re- 
gards its  principal  elements  : — 


Corpuscles, 

Fibrine,      .... 

Albumen,  .... 

(The  average  in  non-pregnant  women  is  70-5.) 
Water 801-6 

(The  average  in  non-pregnant  women  is  791'1.) 

My  colleague  and  friend,  M.  Eegnauld,  has  the  following  table  in  his  thesis, 
and  I  think  it  so  important  that  I  give  it  entire  : — 


V^verage. 

Maximum. 

Minimum. 

lllS 

1271 

87-7 

35 

4- 

2-5 

661 

68-8 

62-4 

278 


GENERATION. 


Tab/e  showing  the  Composition  of  1000  Parts  of  Blood  from  25  Women  at 
various  Stages  of  Pregnancy. 


STAGES   OF   PREGN'ANCT. 

;nti  of  the  serum, 
neii. 

a 

S 

s 

>• 

to 

< 

o 

.a 
fa 

3 
S 

3 
< 

3 
O 

o 

7J 

-a 
5 

a 
> 

1.  2d  month, 

10 

2-60 

70-50 

125  35 

1175 

789  80 

2.  End  of  2d  month. 

21 

2-80 

70-18 

126-40 

9-30 

991-32 

3.  3d  month,    . 

32 

2-70 

67-30 

122  60 

10-20 

797-20 

4.  3  months,     . 

27 

1-98 

70-25 

126  22 

8-65 

792-60 

5.  3  months,  ^, 

18 

290 

6809 

116-91 

11-40 

800-70 

6.  4  months,     . 

39 

2-40 

69-35 

12718 

10-50 

790  57 

7.  5  months,     . 

31 

2-43 

69-40 

123-90 

8-75 

795-52 

8.  6  months,  ^, 

29 

2-80 

68-85 

99-76 

10-50 

81809 

9.  7  months,    . 

27 

3-25 

69  20 

120-40 

7-90 

799-25 

10.  7  months,    . 

35 

2-79 

68-30 

107-92 

975 

Sll-24 

11.7  months,    . 

22 

320 

68-66 

118-40 

10-20 

799  54 

12.  7  months,  J, 

23 

416 

69-18 

99-41 

8-43 

818-82 

13.  End  of  7th  month, 

i      \ 

19 

3-30 

69-07 

112-50 

965 

805  48 

14.  End  of  7th  month. 

25 

2-78 

65-43 

100-77 

10-20 

820-82 

15.  Beginning  of  the  8th  month, 

29 

3-31 

6618 

115-44 

9-43 

805  62 

16.  Beginning  of  the  8th  month, 

38 

.3-74 

64-92 

99-36 

11-20 

820  78 

17.  Beginning  of  the  8th  month, 

20 

416 

6720 

103-40 

9-50 

815-74 

18.  8  months,  ^,          .         .         . 

22 

4-47 

66-82 

95  60 

10-95 

S-2-2-16 

19.  9  months,     . 

25 

3-70 

68-25 

108-90 

9-85 

809  30 

20.  9  months,     . 

24 

4-89 

65-47 

91-40 

10-75 

827-49 

21.  9  months,     . 

33 

4-42 

66-38 

115-25 

9-24 

804-71 

22.  9  months,     . 

27 

3-69 

64-45 

90-20 

1040 

831  26 

23.   9  months,     . 

25 

4-39 

65-80 

94-90 

11-65 

6-J3  36 

24.  9  months,     . 

28 

3-86 

68-92 

102-80 

9-96 

81446 

25.  9  months,     . 

26 

4-28 

6627 

99-75 

9  80 

819-90 

The  table  shows,  evidently,  that  conformably  with  the  results  already  men- 
tioned :  1.  The  proportion  of  fibrine  is  not  increased  in  the  blood  of  pregnant 
women  until  about  the  sixth  month,  but  from  that  time  it  increases  until  deli- 
very. 2.  That  from  the  beginning  of  pregnancy,  the  proportion  of  corpuscles  is 
sensibly  diminished ;  but  that  though  the  diminution  is  small  for  the  first  five 
or  six  months,  since  it  yields  an  average  of  177'4,  it  is  sometimes  considerable 
in  the  second  half,  and  especially  at  the  end  of  gestation,  at  which  period  the 
average  is  101-4.  3.  Like  MM.  Becquerel  and  Rodier,  M.  Regnauld  found  a 
decrease  of  albumen,  which  is  lowered  from  70-5,  the  physiological  standard  in 
the  non-impregnated  condition,  to  68-6  in  the  first  seven  months,  and  to  66-4  in 
the  two  last.  4.  The  proportion  of  water  in  the  blood  increases  sensibly  towards 
the  end  of  the  ninth  month;  thus,  the  average  of  the  first  thirteen  analyses, 
corresponding  with  the  first  seven  months,  is  expressed  by  80062,  and  that  of 
twelve  bleedings  performed  during  the  two  last,  by  817-96. 

We  would  also  add  with  M.  Regnauld,  that  not  only  is  the  serum  more  abun- 
dant relatively  to  the  fibrine  and  corpuscles,  but  that  it  contains  less  solid  matter, 


DISEASES    OF    PREGNANCY.  279 

which  of  course  helps  to  increase  the  total  amount  of  water  contained  in  the 
blood. 

Now,  what  conclusions  can  be  drawn  from  the  results  just  mentioned  ?  One 
prominent  fact  claims  the  attention,  namely,  the  diminished  amount  of  the  cor- 
puscles, and  the  increased  quantity  of  water,  which  is  almost  always  observed  in 
the  blood  of  women  at  an  advanced  stage  of  gestation.  Now,  it  is  universally 
known  at  the  present  day,  that  the  essential  character  of  chlorosis  and  anremia 
consists  in  the  diminution  of  the  corpuscles,  and  the  increase  of  the  water. 
These  two  results  of  chemical  analysis  are,  besides,  in  accordance  with  the 
physical  qualities  of  the  blood ;  for,  as  we  have  already  said,  the  clot  is  generally 
small.  We  shall  proceed  to  explain  why  it  often  presents  a  coating  of  variable 
thickness. 

The  proportion  of  the  fibrine  during  pregnancy  is  never  below  the  physiological 
average ;  on  the  contrary,  it  is  almost  always  above  it.  It  must  be  confessed  that 
the  explanation  of  the  fact  is  difficult,  for  the  increase  of  fibrine  is  a  constant  and 
pathognomonic  characteristic  of  inflammation.  It  is  true  that  we  may  suppose 
the  development  of  the  new  being  to  produce  an  excitement,  an  exaltation  of  the 
vital  functions  of  the  female,  amounting  almost  to  inflammation.  The  supposi- 
tion, too,  seems  quite  plausible,  if  we  consider  that  the  increase  of  fibrine,  which 
takes  pla«e  only  at  certain  stages  of  pregnancy,  represents  rather  a  high  physio- 
logical maximum  than  the  common  average  of  the  inflammatory  condition. 

The  deficient  nutrition  of  the  mother,  who  is  obliged,  whatever^may  happen, 
to  supply  the  foetus  with  the  food  required  for  its  development,  may  also  explain 
the  excess  of  fibrine,  and,  in  addition,  the  decrease  of  the  corpuscles ;  for  the 
experiments  of  M.  Andral  have  shown  that  the  blood  of  dogs,  subjected  to  cer- 
tain degrees  of  abstinence,  presented  the  characters  of  chloro-anaimia,  and  coin- 
cided with  a  marked  increase  of  the  fibrine.  Again,  if  we  admit  with  some 
modern  chemists,  that  the  fibrine  is  formed  at  the  expense  of  the  albumen  of  the 
blood,  may  we  not  find  in  the  considerable  diminution  of  the  latter  the  cause  of 
the  increase  of  the  former  ? 

"Whatever  the  cause  may  be,  the  large  proportion  of  the  fibrine  explains 
simultaneously  the  form  and  consistence  of  the  clot,  and  the  coating  which  often 
covers  it.  Whenever,  says  M.  Andral,  the  blood  retains  its  fibrine  and  loses  its 
corpuscles,  as  in  chlorosis  and  spontaneous  anaemia,  it  gives  rise  to  the  formation 
of  a  complete  huffy  coat.  Therefore,  the  latter  may  be  present  without  being 
necessarily  indicative  of  inflammation.  How  much  greater  reason,  then,  is  there 
for  its  appearance  in  pregnancy,  when  not  only  is  the  amount  of  corpuscles  dimi- 
nished, but  the  absolute  proportion  of  fibrine  is  increased,  and  attains  even  the 
limits  of  inflammation.  The  presence  of  the  coating  is,  therefore,  a  full  confir- 
mation of  the  analogy  which  we  have  endeavored  to  establish  between  the  blood 
of  chlorotic  patients  and  that  of  pregnant  females. 

If  an  excess  of  fibrine  be  always  a  sign  of  inflammation,  may  we  not  believe, 
with  M.  Andral,  that  there  is  a  certain  connection  between  this  state  of  the  blood 
during  pregnancy  and  the  frequent  occurrence  of  inflammation  after  delivery  ? 
We  can,  indeed,  understand  how  it  should  give  rise  to  such  a  predisposition  in 


280  GENERATION. 

the  economy,  that  occasional  causes,  which  are  usually  insufficient,  may  exert  a 
deleterious  influence  upon  a  woman  whose  blood  already  contains  the  germ  of  an 
alteration  peculiar  to  the  inflammatory  condition. 

Finally,  we  would  add  that  MM.  Becquerel  and  Rodier,  the  only  observers 
whose  analyses  give  the  proportion  of  iron  in  the  blood  of  pregnant  women,  have 
shown  that  it  is  below  the  physiological  average.  Thus,  in  1000  grammes  of  the 
calcined  blood  of  a  healthy  and  non-pregnant  woman,  the  average  proportion  of 
iron  is  0-541 ;  in  that  of  the  pregnant  female  it  is  0-44:9  ;  and  in  well-marked  chlo- 
rosis it  is  0-366.  The  proportion  of  iron  follows,  therefore,  that  of  the  corpuscles, 
and  the  expression  of  its  amount  during  pregnancy  will  serve  to  indicate  the 
transition  from  the  healthy  condition  to  confirmed  chlorosis. 

In  reference  to  the  question  before  us,  the  diminution  of  the  albumen  is  of  less 
importance;  it  were  impossible,  however,  not  to  observe  the  connection  between 
it  and  the  infiltrations  or  efl'usions  of  serum,  which  are  so  common  during  preg- 
nancy.    We  shall  recur  to  this  subject  hereafter. 

From  all  that  has  been  said,  we  think  it  may  be  concluded  that  the  principal 
elements  of  the  blood  undergo  alterations  during  pregnancy  analogous  to  those  of 
chlorosis. 

2.  TliP  Functional  Disorders  of  Pregnancy  hitherto  attributed  to  Plethora  are 
those  of  Chlorosis. — Most  of  the  authors  who  have  written  upon  the  functional 
disorders  of  pregnancy  have  attributed  them  to  plethora,  on  account  of  the  pecu- 
liar physiognomy  which  they  present.  Thus,  because  in  many  pregnant  females 
they  observed  fulness  and  hardness  of  the  pulse,  a  feeling  of  heaviness  in  the 
head  with  somnolence,  vertigo,  ringing  in  the  ears,  flashes  of  heat,  sudden  flush- 
ings of  the  face,  &c.,  they  regarded  them  unhesitatingly  as  the  expression  of 
encephalic  congestions,  themselves  the  consequence  of  general  plethora. 

Now,  it  is  really  only  necessary  to  read  the  list  of  symptoms  belonging  to 
chlorosis,  in  order  to  be  convinced  that  they  are  identical  for  the  two  aS"ections. 
This  is  easily  explained,  says  M.  Andral,  by  observing  that  if  the  mere  passage 
of  too  great  an  amount  of  corpuscles  through  the  vessels  of  the  brain  appears  to 
account  sufficiently  for  the  cerebral  disorders  witnessed  in  plethora,  it  follows 
that  too  small  an  amount  of  corpuscles  traversing  the  same  vessels  will  produce 
similar  disorders ;  so  that  too  great  or  too  small  an  amount  of  corpuscles  deranges 
certain  actions  of  the  brain  in  the  same  manner.  Therefore,  the  true  cause  of 
the  symptoms  is  not  to  be  judged  of  by  their  external  characters,  but  only  by  the 
changes  in  the  blood.  Now,  the  analysis  of  the  blood  of  a  large  number  of 
females,  who  complained  of  these  supposed  plethoric  phenomena,  has  shown  a 
marked  diminution  of  corpuscles  and  an  increase  of  serum. 

Besides,  if  we  remember  what  has  already  been  said  concerning  the  pathology 
of  pregnancy,  it  will  be  found  that  there  is  hardly  one  of  the  functional  disorders 
yet  studied,  which  is  not  also  observed  in  chlorotic  women.  What  is  more  com- 
mon than  to  find  in  chloro-ansemic  patients  the  want  of  appetite,  disgust  for  food, 
whimsical  and  depraved  tastes,  cramps  and  pains  in  the  stomach,  nausea  and 
■vomiting,  in  short,  all  those  symptoms  of  gastralgia  which  render  many  preg- 
nancies so  suflFering.     Are  not  also  the  headaches,  toothaches,  faintings,  and  the 


DISEASES    OF    PREGNANCY.  281 

facial,  frontal,  orbital,  or  temporal  neuralgias,  common,  so  to  speak,  to  the  two 
conditions  ?  As  regards  the  circulation,  do  we  not  observe  the  same  modifica- 
tions in  the  strength  of  the  impulse,  the  rhythm,  and  the  clearness  of  the 
pulsations  of  the  heart,  and  is  not  a  bellows  murmur  also  heard  in  the  principal 
vascular  trunks  ? 

Some  of  these  various  disorders,  such  as  the  nervous  phenomena,  are  more  par- 
ticularly observed  in  the  first  half  of  pregnancy;  others,  such  as  the  pretended 
symptoms  of  plethora,  trouble  more  especially  those  females  who  have  reached  a 
more  advanced  period.  It  must,  however,  be  confessed,  that  sometimes  all  of 
them  appear  at  the  beginning,  and  sometimes  at  the  end  of  gestation,  which  fact 
some  persons  have  thought  to  militate  against  my  theory.  Why,  said  M.  Jacque- 
miei",  should  the  same  symptoms,  which  are  regarded  as  disorders  due  to  sym- 
pathy with  the  uterus,  if  they  appear  during  the  first  half  of  pregnancy,  be 
considered  as  caused  by  chlorosis,  if  they  appear  during  the  second  half?  Is 
there  not  something  arbitrary  and  artificial  in  this, — something  which  seems  to 
have  been  devised  expressly  for  the  support  of  a  theory  ? 

In  the  first  place,  I  would  observe  that  I  have  only  spoken  of  the  uncomfort- 
able sensations  which  women  experience  in  the  latter  months;  but  in  supposing 
the  similarity  of  the  symptoms,  there  is  nothing  irrational  in  attributing  to  them 
a  diiferent  origin.  I  may  be  allowed  to  recall  what  takes  place  in  the  case  of  a 
young  girl  becoming  chlorotic  :  it  will  be  seen  that  the  succession  of  phenomena 
is  absolutely  the  same  as  what  I  have  supposed  for  the  chlorosis  of  pregnant 
women.  A  healthy  young  girl  reaches  the  age  of  puberty,  when,  under  the 
influence  of  causes  which  we  often  cannot  appreciate,  the  menstruation  fails  to 
become  established,  or  takes  place  only  in  an  imperfect  or  irregular  manner.  The 
uterus,  being  disturbed  in  the  exercise  of  its  monthly  functions,  soon  reacts  upon 
all  the  other  organs.  The  appetite  diminishes,  the  stomach  becomes  capricious, 
the  tastes  whimsical,  the  digestion  painful;  and  from  the  persistence  of  this  diffi- 
cult digestion  results  incomplete  assimilation,  and  soon  deficient  nutrition.  After 
the  lapse  of  a  few  weeks  or  months,  the  defective  nutrition  produces  an  alteration 
in  the  composition  of  the  blood,  which,  when  carried  to  a  certain  degree,  pro- 
duces all  the  symptoms  of  chlorosis, — symptoms  bearing  a  strong  resemblance  to 
those  which  preceded  and  caused  the  general  disease  of  which  they  are  the 
expression. 

No  one,  certainly,  will  deny  the  truth  of  the  picture  just  drawn.  Now,  is  not 
the  same  succession  of  phenomena  witnessed  in  pregnancy  ?  In  both  cases,  is  it 
not  the  irritation  of  the  uterus  produced  by  the  new  functions,  which  first  reacts 
upon  the  other  functions  of  the  economy,  disturbing  their  regular  fulfilment, 
which  afterward  interferes  with  the  assimilation  of  nutritive  matters,  and  which 
finally  produces  chlorosis?  Is  not  the  latter  condition  indicated  in  the  pregnant 
woman,  as  in  the  young  girl,  by  the  same  symptoms?  Where,  then,  is  the  dif- 
ference ?  And  if  it  be  allowed  that  the  primary  functional  disorders  of  the  young 
girl  are  purely  sympathetic,  whilst  those  which  occur  later  are  attributable  to 
chlorosis,  why  should  we  refuse  to  acknowledge  the  same  as  occurring  during 
pregnancy  ? 


282  GENERATION. 

After  thus  recalling  the  fact,  that  all  the  functional  disorders  of  chlorosis  are 
sometimes  observed  during  pregnancy,  it  truly  becomes  a  matter  of  astonishment 
that  the  resemblance  between  the  two  should  not  have  been  noted  earlier,  and 
that  it  should  have  been  left  for  recent  analyses  to  excite  the  suspicion  that  the 
same  symptoms  might  be  due  to  the  same  cause. 

The  pathological  anatomy  and  symptomatology  being  then  in  accordance  with 
each  other,  it  remains  to  be  seen  whether  the  treatment  will  afford  another  evi- 
dence of  the  nature  of  the  disorder. 

3.  Plethora  was  formerly  considered  so  common,  and  so  exclusively  the  cause 
of  the  diseases  of  pregnancy,  that  bloodletting  had  become  a  general  practice. 
So  strongly  impressed  were  many  women  with  the  idea  of  the  necessity  of  bleed- 
ing, that  they  thought  themselves  under  an  obligation  to  have  recourse  to  it  by 
the  time  they  had  reached  the  fifth  month  of  gestation,  and  even  demanded  it 
before  consulting  their  physician.  Most  practitioners  declined  performing  these 
so-called  preventive  bleedings,  though  all  regarded  venesection  as  the  best  means 
of  overcoming  plethora,  that  is  to  say,  the  assemblage  of  phenomena  attributed 
thereto.  If  the  latter  proposition  were  true,  it  would  constitute  an  unanswerable 
objection  to  the  theory  we  are  endeavoring  to  establish.  Fortunately,  however, 
such  is  not  the  case. 

I  certainly  do  not  wish  to  deny  the  amelioration  produced  by  bleeding  in  cer- 
tain cases;  but  it  proves  nothing  against  the  poverty  of  the  blood,  and  the  chloro- 
anaemia.  The  lessened  proportion  of  the  corpuscles,  does  not  necessarily  involve 
a  diminution  of  the  entire  mass  of  the  blood,  as  the  word  anamia  applied  to  this 
alteration  would  seem  to  indicate.  Generally,  on  the  contrary,  the  amount  of 
this  fluid  remains  the  sanie,  and  sometimes  even  is  considerably  increased ;  thus 
corresponding  with  what  M.  Beau  states  to  be  habitually  the  case  in  chlorosis. 
A  true  plethora,  which  might  be  styled  serous,  then  exists,  in  which  case,  espe- 
cially to  the  usual  signs  of  anaemia,  are  superadded  headache,  vertigo,  ringing  in 
the  ears,  &c.;  and  under  these  circumstances,  bleeding  may  afford  relief  by  dimi- 
nishing the  amount  of  blood.  The  same  result  is  obtained  in  ordinary  chlorosis, 
when  bleeding  is  practised  for  the  removal  of  local  congestions.  But,  in  preg- 
nancy as  in  chlorosis,  this  alleviation  is  but  temporary,  and  if  the  proportion  of 
corpuscles  be  not  brought  up  to  the  healthy  standard  by  proper  hygienic  and 
therapeutic  measures,  the  same  symptoms  will  soon  reappear,  and  with  greater 
intensity.  The  abstraction  of  blood  is,  therefore,  in  any  case,  but  a  palliatory 
measure,  only  to  be  employed  in  extreme  cases,  when  the  general  symptoms  are 
very  severe,  but  which  had  better  have  been  avoided  by  administering  tonics  and 
ferruginous  preparations  at  an  earlier  period. 

An  animal  diet,  and  preparations  of  iron,  have,  for  six  years  back,  always  ap- 
peared to  me  to  be  quite  as  useful  against  the  functional  disorders  of  pregnancy, 
as  against  those  of  chlorosis.  Unless  they  be  very  serious,  I  no  longer  bleed  for 
palpitations,  pains  in  the  head,  or  suffocations,  nor  have  I  known  them,  in  a  single 
instance,  to  resist  the  use  of  the  preparations  of  iron  longer  than  a  couple  of 
weeks.  Even  when  the  gravity  of  the  accidents  has  obliged  me  to  bleed  to  the 
extent  of  six  or  eight  ounces  at  the  utmost,  I  begin  immediately  with  the  use  of 


DISEASES     OF     PREGNANCY.  283 

iron,  and  it  is  very  rarely  that  I  am  obliged  as  formerly  to  recur  to  venesection. 
Hemorrhage  from  the  bowels  might,  in  some  cases,  remove  the  necessity  for 
phlebotomy,  and  M.  Blot  was  certainly  right  in  advising  gentle  purgatives  under 
these  circumstances. 

There  is  still  another  condition,  in  which  I  have  associated  iron  and  bleeding 
with  advantage ;  with  what  propriety  we  shall  next  see. 

The  excess  of  impoverished  blood  in  pregnancy,  may,  as  in  chlorosis,  give  rise 
to  local  congestions,  which  congestion,  when  carried  beyond  certain  limits,  ex- 
plains the  occurrence  of  epistaxis,  and  the  less  frequent  haemoptysis  and  hcema- 
temesis,  all  which  seem  to  be  the  result  of  an  effort  on  the  part  of  nature  to 
diminish  the  vascular  fulness.  These  accidents  are  unusual  during  pregnane}'', 
or,  at  least,  rarely  occur  to  an  alarming  extent.  The  reason  seems  to  be,  that 
from  the  moment  of  conception  until  delivery,  all  the  vital  powers  appear  to  be 
concentrated  upon  a  single  organ,  which  forms  a  centre  of  fluxion,  towards  which 
all  the  troubles  of  the  organism  converge ;  this  organ  is  the  uterus.  The  con- 
gestion, which  in  the  chlorotic  patient  occurs  in  the  head  or  the  chest,  here  takes 
place  in  the  womb,  and  the  extraordinary  development  of  the  vessels  of  the 
uterus,  and  their  more  or  less  intimate  connection  with  those  of  the  foetus,  suffi- 
ciently explain  the  danger  of  an  over-determination  of  fluid.  At  a  very  early 
period,  the  congestion  may  occasion  the  rupture  of  one  of  the  numerous  capillary 
vessels  distributed  upon  the  internal  surface  of  the  mucous  membrane  (parietal 
or  epichorial  decidua) ;  rather  later,  the  congestion  may  be  great  enough  to 
rupture  one  of  the  utero-placental  vessels,  and  in  both  cases  give  rise  to  an  effu- 
sion, which,  by  destroying  wholly  or  in  part  the  utero-placental  relations,  proves 
fatal  to  the  child. 

These  uterine  congestions,  which  are  properly  considered,  in  some  cases,  as  the 
consequence  of  general  pUtJiora,  I  have  witnessed  much  oftener  in  feeble  and 
anjemic  women.  They  almost  always  appear  at  the  menstrual  periods,  as  though 
the  monthly  periodicity  excited  at  those  times  a  more  active  vitality  in  the  uterus. 
The  woman  complains  of  tension,  of  swelling  of  the  abdomen,  of  a  feeling  of 
weight  in  the  pelvis,  the  groins,  and  upper  part  of  the  thighs;  she  also  soon 
suffers  pain  in  the  region  of  the  kidneys  and  in  the  loins.  If  the  proper  mea- 
sures are  not  employed,  the  vascular  congestion,  and  the  pressure  upon  the 
uterine  walls  resulting  from  it,  irritate  the  organ ;  slight  contractions  occur,  some- 
times even  a  little  blood  flows  from  the  vulva,  and  announces  a  threatened 
abortion.  These  symptoms  are  almost  always  accompanied  with  marked  vesical 
tenesmus.  Can  the  latter  be  due  to  pressure  on  the  neck  of  the  bladder,  pro- 
duced by  an  increase  in  the  size  and  weight  of  the  uterus  caused  by  the 
congestion  ? 

It  is  evident  that  when  these  symptoms  of  uterine  congestion  appear,  prudence 
dictates  a  recourse  to  all  the  means  likely  to  effect  a  revulsion.  Thus,  sinapisms 
to  the  upper  and  posterior  part  of  the  back,  seven  or  eight  dry  cups  to  the  upper 
part  of  the  chest,  and  finally,  if  these  measures  are  insufficient,  bleeding,  to  the 
extent  of  six  or  eight  ounces,  as  a  powerful  revulsive,  is  very  useful.  But,  even 
here,  the  bleeding  may  have  only  a  momentary  effect  by  destroying  the  local 


284  GENERATION. 

plethora,  and  by  no  means  enables  us  to  dispense  with  medicines  capable  of 
modifying  the  state  of  the  blood.  We  shall  return  to  this  subject  under  the 
head  of  Preventive  Treatment  of  Abortion.  It  is  proper,  however,  that  I  should 
say  in  this  place,  that  many  of  my  patients  who  had  suffered  frequent  miscar- 
riages, have  been  enabled  to  attain  their  full  period  by  the  use  of  iron  adminis- 
tered from  the  beginning  of  pregnancy. 

We  see,  therefore,  and  I  call  the  attention  of  practitioners  to  this  point,  that  if 
the  medicament  which  cures  a  disease  sometimes  also  proves  its  nature,  then  the 
disorders  which  we  have  described  are  oftenest  due  to  chloro-ansemia,  and  not  to 
plethora.  The  latter  proposition,  confirmed  as  it  is  by  pathological  anatomy  and 
symptomatology,  I  hold  to  be  incontestable. 

I  say,  oftenest,  for  I  would  not  have  my  assertion  regarded  as  absolute. 
jThough  true  plethora,  that  which  is  distinguished  from  serous  plethora  by  an 
increase  in  the  amount  of  the  corpuscles,  be  rare,  it  nevertheless  is  sometimes 
met  with,  especially  at  a  very  early  stage  of  gestation.  Females  of  a  really 
plethoric  constitution,  whose  menstrual  discharge  is  habitually  abundant  and 
high-colored,  may  retain  this  constitutional  peculiarity  during  pregnancy,  and 
sometimes  even  have  it  increased.  The  sixty  odd  analyses  which  we  have 
quoted,  show  that,  in  several  instances,  the  proportion  of  corpuscles  underwent 
no  diminution  in  the  earlier  months,  and  that  in  the  case  of  one  woman,  who  had 
reached  the  end  of  the  second  month,  M.  Andral  found  them  increased  to  one 
hundred  and  forty-five.  It  is  even  probable  that,  when  analyses  shall  be  more 
numerous,  the  same  peculiarity  will  be  remarked  in  some  cases  of  advanced  preg- 
nancy. For  my  own  part,  I  have  certainly  met  with  females  whose  antecedents, 
symptomatic  expression,  and  the  physical  properties  of  whose  blood  aflForded  every 
indication  of  plethora. 

The  fact  of  our  having  observed  but  few  instances  of  the  latter  class,  is  ex- 
plained by  our  practising  in  the  metropolis,  where  all  debilitating  influences  are 
collected.  The  hygienic  conditions  in  which  women  live  in  the  country,  dispose 
them  less  to  chlorosis,  and  it  is  exceedingly  probable  that  their  blood  is  not  so 
much  altered  during  pregnancy  as  in  the  cases  we  have  noticed.  To  this,  I 
think,  is  certainly  due  their  exemption  from  the  functional  disorders,  nervous  or 
otherwise,  which  so  commonly  afi'ect  the  females  of  large  eities.  This  is  an  ad- 
ditional argument  in  favor  of  my  theory. 

Though  such  women  are  exposed  to  the  general  consequences  of  plethora,  they 
present  more  frequently  the  signs  of  local  or  uterine  plethora,  especially  during 
the  first  half  of  pregnancy,  at  the  periodic  returns  of  the  menstrual  epochs.  The 
local  phenomena,  as  tension,  swelling  of  the  abdomen,  feeling  of  weight  in  the 
pelvis,  are  very  strongly  marked  in  their  cases.  The  circulation  of  the  foetus, 
also,  sometimes  appears  to  share  in  the  troubles  of  the  maternal  circulation,  for 
these  signs  of  congestion  are  frequently  observed  to  be  followed  by  the  weaken- 
ing, diminished  frequency,  and  even  complete  cessation  of  its  active  motions; 
and  if  the  motions  have  not  yet  been  perceived,  the  plethoric  condition  may 
greatly  retard  their  appearance.  However  difiicult  the  explanation  of  these  pecu- 
liarities may  appear,  they  are  too  common  to  be  doubted.     The  best  proof  that 


DISEASES    OF    PREGNANCY.  285 

can  be  given  of  the  effect  of  this  local  congestion  upon  the  motions  of  the  child, 
is  their  prompt  reappearance  after  a  venesection  made  at  the  proper  time;  and  it 
very  frequently  happens  that  a  woman  who  is  five  months,  or  five  months  and  a 
half  gone,  without  having  felt  them,  perceives  them  suddenly  after  bleeding. 

It  is  unnecessary  to  state,  that  here  bloodletting  constitutes  the  proper  treat- 
ment, and  that  the  quantity  abstracted  may  be  regulated  by  the  circumstances  of 
the  individual  cases.  It  is,  however,  better  to  practise  several  small  bleeding;s 
at  short  intervals,  than  to  depend  upon  a  single  copious  one.  The  production  of 
syncope  should  be  studiously  avoided. 

We  shall  have  occasion,  when  treating  of  abortion,  to  finish  the  study  of  the 
therapeutical  indications.  (See  Abortion.)  We  shall,  however,  mention  here  the 
advice  given  by  Gardien.  In  common  with  some  other  authors,  he  recommends 
the  application  of  leeches  to  the  groins,  the  anus,  or  upper  part  of  the  thighs,  in 
cases  of  uterine  congestion.  It  seems  to  us  to  be  dangerous  advice,  for  inde- 
pendently of  their  antiphlogistic  action,  the  leeches  produce  a  marked  revulsion, 
for  which  effect  indeed  they  are  applied  in  amenorrhea.  I  should  fear  lest  their 
revulsive  action  in  these  cases  might  increase  the  disorders  instead  of  remedying 
them.  The  same  may  be  said  of  bleeding  from  the  foot.  Therefore,  I  prefer 
having  recourse  to  venesection  in  the  arm,  which  is  both  depletory  and  revulsive, 
whenever  the  abstraction  of  blood  seems  to  be  indicated. 

To  recapitulate,  the  functional  disorders  of  pregnancy,  as  cephalalgia,  giddi- 
ness, vertigo,  ringing  in  the  ears,  dyspnoea,  palpitations,  &c.,  are  rarely  due  to 
true  plethora,  but  most  generally  to  chloro-anaemia.  We  might  indeed  distin- 
guish for  pregnant  women  a  very  rare  sanguineous  plethora,  and  a  very  common 
serous  plethora. 

Independently  of  this  marked  diminution  of  globules  and  albumen,  the  blood 
is  sometimes  considerably  altered  by  admixture  with  the  elements  of  the  urine. 
This  alteration,  which  has  been  described  of  late  by  the  Germans  under  the  title 
of  urcemia,  and  of  which  we  shall  soon  have  occasion  to  speak,  is  a  capital  fact 
in  the  etiology  of  several  diseases  which  are  liable  to  appear  in  the  puerperal 
condition.  We  merely  state  the  fact  for  the  present,  leaving  further  notice  of  it 
until  we  come  to  treat  of  the  lesions  of  the  urinary  secretion. 

§  2.  Varices,  Hemorrhoids. 

A  varicose  condition  of  the  veins  in  the  lower  extremities,  the  vagina,  and 
inferior  part  of  the  rectum,  is  quite  a  common  occurrence  towards  the  latter  part 
of  gestation,  though,  as  regards  treatment,  the  varicose  veins  in  the  limbs  only 
require  the  usual  precautions  to  prevent  their  rupture.  For  this  a  methodical 
compression  is  the  best  remedy,  and  every  attempt  at  a  radical  cure  should  be 
discountenanced. 

Hemorrhoids,  like  varices,  are  an  ordinary  consequence  of  the  uterine  pressure 
on  the  hypogastric  vessels;  but  they  may  likewise  be  frequently  produced  by 
constipation,  and  the  attendant  accumulation  of  hard  matters  in  the  rectum. 
The  bleeding  piles  are  generally  less  disastrous ;  but  the  others  are  more  grave 


286  GENERATION. 

and  very  painful.  In  fact,  it  often  happens  that  women  affected  with  them,  can 
neither  stand  nor  walk,  and  they  are  even  troubled  when  seated. 

The  first  indication  is  to  combat  the  costiveness,  and  then  to  assuage  the  pain 
by  tepid  bathing,  cataplasms,  and  emollient  and  narcotic  lotions,  or  the  poplar 
ointment  may  be  applied  to  the  tumors ;  and  where  they  are  internal,  a  supposi- 
tory of  cocoa-butter  might  be  introduced  into  the  rectum.  Liniments  containing 
opium  and  belladonna  will  frequently  relieve  the  patients ;  but  this  is  all  that  we 
could  prudently  do  under  the  circumstances. 

AVhen  the  inflammation  and  turgescence  are  very  great,  bleeding  in  the  arm 
is  advisable,  as  this  is  much  preferable  to  the  application  of  leeches  in  the  imme- 
diate neighborhood  of  the  tumor;  true,  the  latter  calm  the  pains  temporarily, 
but  then,  in  certain  females,  they  might  bring  on  an  abortion.  I  have  never 
known,  says  Desormeaux,  the  application  of  leeches  on  the  tumors,  or  the  inci- 
sion of  the  latter,  to  procure  any  durable  relief. 

Where  the  irritation  from  the  piles  seems  to  react  on  the  womb,  and  threatens 
a  uterine  hemorrhage,  M.  Gendrin  has  derived  signal  advantage  from  cold 
applications  around  the  pelvis.  In  those  cases,  says  he,  if  the  hemorrhage  is 
imminent,  we  augment  the  activity  of  the  topical  remedies  placed  directly  over 
the  parts  affected,  by  using  cold  baths  to  the  breech  at  the  same  time,  the  tem- 
perature of  the  water  never  having  been  lower  than  12°  or  15°  (Centigrade, 
equivalent  to  54°  or  59°  Fahr.).  I  have  several  times  employed  cold  injections 
successfully.  The  plan  is  to  take  every  evening  a  large  cold  enema,  which  after 
being  discharged  is  followed  by  a  small  one,  which  ought  to  be  retained. 

We  shall  speak  more  fully  of  the  varicose  condition  of  the  vaginal  veins  under 
the  article  Thrombus  of  the  Vulva. 


ARTICLE    IV. 
lesions  of  the  secretions  and  excretions. 

§  1.  Pttalism. 

Ptyalism,  or  a  hypersecretion  of  saliva,  sometimes  occurs  during  pregnancy. 
It  generally  lasts  but  a  short  time,  rarely  more  than  two  months.  One  case, 
however,  is  mentioned  by  M.  Brachet,  in  which  the  salivation  commenced  in  the 
second  month,  and  lasted  for  a  month  after  delivery,  and  I  have  quite  recently 
observed  a  similar  instance  in  the  case  of  the  wife  of  one  of  my  professional 
brethren.  It  frequently  returns  in  several  successive  pregnancies.  I  have  seen 
it  continue  between  sis  and  seven  weeks  in  the  two  first  pregnancies  of  a  lady 
who  has  since  had  another  child  without  a  recurrence  of  the  affection ;  and  M. 
Danyau,  Jun.,  mentions  a  patient  who  was  profusely  salivated  for  five  months  in 
her  first  pregnancy,  and  still  longer  and  more  profusely  in  two  succeeding  gesta- 
tions. 

However  considerable  the  salivation  may  be,  it  is  rather  a  disagreeable  incon- 
venience than  a  serious  complication.     Though  it  has  in  no  case  materially 


DISEASES    OF    PREGNANCY.  287 

affected  tlie  health,  some  women  have  been  so  annoyed  with  the  continual  spit- 
ting, and  the  flow  of  saliva  which  sometimes  deluges  the  pillow  at  night,  as  to 
insist  upon  being  relieved  of  it.  Happily,  in  a  large  proportion  of  cases,  the 
ptyalism  ceases  spontaneously,  for  no  great  confidence  can  be  reposed  in  the 
measures  generally  resorted  to  for  its  removal.  Some  advantage,  however,  may 
be  derived  from  the  use  of  aromatic  infusions  and  slightly  astringent  gargles. 
Like  Desormcaux,  I  have  found  it  useful  to  recommend  the  patients  constantly 
to  keep  a  little  piece  of  sugar  candy  in  the  mouth.  Others,  again,  advise  lumps 
of  gum  arable,  and  pieces  of  ice.  It  is  useful  to  be  acquainted  with  these  various 
measures,  if  only  to  keep  up  the  patience  of  the  sufferer,  by  varying  them  from 
time  to  time  until  the  disorder  ceases  of  its  own  accord. 

Some  authors  seem  to  have  dreaded  the  effect  of  the  sudden  suppression  of  a 
profuse  salivation.  Two  cases  are  mentioned,  in  one  of  which  apoplexy,  and  in 
the  other  symptoms  of  suffocation,  appeared  to  result  from  it.  I  do  not  think 
that  the  relation  of  cause  and  effect  has  been  satisfactorily  .shown  in  these  cases, 
and  am  tempted  to  believe  that  here,  as  in  many  other  instances,  it  has  been 
erroneously  concluded,  ^os<  hoc,  ergo  projpter  hoc. 

§  2.  Secretion  and  Excretion  op  the  Urine. 

The  renal  secretion  is  rarely  increased  during  pregnancy ;  those  writers  who 
have  stated  the  contrary,  having  been  deceived  by  the  frequent  inclinations  to 
urinate  which  females  experience  at  certain  periods  of  pregnancy.  These  re- 
peated desires  are  due  to  a  true  vesical  tenesmus,  produced  by  the  compression 
exerted  upon  the  body  and  neck  of  the  bladder  by  the  uterine  tumor.  They 
occur  every  hour,  sometimes  oftener,  and  are  relieved  by  the  discharge  of  a  few 
drops  of  urine. 

The  pressure  of  the  uterus  upon  the  neck  of  the  bladder  is  sometimes  so  great 
as  to  obstruct  the  emission  of  urine,  and  render  it  painful  or  even  impossible. 
This  difficulty  in  urinating  may  occur  in  the  commencement  of  pregnancy,  either 
when  the  pelvis  is  too  large,  and  permits  the  uterus  to  remain  a  long  time  in  the 
excavation,  or  on  the  occurrence  of  a  prolapsus  uteri,  or  those  other  displacements 
of  this  organ  known  as  anteversion  and  retroversion. 

Most  frequently,  however,  it  appears  towards  the  end  of  gestation,  either 
because  the  uterus,  from  being  pushed  down  by  the  presenting  part  of  the  foetal 
head,  early  engages  in  the  excavation,  or  because  the  womb  is  forcibly  carried 
forwards ;  in  the  latter  case  the  body  of  the  bladder  is  pressed  upwards,  and  in 
front  by  the  uterus,  and  its  neck  forced  against  the  superior  margin  of  the  sym- 
physis pubis. 

When  the  anteversion  is  well  marked,  the  body  of  the  bladder  forms  an  angle 
with  the  neck;  in  some  cases  it  is  even  lower,  whence  the  introduction  of  a 
catheter  is  then  exceedingly  troublesome.  After  all,  the  difficulty  of  urinating 
still  persists  until  term,  whatever  we  may  do,  for  we  can  only  alleviate  it  by  tepid 
bathing,  the  horizontal  position,  and  more  particularly  by  the  use  of  a  bandage 
to  sustain  the  abdomen. 

Where  the  retention  is  complete,  the  bladder,  by  becoming  distended,  may 


288  GENERATION. 

increase  so  much  in  size  as  to  reach  the  umbilicus,  and  its  excessive  distension 
might  produce  an  inflammation  or  even  a  rupture,  especially  during  the  throes 
of  labor;  but  where  the  neck  is  not  altogether  obliterated  by  the  pressure,  an 
incontinence  of  urine  may  ensue ;  the  fluid  dribbling  away  drop  by  drop,  though, 
unfortunately,  that  is  not  always  the  case,  and  the  catheter  must  then  be  re- 
sorted to. 

I  have  already  said  this  operation  is  attended  by  difficulties  under  such  cir- 
cumstances, and  when  it  is  quite  impossible  to  perform  it,  the  distress  may  be 
relieved,  in  a  measure,  by  pressing  back  the  uterus  from  the  symphysis  pubis 
with  the  two  fingers  introduced  into  the  vagina,  and  the  woman  should  be  taught 
to  aid  herself  in  this  way. 

In  some  instances,  the  female  suff"ers  at  the  latter  stages  a  considerable  smart- 
ing or  pain  in  urinating,  as  sharp  as  if  there  was  a  stone  in  the  bladder;  these 
symptoms  arise  from  a  true  catarrh  of  the  body,  or  at  least  of  the  neck  of  this 
organ  :  the  urine,  in  fact,  often  contains  whitish  flakes  of  purulent  matter.  Such 
symptoms  require  the  general  antiphlogistic  treatment,  local  bathing,  emollients, 
and  mucilaginous  drinks.  As  a  general  rule,  women  only  suffer  from  an  inconti- 
nence of  urine  during  the  last  three  months,  and  then  the  delivery  is  the  only 
remedy;  however,  it  shows  itself  in  the  early  stages  of  gestation  in  certain 
females,  being  evidently  produced  by  the  pressure  which  the  uterus,  that  is  still 
within  the  pelvis,  makes  on  the  neck  of  the  bladder,  and  it  lasts  until  the  womb 
rises  above  the  superior  strait.  If  the  incontinence  remains  after  the  fifth  month, 
the  symptoms  may  be  relieved  by  injections  of  warm  water,  and  by  the  internal 
use  of  tonics. 

Though  the  amount  of  urine  is  not  changed,  its  composition  sometimes  under- 
goes alterations  which  it  is  important  to  be  acquainted  with. 

I  shall  not  return  to  the  consideration  of  the  peculiar  pellicle  called  kyesteine 
by  M.  Nauche,  and  whose  diagnostic  value  we  have  already  determined  (see 
page  134) ;  but  I  shall  proceed  to  notice  a  very  remarkable  fact,  which  we  shall 
often  have  occasion  to  refer  to :  I  speak  of  the  presence  of  albumen,  which  is 
found  in  greater  or  less  amount  in  the  urine  of  some  women  at  an  advanced 
stage  of  pregnancy. 

§  3.  Albuminuria.     Ur^bmia. 

The  credit  of  having  called  the  attention  of  physicians  to  the  presence  of  albu- 
men in  the  urine  of  pregnant  women  belongs  to  M.  Rayer,  whose  admirable  and 
laborious  investigations  of  the  diseases  of  the  kidneys  have  thrown  so  much  light 
upon  the  pathology  of  those  organs.  He  was  the  first  to  endeavor,  in  his  splendid 
work,  to  determine  the  eff"ect  of  this  alteration  of  the  urinary  secretion  upon  the 
health  of  the  mother,  and  the  regular  development  of  the  foetus.  Afterward, 
followed  the  observations  of  Dr.  Lever  and  of  Dr.  Cahen,  who,  by  the  advice  of 
his  master,  M.  Rayer,  published  a  good  thesis  upon  the  subject.  Next  came  the 
interesting  memoir  of  MM.  Devillicrs  and  Regnauld,  and  another  thesis  by  M. 
Blot.     More  recently,  two  manuscript  memoirs  by  MM.  Imbert  Goubeyre,  and 


DISEASES     OF    PREGNANCY.  289 

Bacli,  and  the  researches  of  Frerich,  Schotten,  and  Wieger,  have  shed  some  light 
upon  this  still  obscure  point  of  puerperal  pathology. 

It  is  known  that  albuminuria  is  generally  the  symptom  of  an  organic  disease 
of  the  kidneys,  which  almost  always  proves  fatal ;  hence,  it  may  be  readily  un- 
derstood, that  when  this  change  in  the  urine  is  observed  during  pregnancy,  it 
becomes  at  once  desirable  to  ascertain  whether  it  be  necessarily  due  to  the  same 
cause,  or  whether  it  be  merely  one  of  the  numerous  modifications  produced  in 
the  economy  by  gestation. 

In  the  first  case,  it  is  a  very  serious  affection,  calculated  to  awaken  all  the 
solicitude  of  the  physician ;  in  the  second,  it  is  but  a  temporary  functional  dis- 
order, which  will  most  probably  disappear  with  the  cause  that  produced  it. 
Unfortunately,  in  the  present  state  of  our  knowledge,  it  is  very  difficult  to  decide 
the  question.  For,  on  the  one  hand,  1.  The  normal  diminution  of  the  albumen 
in  the  blood  of  pregnant  women,  which  diminution  is  much  greater  in  patients 
affected  with  albuminuria,  since  MM.  Devilliers  and  Regnauld  have  observed  it 
to  descend  to  56-39,  would  lead  to  the  supposition  that  the  cases  under  conside- 
ration were  but  exaggerations  of  what  oi'dinarily  occurs,  and  that  the  elimination 
of  a  larger  amount  of  albumen  than  usual  from  the  blood,  be  the  cause  what  it 
may,  accounts  for  its  evacuation  by  the  urine.  2.  The  albuminuria  of  preg- 
nancy is  not  generally  accompanied  by  the  functional  disorders  and  the  symptoms 
to  which  it  gives  rise  when  connected  with  disease  of  the  kidneys ;  and  the 
dropsy  itself,  which  is  almost  constantly  observed  in  the  latter  case,  is  sometimes 
wanting  in  pregnant  women  affected  with  albuminuria,  as  was  twice  observed  by 
MM.  Kegnauld  and  Devilliers,  as  I  have  myself  witnessed,  and  as  M.  Blot  found 
to  be  the  case  twenty-three  times  out  of  forty-one.  3.  Lastly,  in  the  majority  of 
instances,  it  disappears  immediately  upon  the  termination  of  the  pregnancy  which 
caused  it ;  and  when  we  consider  the  obstinacy  of  albuminous  nephritis,  it  is  diffi- 
cult to  account  for  this  sudden  disappearance  of  a  disease,  which,  under  other 
circumstances  than  the  puerperal  condition,  so  frequently  has  a  fatal  termination. 
On  the  other  hand,  however,  observation  shows  that  in  almost  all  the  cases  in 
which  women  die  of  the  convulsions  which  too  frequently  complicate  albuminuria, 
the  kidneys  present  the  anatomical  characteristics  of  albuminous  nephritis,  the 
more  or  less  advanced  degrees  of  alteration  appearing  to  correspond  with  the 
duration  of  the  disease  and  the  amount  of  albumen  discharged.  Many  times 
have  I  had  occasion  to  observe  this  fact,  and  fearing  lest  I  should  interpret  the 
alterations  erroneously,  have  almost  uniformly  presented  the  kidneys  to  the 
examination  of  M.  Rayer,  who  generally  recognized  in  them  the  second,  some- 
times the  third,  and  only  once  the  fourth  degree  of  alteration. 

The  learned  physician  of  La  Charite  considers  the  more  frequent  occurrence 
of  the  anatomo-pathological  characters  of  the  second  degree  of  the  disease  to  be 
due  solely  to  the  recency  of  the  latter,  and  by  no  means  to  a  difference  of  nature. 
It  is  no  less  the  consequence  of  a  renal  hyperjemia,  which  he  supposes  may  be 
caused  in  many  cases  by  compression  of  the  emulgent  veins  by  the  enlarged 
uterus,  and  the  consequent  obstruction  to  the  return  of  the  venous  blood.  That, 
in  simple  cases,  it  generally  disappears  promptly  after  delivery,  is  probably  due 

19 


290  GENERATION. 

to  the  consequent  cessation  of  the  congestion  of  the  kidney  which  was  maintained 
by  the  pregnancy. 

We  see,  therefore,  that  the  question  is  far  from  being  settled ;  whilst  M.  Blot, 
for  example,  regards  puerperal  albuminuria  as  generally  unconnected  with 
Bright's  disease,  M.  Bach,  of  Strasbourg  (unpublished  memoir,  crowned  by  the 
Academy),  thinks  that  it  is  only  sometimes  due  to  albuminous  nephritis,  and  M. 
Imbert  Goubeyre  (unpublished  memoir,  crowned  by  the  Academy)  endeavors  to 
prove  that  it  is  always  a  sign  of  Bright's  disease.  Now,  is  it  impossible  to  throw 
a  little  light  upon  this  question,  which  is  still  so  obscure  ? 

Healthy  urine  contains  no  albumen,  and  the  same  is  true  for  the  healthy  woman 
in  the  puerperal  condition.     Albuminuria,  therefore,  always  indicates  a  patho- 
logical condition  of  which  it  is  the  symptom;  for  every  functional   disorder, 
whether  temporary  or  persistent,  supposes  a  momentary  or  prolonged  alteration 
of  the  organs  whose  office  it  is  to  accomplish  the  function.     Therefore,  the  in- 
vestigation of  the  causes  of  albuminuria,  implies  that  of  the  general  or  local 
aflfections  which  are  capable  of  producing  it.     But  lest  we  should  go  astray  in 
these  researches,  it  is  very  important  to  ascertain  a  priori,  what  are  the  organs 
upon  which  the  accomplishment  of  the  urinary  secretion  devolves.     The  kidney 
is  supposed  to  be  exclusively  intrusted  with  this  office,  and  thus  it  happens  that 
the  material  explanation  of  all  the  disorders  of  the  secretion  is  sought  for  in 
lesions  of  that  organ.     Now,  as  M.  Pidoux  has  very  judiciously  observed,  the 
secretion  of  urine  is  not  confined  to  the  kidney,  since  it  takes  place  previous  to 
the  formation  of  the  latter.     (Uric  acid  and  the  other  elements  of  the  urine  have 
been  discovered  in  the  fluid  contained  within  the  allantoid.)     The  process  of 
assimilation  which  is  so  active  in  the  fcetus,  can  only  be  understood  by  supposing 
a  contemporaneous  process  of  decomposition.    The  blood  which  flows  to  the  organ 
is  already  charged  with  the  elements  of  urine  which  are  to  be  separated  from  it 
in  the  passage.     The  function  begins  in  all  parts  of  the  economy  by  this  admix- 
ture of  heterogeneous  elements  with  the  blood,  and  is  completed  in  the  kidney 
by  their  elimination  from  the  circulating  fluid,  which  is  returned  in  a  purified 
condition.     oNI.  Pidoux  was  therefore  right  in  saying,  that  the  secretion  of  urine 
is  at  once  a  local  and  general  function ;  general,  because  it  commences  every- 
where, and  local,  because  it  ends  in  the  kidney.     To  study  the  latter  organ  ex- 
clusively, when  we  wish  to  obtain  a  physiological  idea  of  the  function,  is  to 
neglect  an  important  element ;  so,  also,  in  pathology,  always  to  expect  to  find  the 
cause  of  the  disorders  of  the  urinary  secretion  in  alterations  of  the  kidney,  is  to 
overlook  a  multitude  of  other  causes  which  may  have  a  corresponding  influence. 
The  elements  of  the  blood  conveyed  by  the  renal  artery  exist  in  health,  in  a  fixed 
proportion,  and  certain  of  them  are  destined  to  be  eliminated  by  the  kidneys. 
Now  it  is  easy  to  understand  that  if  an  alteration  in  the  structure  of  these  organs 
is  capable  of  modifying  both  the  quantity  and  quality  of  the  matters  eliminated, 
an  alteration  of  the  fluid,  such,  for  example,  as  the  diminution  or  increase  of  its 
solid  or  fluid  parts,  may  also  have  the  same  eff'ect.     Clinical  observation  and  post- 
mortem examination  give  constant  support  to  this  idea ;  for  though  we  sometimes 
find  a  material  lesion  of  the  kidney  to  which  we  attribute  the  albuminuria,  we 


DISEASES    OF    PREGNANCY.  291 

are  very  frequently  obliged  to  recognize  it  also  in  certain  general  diseases,  as 
scarlatina,  typhoid  fever,  cholera,  &c.,  in  which  the  renal  affection  is  often  want- 
ing. In  Bright's  disease  itself,  or  at  least  in  certain  cases  in  which  the  presence 
of  albumen  in  the  urine  and  all  the  other  symptoms  of  granular  nephritis  had 
been  detected  during  life,  the  autopsy,  though  conducted  with  the  greatest  care, 
revealed  no  alteration  of  the  kidneys.  (Forget,  of  Strasbourg.)  Finally,  Ken- 
nedy found  the  kidneys  to  be  perfectly  healthy  in  several  cases  of  dropsy  with 
albuminuria  following  scarlatina.  Must  we  conclude  from  thence  that  Bright's 
disease  did  not  exist  in  those  cases  ?  Certainly  not ;  the  disease  was  present,  but 
the  pathological  alteration  was  confined  to  the  fluids. 

It  is,  therefore,  proved  satisfactorily,  that  albuminuria  with  or  without  ana- 
sarca, is  sometimes  the  sign  of  an  alteration  of  the  fluids.  Now,  why  may  not 
the  same  be  the  case  during  pregnancy?  Does  the  blood  then  retain  its  normal 
composition  ?  Have  we  not  shown  that  it  suffers  a  marked  diminution  of  its 
corpuscles  and  albumen,  and  an  evident  increase  in  the  proportion  of  water  ? 
When  we  compare  the  composition  of  the  blood  during  pregnancy  with  that  ob- 
served by  M.  Andral  and  Becquerel  in  albuminous  nephritis,  it  is  impossible  not 
to  be  struck  with  the  analogy,  for  the  latter  have  demonstrated  a  notable  decrease 
in  the  proportion  of  both  corpuscles  and  albumen. 

Finally,  many  authors  have,  like  Christison,  thought  that  they  had  detected 
urea  in  considerable  amount  in  the  blood  of  individuals  affected  with  Bright's 
disease.  But  few  examinations  have  been  made  of  the  blood  of  pregnant  women 
with  albuminuria;  two  cases,  however,  occurring  at  the  Clinical  Lying-in  Hospital 
at  Vienna,  and  recorded  in  Braun's  Journal,  seem  to  prove  that  there  was  an 
excess  of  urea  in  the  blood  of  two  females  affected  with  albuminous  urine,  and 
who  died  of  eclampsia.  (Bach,  loc.  cit.) 

This  alteration  of  the  fluids  being  well  ascertained,  it  becomes  impossible,  as 
we  have  said  already,  to  deny  its  influence  upon  both  the  quality  and  quantity  of 
the  urinary  secretion ;  the  influence  will,  however,  be  in  relation  with  the  dura- 
tion and  degree  of  the  alteration.  If  the  latter  be  very  slight,  the  effect  will  be 
almost  nothing ;  if  more  prolonged  or  more  intense,  it  will  occasion  greater  de- 
rangement of  the  function,  indicating  its  existence  by  albuminuria  and  anasarca. 
All  this  may  take  place  without  appreciable  lesion  of  the  kidneys ;  but,  as  M. 
Pidoux  has  observed,  the  function  is  one  and  the  apparatus  is  one ;  and  if  the 
function  be  primarily  affected,  the  life  of  all  the  parts  will  be  so  simultaneously : 
their  physical  or  visible  alterations  may  then  appear  successively,  and  nephritis 
become  manifest. 

This  succession  of  pathological  phenomena  seems  to  me  to  throw  much  light 
upon  the  etiology  and  nature  of  puerperal  albuminuria,  and  to  reconcile  appa- 
rently contradictory  facts  and  opinions.  It  were  certainly  going  too  far  to  say 
that  all  cases  of  albuminuria  during  pregnancy  are  attended  with  albuminous 
nephritis ;  it  is  an  opposite  exaggeration,  on  the  other  hand,  to  insist  that  there 
very  rarely  exists  a  connection  between  the  albuminous  urine  and  the  disease 
described  by  Bright.  The  true  statement,  we  think,  would  be  :  that  pregnancy 
generally  produces  a  notable  change  in  the  relative  proportion  of  the  elements  of 


292  GENERATION. 

the  blood,  wliich  change  consists  essentially  in  a  diminution  of  the  solid  consti- 
tuents. This  alteration  of  the  fluids  constitutes  an  unfortunate  predisposition ; 
for  should  it  be  conjoined  with  imperfect  nutrition,  destitution,  privations  in  a 
cold  and  damp  season,  chagrins,  &c.,  it  may  increase,  and  become  the  starting- 
point  of  a  general  disorder,  which,  however,  is  not  always  of  the  same  character. 
In  one  case,  the  proportion  of  the  corpuscles  may  be  diminished,  the  amount  of 
albumen  undergoing  but  little  alteration ;  and  then  we  find  chlorosis,  and  its 
accompanying  cortege  of  symptoms,  manifesting  itself;  in  another  case,  the  cor- 
puscles descend  but  a  little  below  their  normal  proportion,  whilst  the  albumen 
decreases  very  sensibly  with  the  immediate  appearance  of  albuminuria,  anasarca, 
and  all  the  symptoms  of  a  general  disorder,  which  at  a  later  period  is  localized 
in  the  kidney  and  produces  granular  nephritis.  In  a  word,  there  exists,  in  our 
opinion,  as  in  pregnancy,  a  tendency  to  the  diminution  of  the  corpuscles  and  to 
chlorosis ;  there  is  also  present  an  unfortunate  disposition  towards  the  reduction 
of  the  albumen  of  the  blood  and  to  Bright's  disease.  This  is  what  makes  albu- 
minuria so  common  during  gestation,  especially  in  the  poorer  classes,  that  M. 
Blot  observed  it  forty-one  times  out  of  two  hundred  and  five  cases,  occurring  at 
the  Maternity  Hospital,  whilst  it  is  rather  rarely  met  with  in  civil  practice. 

The  elimination  of  albumen  from  the  blood  is,  therefore,  the  fundamental 
fact,  and  that  it  exists  during  pregnancy  is  proved  by  all  analyses.  It  is  almost 
the  physiological  condition  of  the  pregnant  female,  but  if  exaggerated,  it  gra^ 
dually  becomes  pathological. 

M.  Blot's  mistake  consists  in  his  confining  Bright's  disease  to  the  renal  altera- 
tion exclusively.  The  granular  nephritis  is,  however,  but  one  of  the  anatomical 
manifestations  of  the  disease,  and  may  be  altogether  wanting  though  the  albu- 
minuria and  all  the  other  symptoms  are  present.  Whilst  insisting  so  strongly 
upon  the  cases  of  puerperal  albuminuria  without  renal  alteration,  with  the  object 
of  proving  that  the  presence  of  albumen  is  but  very  rarely  the  consequence  of 
Bright's  disease,  he  proves  absolutely  nothing;  since  he  neglects  the  most  im- 
portant term  of  the  question,  to  wit :  the  general  alteration  of  the  fluid.  Must 
typhoid  fever  be  absolutely  denied,  says  M.  Imbert  Goubeyre,  simply  upon  the 
ground  that  the  intestinal  eruption  is  wanting  at  the  autopsy  ?  Are  not  variolce 
sine  vai'iolis  described  by  authors,  and  is  it  always  necessary  that  a  fiilse  mem- 
brane should  be  present  upon  the  pharynx  in  cases  in  which  persons  have  died 
with  all  the  general  symptoms  of  pseudo-membranous  angina,  to  justify  the  sup- 
position that  they  perished  with  the  same  infection  that  produces  the  latter  ? 

This  general  alteration  is  of  itself  capable  of  producing  the  elimination  of 
albumen ;  but  when  existing  in  a  slight  degree  only,  and  therefore  unequal  to 
the  production  of  albuminuria,  may  have  its  action  assisted  by  the  active  or  pas- 
sive congestions  to  which  the  kidney  may  be  exposed  during  pregnancy,  and 
especially  during  labor.  Those  simple  hyperremias  of  the  kidney,  which  are  so 
often  seen  after  death,  and  which  are  really  the  first  degree  of  granular  nephritis, 
do  not  appear  to  have  any  other  cause. 

The  marked  influence  which  a  first  pregnancy  appears  to  have  in  the  produc- 
tion of  albujcninuria  (the  resistance  of  the  walls  of  the  abdomen  increase  greatly 


DISEASES     OF     PREGNANCY.  293 

the  pressure  sustained  by  the  parts  situated  behind  the  uterus),  is  thus  explained, 
as  also  the  rapidity  with  which  the  albumen  frequently  disappears  after  labor. 

Let  us  now  see  to  what  symptoms  the  albuminuria  may  give  rise. 

In  the  last  edition  of  this  work,  we  stated  that  puerperal  albuminuria  did  not 
usually  give  rise  to  the  symptoms  which  accompany  Bright's  disease.  This  is 
true  for  the  light  cases,  which,  happily,  are  the  most  frequent;  but  science  has 
progressed,  and  modern  researches  have  proved  that  certain  of  the  affections  of 
the  pregnant  female,  whose  cause  and  nature  were  entirely  unknown,  coincide 
with  albuminuria,  and  very  probably  are,  like  it,  the  consequence  of  extensive 
elimination  of  albumen  from  the  blood.  Thus,  in  several  cases  of  amaurosis 
occurring  during  pregnancy,  MM.  Simpson,  Imbert  Goubeyre,  and  others,  have 
detected  albumen  in  the  urine.  The  same  is  true  of  certain  cases  of  obstinate 
headache,  of  lumbar  pains  and  pleurodynia,  of  paralysis  (hemiplegia  or  para- 
plegia), (Robert  Johns,  Simpson,  Imbert  Goubeyre),  and  of  contractions,  hemor- 
rhages (Blot),  &c. 

Now,  M.  Imbert  Groubeyre's  remark  is  very  important,  namely,  that  all  these 
phenomena  are  found  in  the  symptomatology  of  Bright's  disease,  which  confirms 
the  comparison  that  we  have  made. 

The  symptoms  just  mentioned,  and  to  which  we  would  have  added  eclamptic 
convulsions,  were  it  not  our  intention  to  treat  of  them  at  length  hereafter,  are, 
happily,  quite  rare,  and  hardly  ever  appear  except  at  an  advanced  stage  of  the 
disease.  Another  is  much  more  common,  namely,  general  infiltration  or  anasarca, 
which  should  be  distinguished  carefully  from  oedema  of  the  lower  extremities. 
The  latter,  indeed,  is  merely  an  effect  of  the  obstruction  of  the  abdominal  venous 
circulation  caused  by  the  uterine  tumor. 

General  infiltration  is  not  so  uniform  an  accompaniment  of  albuminuria  as  I 
thought  formerly.  In  order  to  determine  its  relative  frequency,  it  is  necessary 
not  only  to  examine  the  urine  of  infiltrated  females,  as  was  my  practice,  but  to 
investigate  carefully  the  urine  of  all  pregnant  women,  as  was  done  by  M.  Blot. 
It  will  then  be  discovered  that  many  patients  with  albuminuria  present  not  a 
trace  of  oedema.     M.  Blot  found  it,  we  have  said,  in  23  cases  out  of  41. 

It  is  proper  to  observe,  that  this  absence  of  infiltration  is  also  often  noticed  in 
the  ordinary  Bright's  disease.  By  a  collection  of  observations  with  autopsies, 
derived  from  various  authors,  Frerich  found  that  of  220  cases  of  Bright's  dis- 
ease, 175  were  accompanied  with  oedema,  and  45  were  free  from  it. 

Progress,  Duration,  Termination. — It  is  very  difficult,  not  to  say  impossible 
to  determine  with  certainty  when  the  albuminuria  commences;  to  do  this,  it 
would  be  necessary  to  examine  daily  the  urine  of  a  large  number  of  women 
during  the  entire  period  of  pregnancy.  Hitherto,  it  has  generally  been  observed 
only  during  the  latter  months.  M.  Bach,  of  Strasbourg,  however,  says  that  he 
has  seen  it  at  six  weeks  in  a  very  nervous  person.  I  once  detected  it  at  four 
months  in  a  greatly  infiltrated  primiparous  female,  who  was  delivered  at  six 
months  of  a  still-born  child,  and  whose  urine  was  slightly  albuminous  eichteen 
months  afterwards,  although  the  infiltration  had  disappeared  since  six  months. 
M.  Cahen  mentions  in  his  thesis  three  cases,  I'ecorded  in  the  fifth  and  sixth 


294  GENERATION. 

niontlis,  and  M.  Bach  two  others.  Perhaps,  now  that  attention  is  directed  to 
this  point,  such  facts  will  multiply;  but  tho.se  observed  hitherto  have  almost 
always  been  noticed  in  the  latter  stages.  Sometimes  it  appears  only  at  the 
moment  of  delivery,  under  the  influence  of  the  parturient  efforts,  which  are  well 
calculated  to  produce  congestion  of  the  kidneys. 

When  once  begun,  the  progress  of  albuminuria  is  liable  to  great  variation; 
sometimes  it  continues  uninterruptedly  until  the  commencement  of  labor,  and 
increases  during  its  continuance ;  at  others,  it  varies  greatly  in  intensity,  and 
may  even  cease  completely  for  several  days,  then  reappear,  and  again  stop  at  very 
indefinite  intervals. 

When  it  begins  during  labor  or  shortly  before,  it  often  disappears  a  few  hours 
or  days  after  delivery;  but  it  follows  from  the  facts  collected  by  M.  Imbert 
Groubeyre,  that  so  prompt  a  cessation  is  not  as  common  as  I  had  thought,  and  as 
51.  Blot  had  stated.  Though  there  are  cases,  says  M.  Imbert  (roubeyre  (memoir 
quoted),  in  which  the  albumen  disappears  with  rapidity,  in  others  it  continues, 
and  passes  into  chronic  and  confirmed  Bright's  disease.  From  a  statement  by 
this  author,  it  appears  that  of  65  cases  of  puerperal  albuminuria  unaccompanied 
with  eclampsia,  21  proved  fatal  during  pregnancy  and  the  lying-in;  and  6  from 
the  third  to  the  fourteenth  month  after  delivery;  5  cases  became  chronic,  and 
were  found  to  be  still  existent,  two,  eight,  ten,  and  fourteen  months,  and  seven 
years  after  the  labor. 

I  but  just  now  mentioned  a  case  in  which  albumen  was  detected  in  the  urine 
eighteen  months  after  delivery. 

These  differences  appear  to  me  to  be  due  to  the  greater  or  less  intensity  of  the 
disease.  When  the  alteration  of  the  fluids  is  but  slight,  especially  when  it  has 
existed  for  but  a  short  time,  and  occurs  towards  the  end  of  gestation,  or  only 
during  the  labor,  when,  finally,  the  active  or  passive  congestion  of  the  kidneys, 
produced  by  obstruction  of  the  venous  circulation,  has  had  its  influence  in  causing 
the  albuminuria,  we  can  understand  how  the  removal  of  one  of  the  causes,  by 
delivery,  may  leave  the  other  incapable  of  sustaining  the  functional  disorder. 
But  when  the  alteration  is  slight,  especially  when  it  dates  back  to  the  middle  or 
first  half  of  the  pregnancy,  it  may  then  continue  for  a  long  time  after  delivery. 
In  these  latter  cases,  granular  nephritis  is  often  present ;  but  I  am  much  inclined 
to  believe  that  sometimes  the  kidney  is  unchanged,  or  very  slightly  altered,  not- 
with:^ta^ding  the  persistence  of  the  albuminuria. 

Has  the  albuminuria  any  effect  upon  the  progress  of  the  pregnancy,  and  upon 
the  life  and  development  of  the  fcetus  ?  M.  Blot  thinks  that  it  has  not,  whilst 
MM.  Cahen,  Bayer,  and  some  others,  hold  the  contrary  opinion. 

I  still  regard  the  view  of  M.  Blot  as  entirely  correct  for  the  slight  cases,  which 
are,  I  repeat,  the  most  common ;  but  it  does  not  appear  to  me  well  founded  as 
regards  those  complicated  with  anasarca,  or  which  begin  before  the  latter  half  of 
gestation.  I  am  very  much  inclined  to  consider  it  as  being  then  a  frequent 
cause  of  abortion,  of  premature  labor,  and  of  death  to  the  foetus. 

We  have  noticed  the  views  of  Simpson  and  others  respecting  the  frequent  occur- 
rence of  albuminuria  in  numerous  puerperal  disorders.  M.  Blot  considers  it  a  cause 


DISEASES     OF     PREGNANCY.  295 

of  hemorvliage.  It  is,  therefore,  as  relates  to  the  prognosis,  a  sign  which  is  always 
calculated  to  excite  solicitude.  As  a  diagnostic  sign,  it  is  certainly  destined  to 
reveal  the  nature  and  etiology  of  a  multitude  of  affections  hitherto  of  very  diffi- 
cult explanation ;  therefore,  it  is  now  indispensable,  in  obscure  cases,  to  examine 
carefully  the  urine  of  pregnant  women,  even  when  unattended  with  dropsy.  It 
may  possibly  be  shown  in  the  future  that  albuminuria  is  a  central  point  towards 
which  converge  a  multitude  of  diseases  of  various  characters,  and  these  researches 
may  throw  light  upon  their  treatment,  which  is  still  so  obscure. 

The  urine,  in  Bright's  disease,  presents  other  alterations  besides  its  admixture 
with  a  certain  proportion  of  albumen.  Thus,  when  submitted  to  microscopic  exa- 
mination at  a  certain  peiiod  of  the  disease,  it  is  found  to  contain  mucous  cor- 
puscles, scales  of  epithelium  derived  from  the  bladder,  ureters,  and  pelvis  of  the 
kidney,  besides  elongated  cylindrical  bodies  formed  of  amorphous  fibrine,  in  the 
substance  of  which  blood  corpuscles  may  be  observed,  either  singly  or  in  groups. 
These  have  been  termed  fibrinous  cylinders,  and  are  regarded  by  Frerich  as 
pathognomonic  of  Bright's  disease. 

Finally,  analysis  shows  a  considerable  decrease  in  the  proportion  of  urea. 

According  to  some  authors,  all  these  peculiarities  are  observable  in  the  urine 
of  pregnant  women  affected  with  albuminuria;  according  to  others,  on  the  con- 
trary, the  fibrinous  cylinders  are  very  rare  in  the  latter  case,  and  M.  Blot  has 
quite  recently  examined  the  urine  of  three  eclamptic  patients  without  discovering 
them. 

I  am  not  prepared  to  decide  upon  this  point,  though  it  seems  to  me  very  pro- 
bable that  this  difference  of  results  is  simply  due  to  the  fact,  that,  in  the  first 
case,  the  kidneys  were  diseased,  whilst  in  the  second,  the  recent  albuminuria  was 
connected  only  with  a  general  alteration  of  the  fluids. 

If  we  have  succeeded  in  showing  that  an  altered  state  of  the  blood  is  the  prin- 
cipal cause  of  a  puerperal  albuminuria,  and  that  this  alteration  consists  chiefly  in 
a  diminution  of  its  solid  constituents,  we  shall  have  no  occasion  to  insist  strongly 
upon  the  advantages  of  a  reparatory  treatment.  Unless  very  evident  symptoms 
of  general  plethora  or  renal  congestion  be  present,  bleeding  would  be  rather  hurt- 
ful than  useful,  in  a  disease  attended  with  so  great  impoverishment  of  the  system  ; 
therefore  a  tonic  medication  should  be  resorted  to  from  the  outset.  A  good 
animal  diet,  assisted  by  the  use  of  whatever  ferruginous  preparation  will  be  most 
readily  supported  by  the  patient,  ought  evidently  to  form  the  basis  of  the  treat- 
ment. The  preparations  of  Peruvian  bark,  and  other  bitters,  may  be  added  with 
advantage. 

The  following  is  the  simplest  method  of  detecting  the  presence  of  albumen. 
After  withdrawing  the  urine  by  the  catheter,  it  is  to  be  poured  into  a  tube  and 
heated.  As  soon  as  it  begins  to  boil,  it  becomes  cloudy,  and  deposits  a  flaky 
coagulum  of  albumen  upon  cooling.  If  another  portion  of  the  same  urine  be 
treated  with  nitric  acid,  the  same  precipitate  is  obtained,  which  is  not  soluble  in 
an  excess  of  the  agent,  as  is  that  afforded  by  specimens  of  urine  containing  a 
large  amount  of  uric  acid. 


296  GENERATION. 

The  use  of  the  catheter  is  necessary,  in  order  to  avoid  the  confusion  produced 
by  the  admixture  of  the  vaginal  secretions  with  the  urine. 

It  is  equally  important  to  ascertain  whether  the  urine  be  acid  or  alkaline  before 
heating  it.  For  it  is  well  known  that  alkaline  urine  subjected  to  heat  will  not 
precipitate  albumen.  Finally,  the  use  of  nitric  acid  as  a  reagent  may  give  rise 
to  a  precipitate  of  uric  acid  and  urate  of  ammonia ;  these,  however,  are  redis- 
solved  in  an  excess  of  acid.     The  acid  should  be  added  drop  by  drop. 

§  4.  Leucorrhcea. 

We  shall  limit  ourselves  to  a  short  notice  of  the  profuse  leucorrhcea  with  which 
women  are  very  often  aflfected  during  pregnancy.  This  discharge,  which  is  some- 
times white  and  sometimes  of  a  yellowish-green  color,  usually  makes  its  appear- 
ance during  the  second  half  of  gestation,  though  I  have  seen  some  persons 
affected  with  it  from  the  early  months.  It  is  generally  coincident  with  the  deve- 
lopment of  numerous  granulations,  which,  as  we  have  already  said,  sometimes 
cover  the  vaginal  mucous  membrane,  and  constitute  what  has  been  described  of 
late  as  granular  vaginitis.  When  it  is  very  profuse,  an  examination  by  the 
speculum  frequently  discovers  numerous  ulcerations  of  the  neck  of  the  uterus. 
We  shall  have  occasion  to  speak  of  these  ulcerations  hereafter.  I  am  convinced 
that  the  vaginal  granulations  and  ulcerations  of  the  cervix  are  very  rarely  as 
serious  during  gestation  as  they  appear  to  be  under  some  other  circumstances, 
since  they  generally  disappear  with  the  pregnancy,  during  which  they  arc  deve- 
loped. 

Sometimes  the  discharge  is  so  abundant  as  to  react  upon  the  functions  of  the 
stomach,  and  I  have  seen  several  patients  with  symptoms  of  gastralgia,  evidently 
connected  with  the  leucorrhcea,  inasmuch  as  they  increased  or  diminished  accord- 
ing as  the  latter  was  more  or  less  profuse. 

This  affection  often  produces,  in  addition,  great  irritation,  a  burning  heat,  and 
sometimes  an  almost  insupportable  itching  of  the  lower  part  of  the  vagina  and 
external  genitals.  A  profusion  of  small  vesicles  appear  upon  the  internal  surface 
of  the  greater  and  lesser  labia,  which,  by  constantly  rubbing  against  each  other, 
finally  give  rise  to  excoriation,  and  render  walking  very  painful. 

Frequent  baths,  lotions,  and  injections  of  cold  water,  to  each  quart  of  which  a 
dessertspoonful  of  subacetate  of  lead  has  been  added,  repeated  several  times 
daily,  according  to  the  degree  of  pain,  are  the  best  remedies.  It  will  also  be 
found  advantageous  to  separate  the  parts  by  introducing  a  piece  of  fine  linen 
between  the  labia,  so  as  to  prevent  friction  whilst  walking.  It  is  unnecessary  to 
say  that  the  introduction  of  the  speculum  during  pregnancy,  requires  that  espe- 
cial care  be  taken  not  to  press  it  too  far. 

Though  the  patient's  sufferings  may  easily  be  alleviated  in  this  manner,  it  is 
more  than  probable  that  the  granulations  will  continue,  and  that  the  discharge 
will  not  cease  entirely;  in  spite  of  all  that  can  be  done,  it  generally  lasts  until 
the  end  of  pregnancy,  and  in  the  great  majority  of  cases  only  terminates  after 
delivery. 


diseases   of   pregnancy.  297 

§  5.  Dropsy  of  the  Cellular  Tissue. 

Another  affection  of  quite  frequent  occurrence,  and  one  whieli  is  often  con- 
nected with  what  accoucheurs  call  plethora,  of  which,  according  to  Chaussier,  it 
is  a  variety  (serous  plethora),  is  serous  infiltration  of  the  cellular  tissue.  This 
infiltration  begins  in  the  feet,  then  extends  to  the  legs,  thighs,  genital  jiarts,  and 
sometimes  rising  above  the  lower  extremities,  invades  the  trunk,  flice,  upper 
extremities,  and  is  sometimes  even  accompanied  by  effusion  into  the  great  serous 
cavities. 

These  dropsies,  upon  which  MM.  Devilliers  and  Kegnauld  have  published  an 
interesting  memoir,  are  by  them  divided  into:  1,  simple  oedemas;  2,  ocdemas 
connected  with  affection  of  the  central  organs  of  respiration  and  circulation ;  3, 
cedemas  with  albuminuria. 

The  oedema  connected  with  lesions  of  the  organs  of  circulation,  generally  in- 
creases during  pregnancy,  but  this  increase  is  especially  due  to  the  unfortunate 
influence  which  gestation  has  upon  all  organic  lesions,  and  we  have  no  occasion 
to  speak  of  it  further.  As  regards  the  two  other  species,  we  think  it  propei-,  in 
order  to  avoid  repetition,  to  include  them  in  the  same  description ;  for  though 
they  have  some  special  characters  upon  which  we  shall  have  to  insist,  they  re- 
semble each  other  in  a  great  many  particulars. 

The  causes  of  the  serous  infiltrations  which  occur  during  pregnancy,  may  be 
divided  into  general  and  local.  As  first  in  importance  of  the  general  causes,  we 
must  rank  the  decrease  in  the  proportion  of  albumen ;  a  decrease  which  has  been 
discovered  by  all  observers  in  the  blood  of  pregnant  women.  According  to  M. 
Andral,  this  special  alteration  of  the  blood  is  the  only  one  which  necessarily 
produces  dropsy.  The  amount  of  effusion  is  dependent  upon  the  extent  of  the 
alteration,  which,  if  considerable,  is  often  attended  with  albuminuria. 

Hydr^emia,  or  serous  plethora,  which  also  produces  oedema  in  certain  chlorotic 
patients,  may  also  give  rise  to  the  same  symptom  during  pregnancy,  and  assist  in 
the  production  of  serous  infiltrations.  When  these  general  alterations  of  the 
economy  are  but  slight,  they  usually  would  be  unequal  to  the  production  of 
oedema,  did  not  the  development  of  the  womb  add  its  local  action  to  their  own. 

The  pressure  of  the  womb  upon  the  surrounding  parts  from  early  pregnancy, 
and  the  obstruction  which  it  occasions  to  the  performance  of  the  functions  of  the 
central  organs  of  respiration  and  circulation  at  an  advanced  stage,  when  by  rising 
into  the  epigastric  region  it  forces  up  the  diaphragm  and  thus  diminishes  the 
thoracic  cavity,  explain  why  the  oedema  commences  in  the  lower  extremities,  and 
why  it  generally  does  not  extend  until  a  much  later  period  to  the  trunk  and  upper 
extremities. 

Progress  and  Si/mpto7ns. — Generally  speaking,  the  oedema  makes  its  appear- 
ance within  the  three  last  months  of  pregnancy,  especially  when  it  appears  to  be 
due  simply  to  a  mechanical  obstruction  of  the  circulation.  But  when  it  results 
from  one  of  the  general  causes  before  mentioned,  it  may  commence  with  the 
pregnancy,  or  in  the  third  or  fourth  months.  However,  as  hydrcemia,  the  dimi- 
nution of  the  albumen  of  the  blood,  and  the  albuminuria,  are  most  generally 


298  GENERATION. 

observed  in  the  latter  lialf  of  a-estation,  we  may  understand  that  the  dropsy  to 
which  they  give  rise  should  also  be  more  common  towards  the  seventh,  eighth, 
or  ninth  month. 

The  progress  of  the  oedema  of  pregnancy  is  generally  slow  and  chronic  ;  some- 
times, however,  it  advances  rapidly  in  a  few  weeks.  Whatever  may  be  the  case 
in  this  respect,  it  generally  begins  by  the  lower  extremities  sometimes  affecting 
one  of  them,  at  others  both.  At  first,  it  is  limited  to  the  feet  and  neighborhood 
of  the  ankles ;  sometimes  even  it  never  gets  farther  than  the  lower  part  of  the 
legs,  though  quite  frequently  it  reaches  the  knees,  the  thighs,  and  external  geni- 
tal parts.  Occasionally  it  invades  the  integuments  of  the  lower  part  of  the  trunk, 
and  in  some  rare  cases,  generally  attended  with  albuminuria,  it  affects  even  the 
face  and  hands. 

In  the  early  stages,  whilst  limited  to  the  lower  part  of  the  legs,  it  disappears 
at  night,  in  consequence  of  the  horizontal  position,  and  is  only  well  marked  to- 
wards the  close  of  the  day.  But  when  the  disease  has  advanced  farthei',  it  con- 
tinues, whatever  position  the  patient  assumes ;  and  although  the  horizontal  pos- 
ture seems  to  diminish  the  swelling  of  the  legs,  it  is  only  because  the  infiltrated 
fluid  is  displaced  to  the  lower  part  of  the  trunk. 

The  amount  of  fluid  extravasated  varies  between  a  slight  puffiness,  and  the 
extreme  swelling  which  makes  standing  and  walking  impossible.  In  the  latter 
case,  the  parts  affected  are  generally  the  seat  of  pain,  of  sensations  of  pricking, 
and  sometimes  of  burning  and  extreme  tension. 

The  oedema  rarely  disappears  before  delivery;  on  the  contrary,  it  generally 
increases  until  near  the  end  of  pregflancy.  Sometimes,  however,  as  MM.  Devil- 
liers  and  Regnauld  have  indicated,  it  undergoes  remarkable  variations.  Thus,  it 
may  disappear  entirely  and  finally,  or  it  may  return  shortly  after;  sometimes  it  is 
observed  to  leave  one  member  and  fix  upon  the  other,  which  had  been  but  par- 
tially affected.  These  changes  are  doubtless  owing  to  mechanical  causes,  the 
action  of  which  varies  or  ceases  with  alterations  in  the  situation  of  the  uterus 
(Devilliers  and  Regnauld) ;  but  they  certainly  may  also  be  occasioned  by  fluctua- 
tions in  the  albuminuria,  which  may  be  suspended  for  a  short  time  and  then  re- 
appear, as  I  have  witnessed  in  one  case  after  labor. 

Terminations. — The  dropsy  of  pregnant  women,  however  caused,  generally 
disapi^ears  quickly  after  labor ;  and  in  cases  of  albuminuria,  the  secretion  of  albu- 
men often  ceases  with  equal  rapidity. 

Prognosis. — If  the  dropsy  be  viewed  as  a  simple  fact,  independent  of  the  com- 
plications which  so  often  attend  and  follow  it,  it  assumes  the  position  of  a  merely 
troublesome  affection ;  but  to  appreciate  the  prognosis  rightly,  it  is  important  to 
remember  that  some  authors  regard  the  oedema  as  favoring  abortion  and  prema- 
ture labor.  They  also  suppose  it  to  be  almost  uniformly  connected  with  the 
etiology  of  eclampsia,  and  often  with  the  development  of  puerperal  fevers ;  and, 
finally,  that  sometimes  the  disappearance  of  the  effusion  after  delivery,  has  been 
followed  by  a  frequently  fatal  serous  congestion  of  the  nervous  centres  or  respi- 
ratory organs.  The  facts  related  by  M.  Lasserre,  leave  no  doubt  in  my  mind  of 
the  truth  of  the  latter  proposition.     It  is  especially  important  to  bear  in  mind. 


DISEASES    OF    PREGNANCY.  299 

that  although  these  dangerous  complications  are  possible  as  a  consequence  of 
simple  oedema,  they  have  been  chiefly  observed  in  cases  of  albuminuria  with  in- 
filtration, and  consequently,  that  the  presence  of  albumen  in  the  urine  adds 
greatly  to  the  gravity  of  the  prognosis.  Hence  the  interest  which  then  attaches 
to  the  examination  of  the  urine. 

The  treatment  of  the  dropsy  of  pregnant  females  should  be  conducted  with  the 
double  purpose  of  overcoming  the  organic  cause  which  so  frequently  produces 
the  oedema,  and  to  stimulate  the  absorption  of  the  effused  fluids.  The  prepara- 
tions of  iron  and  a  tonic  regimen,  appear  to  me  to  be  especially  called  for  in  a 
disease  which  is  so  frequently  connected  with  hydrajmia.  The  presence  of 
albumen  in  considerable  quantity,  even  supposing  it  due  to  a  nephritis,  does  not 
contra-indicate  this  treatment.  The  antiphlogistics  recommended  by  some 
authors,  seem  to  me  likely  to  be  more  hurtful  than  useful ;  and  unless  the  patient 
suff'crs  very  severe  lumbar  pains,  or  to  the  general  infiltration  are  superadded 
dyspnoea,  palpitations,  extreme  giddiness,  and  especially,  evident  indications  of 
uterine  congestion,  threatening  abortion,  I  should  think  it  right  to  proscribe 
bleeding.  Even  under  the  latter  circumstances,  I  would  employ  it  less  as  an 
antiphlogistic  than  as  a  revulsive,  nor  would  I  discontinue  the  use  of  the  iron. 

To  assist  the  absorption  of  the  effused  fluids,  mild  laxatives,  diuretics,  and  dry 
frictions  may  be  used.  To  these  may  be  added  vapor  baths,  provided  the  patient 
,is  able  to  bear  them  without  danger  of  cerebral  congestion. 

If  the  distension  and  size  of  the  lower  extremities  is  so  great  as  to  make  walk- 
ing impossible  and  cause  great  suffering,  and  if  the  genital  parts  are  greatly 
swollen,  their  disengorgement  may  be  facilitated  by  practising  small  incisions,  or 
at  least,  a  number  of  punctures,  with  the  lancet  or  a  needle.  In  several  cases,  I 
have  derived  benefit  from  keeping  compresses,  saturated  with  cold  water,  applied 
to  the  limbs  for  several  days.  Levret  advises  blisters  between  the  thighs  and 
external  labia,  aided  by  slight  punctures  on  the  feet ;  but  inasmuch  as  the  appli- 
cation of  blisters  upon  a  highly  oedematous  limb  is  sometimes  attended  with 
serious  consequences,  I  think  it  prudent  to  abstain  from  them. 

§  6.  Ascites. 

We  have  already  stated,  that  dropsy  during  pregnancy  was  so  far  from  being 
limited  to  the  subcutaneous  cellular  tissue,  that  collections  of  fluid  of  variable 
amount  might  take  place  in  the  great  cavities  of  the  body.  The  efi"usion  within 
the  abdomen  may  occupy  difi"erent  locations ;  thus,  it  may  accumulate  within  the 
amnion,  and  constitute  dropsy  of  the  amnion ;  or  between  the  membranes  of  the 
ovum  and  the  internal  surface  of  the  womb,  in  which  case  it  furnishes  the  fluid 
that  gives  rise  to  hydrorrhcea ;  finally,  by  collecting  within  the  cavity  of  the  peri- 
toneum, it  forms  a  true  ascites. 

Either  of  these  varieties  of  dropsy  may  occur  separately,  or  two  of  them  may 
coexist  in  the  same  female,  as  is  often  the  case  with  ascites  and  hydramnion.  "We 
shall  treat  first  of  ascites. 

This  aff"ection  sometimes  makes  its  appearance  in  the  first  half  of  the  preg- 


300  GENERATION. 

nancy,  though  usually  towards  the  fifth  or  sixth  month,  rarely  later.  When  the 
accumulation  begins  very  early,  it  sometimes  progresses  so  rapidly  that  the  abdo- 
men is  larger  at  the  fifth  month  than  at  the  usual  term  of  gestation,  and  as  the 
infiltration  of  the  lower  extremities  generally  keeps  pace  with  the  effusion  in  the 
abdomen,  the  patients  find  it  impossible  either  to  walk  or  pursue  their  occupations. 

The  progress  of  the  ascites  increases  rapidly;  the  face  is  puffed  and  livid  j  the 
abdominal  walls,  much  thickened  by  infiltration,  add  to  the  size  of  the  belly;  the 
skin  covering  them,  although  distended  and  shining,  sometimes  has  a  tuberculous 
appearance,  as  in  elephantiasis.  The  umbilicus  usually  forms  a  smooth,  i-ounded, 
ti'anslucent  tumor,  of  the  shape  and  size  of  a  hen's  egg,  at  the  base  of  which  the 
umbilical  ring  may  be  felt,  though  it  is  too  much  distended  to  produce  any  cir- 
cular constriction. 

The  greater  labia  share  in  the  general  infiltration,  are  enormously  swollen,  and 
affected  with  a  painful  irritation,  produced  by  their  constant  friction  against  each 
other,  and  contact  with  the  urine. 

The  skin  of  the  lower  extremities  is  so  distended  as  to  seem  ready  to  burst  at 
several  points,  and  is  exceedingly  painful. 

The  progressive  accumulation  of  fluid  in  the  cavity  of  the  peritoneum  soon  ob- 
structs the  regular  performance  of  the  thoracis  functions ;  the  dyspnoea  becomes 
extreme,  the  respiration  very  short,  wheezing,  and  painful;  the  patient  is  obliged 
to  remain  seated  night  and  day ;  yet,  notwithstanding  this  position,  the  hsema- 
tosis  is  so  imperfect  that  she  seems  threatened  with  suffocation  at  every  instant, 
and  has  frequent  attacks  of  faintness.  The  suffering  condition  is  aggravated  by 
an  almost  constant  insomnia,  intense  headache,  extreme  thirst,  and  disgust  for 
food. 

Percussion  of  the  abdomen  detects  readily  the  presence  of  a  large  amount  of 
fluid  in  its  cavity,  though  the  fluctuation  is  not  equal  in  all  parts  of  it.  As 
Scarpa  remarks,  it  is  slight  or  absent  in  the  hypogastrium  and  towards  the  flanks, 
is  manifest  near  the  hypochondriac  regions,  and  very  well  marked  in  the  left  hy- 
pochondrium,  near  the  edges  of  the  cartilages  of  the  false  ribs. 

The  enormous  distension  of  the  parietes  of  the  abdomen  frequently  prevents 
the  uterus  from  being  felt,  and  its  elevation  determined  with  precision.  The 
motions  of  the  child,  though  generally  obscure,  are,  howevei",  still  perceived  by 
the  mother. 

The  prognosis  of  ascites  complicating  pregnancy  is  grave  in  proportion  as  it 
dates  farther  from  the  term  of  gestation.  When  it  appears  only  in  the  latter 
months,  there  is  every  reason  to  hope  that,  notwithstanding  its  rapid  progress,  it 
will  be  arrested  by  delivery,  before  producing  such  disorders  as  seriously  to  com- 
promise the  life  of  the  mother,  and  that,  as  in  the  observation  of  M.  Prestat,  the 
recency  of  the  effusion  will  render  its  absorption  easy  after  delivery.  But  when 
the  ascites  begins  within  the  first  half  of  the  pregnancy  there  is  great  cause  for 
fear,  should  it  progress  rapidly,  lest  paracentesis  should  be  demanded  long  before 
the  ninth  month.  It  were  useless  to  add,  that  the  prognosis  will  be  far  graver, 
if,  as  unfortunately  very  often  happens,  the  ascites  should  coexist  with  dropsy  of 
the  amnion.     If,  says  Scarpa,  there  should  fortunately  be  no  uterine  dropsy,  the 


DISEASES    OF    PREGNANCY.  301 

paracentesis  may  allow  the  pregnancy  to  progress  favorably  through  its  usual 
stages ;  but,  under  the  opposite  circumstances,  it  almost  always  happens  that  the 
womb,  being  excited  by  sympathy,  contracts,  and  delivery  follows. 

Treatment. — The  general  bleeding,  purgatives,  and  diuretics,  employed  with 
the  design  of  retarding  the  advancement  of  the  disease,  have  not  seemed  to  influ- 
ence its  later  progress,  and  it  is  conceivable  that  a  too  long-continued  use  of 
them,  might  be  pi-ejudicial  to  the  pregnancy.  They  should,  therefore,  be  re- 
sorted to  with  the  greatest  reserve,  and  relinquished  as  soon  as  found  to  be 
unsuccessful. 

When  the  disease  has  increased  to  such  an  extent  as  to  threaten  the  life  of  the 
patient,  it  is  evident  that  the  only  resource  consists  in  the  evacuation  of  the  fluid. 
But  where  should  the  puncture  be  made  ? 

The  development  of  the  uterus  makes  it  impossible  to  insert  the  trocar  at  the 
place  of  selection  in  ordinary  ascites.  From  the  circumstance  of  the  fluctuation 
being  particularly  well  marked  in  the  left  hypochondrium,  the  prominence  of 
which  was  greatest  near  the  edge  of  the  false  ribs,  Scarpa  introduced  his  instru- 
ment between  the  uppermost  part  of  the  external  border  of  the  rectus  muscle, 
and  the  edge  of  the  false  ribs  in  the  left  hypochondrium.  The  jiatient  aborted 
two  days  after,  and  recovered. 

George  Langstaff  made  an  incision  two  inches  above  the  umbilicus,  exposed 
the  peritoneum,  and  punctured  it  with  a  medium-sized  trocar,  being  careful  to 
introduce  it  but  a  short  distance  so  as  not  to  wound  the  uterus.  He  had  thus 
given  issue  to  about  ten  pints  of  fluid,  when  the  womb  came  in  contact  with  the 
end  of  the  canula,  interrupting  the  flow,  and  occasioning  so  much  jjain  as  to 
oblige  him  to  withdraw  the  instrument.  As  the  patient  was  unable  to  endure 
any  pressure,  he  introduced  a  medium-sized  gum  elastic  catheter  by  the  opening, 
directing  it  between  the  peritoneum  and  the  anterior  surface  of  the  uterus. 
Peritonitis  foUoioed  eiyht  hours  after  the  operation  ;  three  days  subsequently  to 
the  operation  she  aborted,  and  three  weeks  later  she  was  well. 

Finally,  in  a  case  in  which  a  considei'able  tumor  existed  at  the  umbilicus, 
Ollivier,  of  Angers,  was  decided  by  the  tension  and  thinness  of  the  skin  at  the 
part  to  make  use  of  the  lancet  simply.  This  instrument  was  introduced  in  the 
same  manner  and  to  the  same  depth,  as  for  bleeding,  at  the  middle  and  front  part 
of  the  tumor,  at  the  distance  of  half  an  inch  from  the  circumference  of  the  ring. 
The  water  flowed  immediately  to  the  amount  of  sixteen  pounds. 

For  twelve  days,  the  serum  continued  to  flow  by  the  little  wound,  which  was 
closed  hermetically  on  the  thirteenth.  The  patient,  who  had  been  relieved  at 
once,  experienced  a  return  of  the  accidents  with  the  fresh  accumulation  of  fluid. 
Twenty-eight  days  after  the  first  puncture,  it  became  necessary  to  repeat  it; 
eight  pounds  of  fluid  were  discharged,  and  the  same  alleviation  followed.  Twelve 
days  after  this,  the  woman  was  delivered  of  a  living,  though  feeble  child,  and  in 
fifteen  days  was  discharged  cured. 

This  simple  process,  consisting  of  a  small  puncture  with  the  lancet,  seems  to 
me  preferable  to  Scarpa's  operation  in  the  hypogastrium.  The  latter  might,  in 
some  cases,  endanger  important  organs,  and  could  only  be  preferred  on  account 


302  GENERATION. 

of  the  existence  of  an  old  umbilical  hernia  with  adhesion  of  the  intestines  to  the 
sac.  The  presence  of  this  complication  can  be  readily  discovered  by  holding  a 
candle  behind  the  thin  and  transparent  walls  of  the  umbilical  tumor,  as  for  the  diag- 
nosis of  hydrocele,  when  the  opacity  of  the  exomphalos  will  be  at  once  detected. 

There  is  no  advantage  in  placing  a  foreign  body  in  the  small  opening,  since 
the  flow  of  serum  keeps  the  sides  separated,  and  the  density  and  extreme  thin- 
ness of  the  walls  of  the  tumor  prevent  infiltration  of  the  abdominal  parietes.  The 
observation  of  Langstaff,  above  cited,  as  also  another  fact  related  by  M.  Danyau, 
prove  that  the  introduction  of  a  foreign  body  exposes  to  peritonitis. 

When  the  pregnancy  has  made  but  slight  progress,  the  only  resource  evidently 
consists  in  the  puncture ;  but  when  the  ascites  endangers  the  mother's  life  only 
at  the  eighth  or  ninth  month,  is  it  allowable  to  think  of  premature  artificial 
delivery  ? 

If  the  uterine  dropsy,  of  which  we  are  about  to  speak  in  detail,  complicates  the 
ascites,  and  we  are  able  to  ascertain  that  the  suflferings  of  the  patient  are  in  good 
measure  due  to  the  extreme  size  of  the  uterus,  I  think  that  tapping  would  be 
insufficient,  and  that  the  artificial  induction  of  labor  may  be  attempted  with  ad- 
vantage ;  still,  though  common,  the  hydramnion  is  not  a  necessary  complication, 
and  it  seems  to  me  that  ascites  can  very  rarely  require  the  premature  delivery. 

In  the  eighth,  and  especially  the  ninth  month,  the  evacuation  of  the  peritoneal 
fluid  will  afford  sufficiently  lasting  relief  to  enable  the  woman  to  reach  the  regu- 
lar term  of  pregnancy;  or,  at  least,  it  will  rarely  be  necessary  to  repeat  the  ope- 
ration more  than  once.  Such  was  the  case  with  the  patient  of  Ollivier.  The 
only  fault  to  be  found  with  the  puncture  is  that  of  being  merely  palliatory,  whilst 
it  exhausts  the  strength  if  frequently  repeated.  But  should  the  relief  afforded 
be  such  that  one  or  two  punctures  enable  the  patient  to  reach  the  end  of  the 
ninth  month  with  moderate  suffering,  I  see  no  reason  for  not  preferring  it  to 
premature  delivery,  which  always  places  the  child  in  unfavorable  conditions. 

§  7.  Dropsy  of  the  Amnion. 

The  amniotic  liquid  may  sometimes  augment  to  a  very  considerable  quantity; 
but  as  the  normal  amount  is  very  variable,  it  is  difficult  to  say  above  what  limits 
it  should  be  considered  as  a  disease ;  however,  when  it  exceeds  three  or  four 
pounds,  the  accumulation  may  be  justly  attributed  to  some  morbid  condition. 

In  the  present  state  of  our  science,  it  would  be  absolutely  impossible  to  desig- 
nate the  cause  of  this  singular  affection,  although  some  facts  seem  to  militate  in 
favor  of  its  being  produced  by  an  inflammation  of  the  amnion;  but  this  opiiiioQ 
requires  further  confirmation  to  be  received  without  hesitation,  for,  notwithstand- 
ing Dr.  Mercier  claims  to  have  seen  the  internal  surface  of  the  amnion  covered 
several  times  by  false  membranes,  and  the  membrane  itself  highly  injected,  yet 
other  observers  have  not  detected  anything  of  the  kind.  (Journ.  Gen.  de  Med., 
tom.  xiv.) 

Again,  from  the  cases  cited  by  Drs.  Merriman  and  Lee,  it  would  appear  that 
a  dropsy  of  the  amnion  is  often  associated  with  a  morbid  condition  or  a  bad  con- 
formation of  the  foetus,  or  with  a  state  of  general  infiltration  on  the  part  of  the 


DISEASES    OF    PREGNANCY.  S03 

mother ;  indeed,  some  facts  would  lead  to  the  supposition,  that  constitutional 
syphilis  predisposes  to  this  disease. 

In  a  few  instances,  it  has  seemed  referable  to  sanguineous  plethora ;  but  as  it 
occurs  in  women  of  every  variety  of  condition,  constitution,  and  age,  this  cannot 
be  considered  as  a  fixed  rule  on  this  point.  It  is  much  more  frequent  in  twin 
pregnancies,  and  rarely  supervenes  prior  to  the  fifth  month. 

In  some  cases,  the  dropsy  is  preceded  by  all  the  signs*  of  an  active  inflamma- 
tion; but  most  commonly  a  dull  pain  in  the  uterus,  a  feeling  of  weight  about 
the  pelvis,  and  a  rapid  growth  of  the  organ,  are  the  only  evidences  of  its  exist- 
ence. The  womb  speedily  acquires  a  considerable  volume,  and  is  more  dis- 
tended at  the  fifth  or  sixth  month  than  it  usually  is  at  term.  Further,  the 
development  is  proportionate  to  the  quantity  of  liquid;  thus,  the  latter  often 
amounts  to  five  or  six  pints ;  and  Baudelocque  reports  a  case  in  which  thirteen 
pints  escaped  from  the  uterus,  and  another  one  of  thirty-two  pints.  Certain 
authors  have  even  known  forty  or  fifty  pints  to  exist  in  the  amniotic  cavity. 
The  fluid  is  similar  in  all  respects  to  the  liquor  amnii. 

The  uterus  rarely  becomes  much  enlarged  without  disturbing  the  functions  of 
the  thoracic  organs  in  the  manner  heretofore  described,  and  fiicts  are  not  wanting 
to  prove  that  it  may  even  produce  asphyxia. 

In  a  case  reported  by  Duclos,  the  distension  of  the  womb  was  so  great,  although 
the  gestation  had  only  advanced  to  the  seventh  month,  that  it  enlarged  the  abdo- 
men beyond  measure,  pushed  up  the  diaphragm,  and  interfered  so  much  with 
the  respiration  and  circulation  that  the  woman's  life  seemed  to  be  seriously  com- 
promised. 

The  physicians  called  in  consultation,  decided  in  favor  of  bringing  on  the 
uterine  contractions  as  soon  as  the  neck  showed  any  evidence  of  dilatation ;  but, 
sufi'ocation  being  imminent,  M.  Duclos  ruptured  the  membranes,  at  first  permit- 
ting a  certain  quantity  of  fluid  to  escape,  then,  by  keeping  his  fingers  in  the 
neck,  he  prevented  its  complete  evacuation ;  and  thus,  for  four  times,  after  inter- 
vals of  fifteen  minutes  each,  he  allowed  a  further  flow,  while  slight  pressure  was 
made  over  the  abdomen.  In  this  manner,  fourteen  pounds  were  collected,  with- 
out counting  what  was  lost.  The  symptoms  disappeared  immediately,  but  as  the 
uterus  did  not  appear  capable  of  any  e6"ort,  and  the  neck  offering  no  resistance, 
it  was  easily  dilated,  and  a  living  infant  brought  away  by  the  forceps.  The  child 
was  feeble  and  diminutive,  and  its  limbs  were  very  small.  The  mother  reco- 
vered. 

M.  Evrat,  Sr.,  of  Lyons,  has  published  several  cases  of  almost  complete  as- 
phyxia (lividity  of  features,  cessation  of  pulse,  and  respiration),  in  which  the 
women  were  rapidly  restored  by  the  puncture  of  the  membranes  and  discharge 
of  a  large  amount  of  water. 

A  premature  distension  of  the  uterus  by  amniotic  dropsy,  to  the  size  which  it 
usually  has  at  the  end  of  gestation,  is  capable  of  producing  dangerous  symptoms. 
It  is  astonishing,  as  Scarpa  remarks,  that  in  cases  of  dropsy  complicating  preg- 
nancy, the  womb  should  occasion  symptoms  of  suffocation  which  it  never  deter- 
mines at  the  end  of  the  ninth  month,  though  its  size  be  the  same.    It  is  explained 


304  GENERATION. 

by  the  sudden  and  rapid  development  in  the  first  case,  whilst  in  the  latter  the 
distension  takes  place  almost  imperceptibly,  the  walls  of  the  abdomen  yield  cra- 
dually,  thus  allowing  the  uterus  to  project  more  in  front,  so  as  to  diminish  its 
elevation  slightly,  whilst  it  crowds  much  less  upon  the  diaphragm. 

As  before  said,  ascites  often  coexists  with  the  amniotic  dropsy;  but  as  the  two 
diseases  may  occur  separately,  it  becomes  important  to  establish  their  diiferential 
diagnosis. 

In  ascites  complicating  pregnancy,  the  urine  is  small  in  quantity,  whitish,  and 
turbid,  the  thirst  great  and  constant,  and  the  lower  extremities  and  genital  parts 
mostly  much  infiltrated.  It  is  difficult  and  sometimes  even  impossible  to  distin- 
guish the  shape  and  fundus  of  the  uterus,  on  account  of  the  irregular  form  of  the 
belly,  and  the  enormous  distension  of  the  hypochondriac  regions.  Percussion 
produces  an  undulation,  or  sort  of  fluctuation,  which  is  much  more  perceptible 
at  the  upper  than  at  the  lower  part  of  the  abdomen. 

In  dropsy  of  the  amnion,  the  size  of  the  belly  approaches  much  more  nearly 
that  of  a  uterus  at  term,  although  the  pregnancy  may  not  have  existed  more  than 
five  or  six  months.  The  uterus  is  so  rounded  as  to  be  almost  spherical.  Fluc- 
tuation is  more  obscure,  thirst  slight  or  absent,  urine  natural,  and  in  some  cases 
little  or  no  infiltration  of  the  lower  extremities.  The  umbilical  tumor  is  rarely 
present,  and  when  it  exists,  has  not  the  transparency  observed  in  ascites. 

The  great  enlargement  of  the  womb  often  provokes  premature  contractions  and 
abortion.  Sometimes  the  child  is  born  living,  but  so  little  developed  that  it 
cannot  survive ;  more  frequently,  it  dies  in  the  mother's  womb,  and  is  not  ex- 
pelled until  some  time  after.  When  the  death  of  the  embryo  and  the  dropsy 
come  on  at  an  early  stage,  the  dead  body  may  become  dissolved  in  the  liquid. 
Of  course,  in  the  latter  case  it  would  be  very  difficult  to  distinguish  the  dropsy 
of  the  amnios  from  a  simple  hydrometra,  and  the  diagnosis  can  only  be  made  out 
at  the  time  when  the  fluid  escapes,  by  an  inspection  of  the  membranous  sac  which 
had  enclosed  it;  but  when  the  foetus  is  living,  or  has  died  at  an  advanced  period 
of  intra-uterine  life,  the  ballottement,  together  with  the  pre-existence  of  the  signs 
of  pregnancy,  suffices  to  distinguish  this  affection  from  all  others. 

Dropsy  of  the  amnios,  which  is  so  grave  as  regards  the  infant,  rarely  compro- 
mises the  mother's  life,  or  even  her  health.  Some  unfortunate  cases  have,  how- 
ever, proved  fatal,  though  generally  she  is  merely  incommoded  by  the  excessive 
volume  of  the  womb,  and  the  consequent  interference  with  other  organs.  The 
expulsion  of  the  liquid  is  generally  spontaneous;  the  foetus,  membranes,  and 
placenta  passing  away  with  the  waters;  whence,  the  cause  no  longer  existing,  the 
disease  is  completely  cured. 

According  to  some  authors,  the  rupture  of  the  membranes  and  consequent 
expulsion  of  the  fluid  is  not  always  followed  by  the  birth  of  the  child.  In  this 
case,  the  breach  in  the  membranes  takes  place  at  a  point  considerably  above  the 
neck,  the  uterus  is  relieved  slowly  of  the  superabundant  fluid,  and  the  pregnancy 
proceeds  with  no  other  accident  than  a  moi'e  or  less  frequent  discharge  of  water. 
I  think  that  in  most  of  these  cases,  an  accumulation  of  fluid  between  the  mem- 
branes and  the  uterus,  as  in  the  hydrorrhoea  to  be  spoken  of  hereafter,  has  been 


DISEASES    OF    PREGNANCY.  305 

mistaken  for  amniotic  dropsy.  I  confess,  however,  that  the  following  case,  care- 
fully observed  by  Ingleby,  leaves  hardly  a  doubt  as  to  the  possibility  of  the  fact. 
A  lady  six  months  gone  in  her  third  pregnancy,  lost  suddenly  a  large  quantity  of 
water  during  the  night.  From  this  moment,  until  the  termination  of  pregnancy, 
there  escaped  every  two  or  three  days  a  pint  and  a  quarter  of  fluid.  The  woman 
was  delivered  of  a  large  boy.  The  after-birth  was  expelled  spontaneously.  I 
received  it  in  my  hand,  says  the  author,  so  as  to  avoid  laceration  of  the  mem- 
branes. I  examined  it  with  the  greatest  care,  and  discovered,  besides  the  open- 
ing made  by  the  head  in  the  centre  of  the  membranes,  a  second  opening,  of 
circular  form,  near  the  edge  of  the  placenta.  It  was  doubtless  through  the  latter 
that  the  fluid  escaped  from  time  to  time. 

It  is  proved  by  many  observations,  that  amniotic  dropsy  frequently  recurs  in 
the  subsequent  pregnancies  of  the  same  female. 

A  remarkable  circumstance,  pointed  out  by  MM.  Bunsen  and  Kill,  and  one 
instance  of  which  has  come  under  my  own  notice,  is  a  dropsical  condition  of  the 
foetus,  it  being  sometimes  afiiected  with  hydrocephalus,  and  at  others  with  ascites. 

The  same  authors  also  mention  having  observed  that  in  these  cases  the  pla- 
centa was  often  remarkably  large.  Thus,  in  a  case  reported  by  M.  Kill,  in  which 
the  extreme  distension  of  the  uterus  produced  abortion  at  the  sixth  month,  the 
circumference  of  the  placenta  was  a  third  larger,  and  its  thickness  double  that  of 
ordinary  placentas.  It  was  pale,  and  its  tissue  spongy,  and  when  divided,  the 
vessels  traversing  its  substance  were  found  to  have  almost  the  size  of  the  arteries 
and  umbilical  vein. 

The  abdomen  of  the  foetus  contained  a  large  amount  of  fluid.  The  liver  was 
voluminous,  occupying  almost  the  whole  abdominal  cavity.  Its  structure  was 
normal,  without  any  indication  of  swelling,  but  its  vessels  were  highly  developed. 

This  great  size  of  the  liver  is  supposed  by  the  authors  quoted  to  be  connected 
with  the  extreme  development  of  the  placenta,  whose  enlarged  vessels  would  of 
course  supply  a  great  quantity  of  blood  to  the  umbilical  vein.  (Churchill, 
page  50.) 

When  the  malady  is  once  established,  it  is  exceedingly  diSicult  to  find  the 
proper  remedies — I  will  not  say  to  cure,  but  even  to  impede  its  course — for 
instance,  diuretics  have  usually  proved  of  little  value.  Some  authors,  indeed, 
seem  to  have  observed  good  eff'ects  from  dry  diet;  and  Burns  specially  recom- 
mends cold  bathing.  But,  in  spite  of  all  we  can  do,  the  afi'ection  ordinarily  goes 
on  increasing  until  the  commencement  of  labor;  and  in  the  greater  number  of 
cases,  there  is  nothing  to  be  done  except  to  await  this  event.  However,  if  the 
uterine  tumor  be  of  excessive  size,  more  especially  should  the  dropsy  of  the 
amnion  be  complicated  with  ascites  and  a  general  infiltration,  and  the  patient's 
life  be  endangered  by  the  obstructions  to  the  hematosis,  an  evacuation  of  the 
waters  should  be  determined  upon,  by  rupturing  the  membranes. 

The  punctui-e  is  usually  efiected  by  the  use  of  a  male  or  female  catheter,  or  a 
stylet,  which  is  introduced  through  the  neck,  and  the  membranes  perforated  with 
its  extremity.  When  the  cervix  is  suSiciently  dilated,  the  rupture  may  be  per- 
formed with  the  finger.     When  not  obliged  to  act  quickly,  conti-actions  may  be 

20 


306  GENERATION. 

previously  solicited  by  introducing  and  leaving  a  piece  of  prepared  sponge  in  the 
cavity  of  the  cervix,  or  by  practising  some  douches  upon  the  inferior  segment  of 
the  uterus.  (See  Premature  Artificial  Delivery.)  But  should  the  gravity  of  the 
symptoms  demand  immediate  intervention,  there  would,  I  think,  be  some  advan- 
tage in  following  the  advice  of  M.  Guillemot,  and  to  glide  the  catheter  between 
the  ovum  and  the  uterus,  so  as  to  pierce  the  membranes  far  above  the  neck;  this 
process  would  permit  the  discharge  of  fluid  to  be  controlled,  and  only  the  super- 
abundance, so  to  speak,  to  be  withdrawn.  The  pregnancy  may  afterward  be  left 
to  itself. 

In  case  of  complete  obliteration  of  the  neck,  paracentesis  by  the  vagina,  and 
in  the  vicinity  of  the  uterine  orifice,  must  be  performed.  Scarpa  and  Camper 
recommend  puncturing  between  the  umbilicus  and  pubis.  In  one  of  the  obser- 
vations of  Evrat,  Sr.,  the  operation  was  practised  in  the  place,  so  called  of  elec- 
tion, for  paracentesis.  The  patient  was  delivered  eight  days  afterward  of  two 
living  children,  and  recovered  perfectly.  The  details  given  by  the  author  do  not 
inform  us  whether  the  case  was  one  of  ascites,  or  really  of  amniotic  dropsy,  as  he 
thought. 

The  vaginal  puncture  seems  to  me  likely  to  subject  both  mother  and  child  to 
the  fewest  risks,  in  all  cases  in  which  the  neck  is  inaccessible. 

§  8.  Hydrorrhcea. 

The  Germans  have  given  this  name  to  those  discharges  of  water  that  occur  in 
the  course  of  the  gestation,  but  which,  in  genei'al,  are  neither  preceded  nor  fol- 
lowed by  any  uterine  contractions;  their  nature  is  such  as  to  interfere  but 
slio-htly  with  the  pregnancy,  the  latter  advancing  as  usual  to  term,  and  at  the 
accouchement  the  bag  of  waters  is  regularly  formed. 

This  affection  is  quite  common  in  the  latter  months ;  but  very  rare  at  the 
beo-innino-  of  gestation.  I  obsei-ved  it  once  between  the  third  and  fourth  month, 
and  it  reappeared  but  once  during  the  remainder  of  the  pregnancy,  which  termi- 
nated happily.     (See  Abortion,  article  Diagnosis.) 

The  frequency  of  such  discharges,  and  the  quantity  of  water  lost  each  time, 
are  exceedingly  variable  in  different  cases.  Sometimes  the  liquid  comes  away  in 
•rushes,  at  others  drop  by  drop ;  but  the  amount  may  increase  in  an  incredible 
manner,  and  the  loss  may  occur  but  once,  or  be  renewed  frequently.  Further, 
the  intervals  of  its  appearance  are  very  irregular,  and  lasting  a  long  time  when  it 
does  come  on,  during  which  any  mental  emotions  or  bodily  excitement  singularly 
influence  the  profuseness  of  the  discharge.  On  the  other  hand,  it  augments  in 
quantity  during  the  most  perfect  quietude,  as,  for  instance,  at  night  during 
sleep  ;  its  cause  can  rarely  be  ascertained. 

Most  generally,  the  female  enjoys  her  usual  health  before  the  discharge  comes 
on,  when  she  unexpectedly  finds  herself  wet,  the  fluid  escaping  drop  after  drop,  or 
else  she  hears  the  peculiar  sound  caused  by  the  sudden  irruption  of  a  consider- 
able quantity  of  the  waters.  In  most  cases,  she  suffers  no  pain  either  pending 
or  after  this  discharge ;  though  it  may  happen  that  a  too  rapid  depletion  of  the 
uterus,  and  the  consequent  parietal  retraction,  may  bring  on  some  slight  uterine 


DISEASES    OF    PREGNANCY.  307 

contractions ;  but  if  the  patient  then  keeps  perfectly  still,  they  soon  disappear, 
and  everything  resumes  its  natural  order.  In  color,  the  discharged  water  is 
usually  a  little  yellowish,  very  limpid,  and  at  times  tinged  with  blood,  leaving 
stains  upon  the  linen,  and  having  a  well-marked  spermatic  odor. 

Should  the  hydrorrhoea  be  attended  with  the  uterine  pains,  it  would  be  an  evi- 
dence of  an  approaching  abortion ;  and  some  accoucheurs,  supposing  the  mem- 
branes had  been  ruptured,  have  been  known,  under  such  circumstances,  to  use 
every  effort  to  accelerate  and  to  terminate  a  labor  which  really  had  not  com- 
menced, and  which,  without  their  interference,  would  not  have  occurred  before 
the  ordinary  period. 

This  error  may  be  avoided  by  attending  to  the  fact,  that  the  discharge  was  not 
preceded  by  pain,  and  that  no  modification  of  the  cervix  exists,  which  could 
excite  a  suspicion  of  an  imminent  miscarriage ;  that  the  amount  of  water  dis- 
charged is  frequently  very  great  for  the  stage  of  the  pregnancy,  and  the  quantity 
which  the  amniotic  bag  is  generally  capable  of  containing  at  that  period ;  finally, 
that,  notwithstanding  so  considerable  a  flow  of  liquid,  the  size  of  the  uterus,  its 
consistency  and  elasticity,  are  such  as  it  generally  presents  at  that  period.  These 
remarks  will  at  least  be  suflBcient  to  excite  a  doubt  as  to  the  true  source  of  the 
waters ;  and  from  the  moment  that  there  is  a  doubt,  every  effort  should  be  made 
to  prevent  and  not  to  hasten  abortion. 

These  fluids,  although  having  no  relation  in  their  seat  to  the  liquor  amnii, 
have,  however,  been  called  the  false  ivaters,  so  as  to  distinguish  them  from  those 
which  escape  after  the  membranes  are  ruptured  in  labor. 

Various  opinions  have  been  advanced  as  to  the  nature  and  seat  of  these  false 
waters;  thus,  certain  accoucheurs  have  supposed  that  they  were  contained  be- 
tween the  chorion  and  the  amnion,  and  that  their  escape  is  due  to  a  laceration  of 
the  chorion ;  others,  that  they  are  owing  to  the  rupture  of  an  hydatid,  lodged 
either  in  the  cavity  or  the  neck  of  the  uterus  (Boehmer,  Koederer).  Again, 
Baudelocque  was  of  the  opinion  that  it  resulted  from  the  transudation  of  the 
liquor  amnii  through  the  membranes.  Some  others  explain  it  by  invoking  an 
oedematous  condition  and  an  infiltration  of  the  uterine  cellular  tissue ;  and  lastly, 
Mauriceau,  Camper,  and  M.  Capuron,  have  supposed  that  these  waters  proceed 
from  the  interior  of  the  amnion ;  for,  in  certain  cases,  they  say,  the  membranes  may 
yield  at  a  point  quite  distant  from  the  neck,  and  the  superabundance  of  this  fluid 
will  then  gradually  drain  away,  though  still  an  abortion  may  not  occur.  But  it 
is  an  easy  matter  to  refute  all  these  opinions  by  recalling  the  fact  of  the  fre- 
quency and  abundance  of  the  discharges,  which  often  come  away  in  large  quan- 
tities ;  and  as  regards  the  opinion  of  Mauriceau,  it  is  nothing  more  than  a  mere 
hypothesis;  for  no  one  has  ever  yet  remarked  that  the  "waters"  at  term  were 
less  copious  than  usual  in  those  women  who  had  lost  the  ftilse  waters  several 
times  during  pregnancy;  and,  besides,  the  most  careful  examination  of  the  mem- 
branes after  delivery  has  never  shown  marks  of  laceration  in  any  case. 

It  is  much  more  probable  that  the  fluid  which  thus  escapes  in  the  course  of 
gestation,  sometimes  a  few  days  only  before  term,  had  accumulated  between  the 
internal  uterine  surface  and  some  portion  of  the  membranes  (variable  in  extent) 


308  GENERATION. 

that  were  detached.  This  is  the  view  advocated  by  Xaeg^le,  and  it  has  been 
lately  reproduced  by  one  of  his  pupils  in  a  thesis  sustained  at  Heidelberg,  from 
which  I  have  derived  most  of  these  details.  That  is  to  say,  the  fluid  secreted  by 
the  internal  surface  of  the  organ  gradually  detaches  the  membranes,  thereby 
forming  a  pouch  for  itself  until  its  constantly-increasing  quantity  succeeds  in 
separating  them  as  far  as  the  neck,  when  an  irruption  of  the  liquid  takes  place. 

Now,  if  we  admit  with  Professor  Burdach,  that  an  exhalation  takes  place  from 
the  internal  surface  of  the  uterus,  which,  by  transuding  through  the  membranes, 
reaches  the  amniotic  cavity,  and  thereby  contributes  to  the  nutrition  of  the  fcetus 
during  the  greater  part  of  the  intra-uterine  life,  it  would  be  easy  to  explain  this 
abnormal  accumulation  of  fluids,  either  by  an  excess  of  secretion  or  an  arrest  of 
transudation.  It  may  also  be  explained  by  supposing  that  the  secretion  con- 
tinues beyond  the  ordinary  term,  and  the  liquid  is  obliged  to  create  a  cavity  or  a 
kind  of  reservoir  for  itself  by  detaching  the  membranes  to  a  certain  extent. 

Generally  speaking,  this  is  not  a  serious  affection ;  nevertheless,  if  frequently 
repeated,  it  might  bring  on  premature  contractions. 

The  treatment  is  very  simple.  The  patient  must  maintain  the  most  perfect 
rest,  avoiding  all  moral  and  physical  excitement  during  the  flow,  and  for  seven 
or  eight  days  after  it  has  ceased.  Should  it  be  followed  by  slight  contractions, 
enemata,  containing  laudanum,  would  arrest  them;  and  if  the  discharge  is  accom- 
panied by  any  evidences  of  general  or  local  plethora,  these  symptoms  must  be 
promptly  met  by  the  appropriate  measures. 

ARTICLE    V. 

lesions  of  locomotion. 

§  1.  Relaxation  of  the  Pelvic  Articulations. 

The  question  has  long  been  agitated  whether  the  ligaments  which  unite  the 
bones  of  the  pelvis  are  ever  softened,  and  whether  the  articulations  are  movable. 
Ambrose  Pare  himself,  that  great  surgical  luminary,  did  not  adopt  the  opinion  of 
Hippocrates  until  after  Severin  Pineau  made  a  dissection,  in  1569,  of  a  woman 
recently  delivered,  in  his  presence.  But,  at  the  present  day,  this  question  is 
determined  by  a  very  great  number  of  cases,  and  it  is  now  generally  admitted 
that  a  ramollissement  of  the  symphyses  actually  occurs  in  most  females  during 
gestation. 

This  softening  may  be  and  generally  is  slight;  though  it  may  be  carried  to  so 
o-reat  an  extent  as  to  admit  of  considerable  separation  between  the  articular  sur- 
faces, constituting  then  a  true  pathological  alteration.  Hunter,  Morgagni,  and 
some  others,  cite  instances  where  the  relaxation  was  such  that  the  pubcs  could  be 
drawn  more  than  an  inch  apart. 

With  our  present  knowledge  on  the  subject,  it  is  impossible  to  explain  the 
cause  of  this  softening;  for,  when  trifling,  it  generally  escapes  the  notice  both  of 
the  woman  and  her  physician;  but,  if  well  marked,  a  separation  of  the  bonea 
takes  place  as  just  stated. 


DISEASES    OF    PREGNANCY.  309 

Authors  do  not  agree  as  to  the  manner  in  which  the  separation  is  produced; 
since,  according  to  some,  the  cartilages  are  softened  and  thiclcened  by  the  liquids 
that  penetrate  them,  acting  like  a  piece  of  prepared  sponge  placed  between  two 
bones  to  absorb  the  effused  fluids;  whilst  others  imagine  them  to  resemble  the 
roots  of  the  ivy,  which  insinuate  themselves  into  the  little  crevices  between  the 
stones  of  a  wall,  and  finally  overturn  it.  Louis  thinks  they  act  more  like  dry 
and  porous  wooden  wedges  placed  in  the  fissures  of  a  rock,  which,  by  imbibing 
moisture,  swell  up  and  ultimately  split  the  rock, — or  like  polypi  in  the  nasal 
fossae  and  frontal  or  maxillary  sinuses. 

M.  Lenoir  supposes  that  a  slight  degree  of  this  relaxation  is  due  simply  to 
serous  infiltration  of  the  pelvic  ligaments  resulting  from  the  pregnant  condition ; 
the  articular  surfaces  are,  therefore,  not  separated,  though  separation  is  possible 
under  the  influence  of  actions  tending  to  produce  it.  In  the  more  advanced 
stages,  he  adds  to  this  softening  a  hypersecretion  of  synovia,  which  distends  the 
articular  cavities,  and  separates  the  bones  that  constitute  them.  Mobility,  in 
these  cases,  is  great,  and  if  the  joints  be  opened  in  the  dead  body,  a  viscid  fluid 
is  discharged  abundantly,  as  was  once  observed  by  Morgagni. 

These  relaxations  are  announced  by  pain  in  the  parts  corresponding  to  the 
symphyses,  which  pain  is  particularly  excited  by  any  motions  of  the  inferior 
extremities,  such  as  walking,  standing,  and  also  by  pressure  on  the  joints.  When 
standing,  the  patient  is  conscious  of  the  motion  of  the  sacrum  between  the  iliac 
bones;  she  feels  as  if  she  were  about  to  sink  down,  that  her  trunk  was  going  to 
fall  between  the  thighs,  and  progression  becomes  more  and  more  painful,  difficult, 
and  at  last  impossible,  without  extraneous  support.  Not  unfrequently  the  mo- 
bility may  then  be  detected  by  a  crepitation  or  sensible  rustling,  if  the  inferior 
extremities  or  bones  of  the  pelvis  be  forcibly  moved. 

This  relaxation  may,  according  to  Baudelocque,  oppose  the  spontaneous  termi- 
nation of  the  labor,  by  destroying  the  point  iVappui  which  the  abdominal 
muscles  derive  from  the  bones  of  the  pelvis ;  and  perhaps,  also,  the  distress  pro- 
duced by  the  engagement  of  the  head,  forces  the  woman  to  restrain  the  pains  as 
much  as  possible ;  though,  on  the  other  hand,  from  the  observations  of  Desor- 
meaux,  Smellie,  &c.,  we  learn  that  this  circumstance,  so  far  from  being  a  cause 
of  dystocia,  has  actually  permitted  a  spontaneous  delivery  in  some  eases  where 
the  disproportion  between  the  size  of  the  head  and  the  dimensions  of  the  pelvis 
would  have  otherwise  rendered  it  impossible. 

A  cessation  of  these  pains,  and  a  perfect  consolidation  may  not  take  place 
under  three,  six,  or  eight  months,  or  even  years  after  the  accouchement;  some 
facts  even  prove  that  the  relaxation  of  the  symphyses  may  last  throughout  life, 
notwithstanding  the  most  prudent  measures  are  duly  resorted  to. 

Again,  inflammation,  suppuration,  and  destruction  of  the  cartilages,  and  caries 
of  the  surfaces  of  the  bones,  together  with  all  the  general  symptoms  that  accom- 
pany them,  may  result  therefrom ;  however,  anchylosis  may  still  take  place,  not- 
withstanding the  alteration  of  the  bony  structure. 

When  a  relaxation  in  the  symphyses  is  detected,  the  woman  must  be  directed 
to  observe  the  most  absolute  rest,  and  any  inflammatory  symptoms  should  be  met 


310  GENERATION. 

by  the  appropriate  means ;  in  their  absence,  we  may  apply  gentle  pressure  around 
the  pelvis,  and  make  use  of  some  topical  applications,  general  and  local  tonics, 
and  astringent  and  resolvent  lotions.  After  the  total  disappearance  of  the 
lochia,  Desormeaux  highly  extols  the  employment  of  douches,  sea-bathing,  a 
good  diet#of  nutritive  articles,  the  Spa  and  Seltzer  waters,  wearing  flannel  next 
to  the  skin,  and  dry  frictions.  We  cannot  recommend  too  highly  the  use,  in 
these  cases,  of  the  steel  girdle  of  M.  Martin,  which,  when  tightly  drawn  around 
the  pelvis,  immediately  restores  a  portion  of  its  normal  solidity,  and  facilitates  the 
cure  wonderfully. 

These  measures  should  be  continued  for  a  long  time,  and  even  when  convales- 
cence is  fully  established,  the  greatest  possible  care  must  be  exercised  in  rising, 
•walking,  &c. 

§  2.  Inflammation  of  the  Pelvic  Articulations. 

Inflammation  of  the  pelvic  articulations,  which  is  sometimes  observed  after 
labor,  may  also  occur,  though  more  rarely,  during  pregnancy.  Drs.  Hiller, 
Monod,  Danyau,  and  Professor  Hayn,  of  Koenigsberg,  have  mentioned  instances 
of  it. 

The  disease  generally  begins  without  appreciable  cause,  with  sudden,  acute, 
sometimes  lancinating,  though  usually  heavy  pain,  in  one  or  several  of  the  pelvic 
articulations.  The  pain  is  increased  by  pressure,  standing,  and  especially  by 
attempts  at  walking,  which  is  sometimes  altogether  impossible. 

These  articular  pains  are  sometimes  attended  by  a  febrile  movement,  which  is 
sometimes  severe,  though  generally  quite  moderate.  In  some  cases,  indeed,  there 
is  almost  no  general  reaction. 

The  inflammation,  when  moderate,  usually  yields  promptly  to  proper  treat- 
ment; the  cure  is  almost  perfect  after  twelve  or  fifteen  days,  and  the  delivery 
and  lying-in  seem  to  experience  no  unfavorable  eff'ect  from  it.  In  some  cases, 
however,  whether  in  consequence  of  the  intensity  of  the  inflammation,  or  be- 
cause the  proper  means  were  not  employed  with  sufficient  energy,  the  disease  has 
ended  in  suppuration,  and  in  two  instances  proved  fatal.  In  these  cases,  the 
articular  surfaces  were  found  denuded  of  cartilage.  MM.  Hiller  and  Monod 
mention  two  cases  which  proved  fatal  in  this  manner. 

If  the  pains  are  very  acute,  and  the  general  reaction  decided,  general  and  local 
bleeding  may  be  employed  at  the  outset.  But  when  there  is  no  fever,  and  the 
local  symptoms  are  moderate,  we  may  be  content  with  resolvent  applications, 
restricted  diet,  and  absolute  repose  in  the  horizontal  posture.  Narcotics  may  be 
added  to  the  resolvent  applications,  if  the  pains  are  too  severe. 

§  3.  The  Disposition  to  Falling. 

Among  the  most  common  causes  of  falling,  may  be  reckoned  prominence  of 
the  abdomen,  which  prevents  the  woman  from  seeing  obstacles  that  might  make 
her  stumble,  the  unequal  division  of  the  weight  of  the  body,  the  rapid  increase 
of  this  weight;  and  the  posture  which  females  are  obliged  to  maintain,  so  as  to 


DISEASES    OF    PREGNA:!fCT.  311 

preserve  their  equilibrium.     It  is  evident  that  the  influence  of  these  predisposi- 
tions can  only  be  obviated  by  great  attention  and  prudence. 


ARTICLE   VI. 
lesions  of  innervation. 

§  1.  Sensorial,  Affective,  and  Intellectual  Faculties. 

Those  physicians  who  may  be  willing  to  admit  the  truth  of  the  analogy  which 
we  have  endeavored  to  establish  between  the  sympathetic  disorders  of  pregnancy, 
and  those  observed  in  3'Oung  girls  suifering  from  difficult  or  irregular  menstrua- 
tion, will  readily  understand  the  functional  aberrations  of  the  intellectual  and 
sensorial  faculties  so  often  observed  in  pregnant  women.  Like  the  dysmenor- 
rhoea  which  so  often  produces  chlorosis,  pregnancy  predisposes  to  the  depravation 
of  taste,  of  which  we  have  already  spoken  ;  to  disordered  vision,  and  even  to  com- 
plete amaurosis,  one  case  of  which  is  mentioned  by  M.  Imbert,  and  another  was 
witnessed  by  myself  during  my  term  of  service  at  the  Obstetrical  Clinic  of  the 
Faculty;  also,  to  more  or  less  complete  deafness,  of  which  I  have  observed 
several  instances.  Most  of  these  disorders  usually  disappear  a  short  time  after, 
and  sometimes  even  before  delivery,  nor  do  they  indicate  a  special  treatment.  I 
have,  however,  had  a  young  female  under  my  charge,  whose  deafness  resisted  the 
most  energetic  measures. 

The  pre-existing  alterations  of  certain  organs  of  the  senses,  are  sometimes  very 
happily  modified  by  the  occurrence  of  pregnancy.  A  young  woman,  whose  im- 
perfect vision  had  obliged  her  to  use  spectacles  from  childhood,  found  her  sight 
so  much  improved  immediately  after  the  beginning  of  pregnancy  as  no  longer  to 
have  need  of  glasses.    (Obs.  de  Salmat,  Cent.  Ill,  Obs.  27.) 

The  same,  nearly,  is  the  case  with  the  disorders  sometimes  observed  of  the 
affective  and  intellectual  faculties.  I  knew  a  young  lady  pregnant  for  the  first 
time,  whose  former  love  for  her  husband  was  replaced  by  an  antipathy  which  she 
was  barely  able  to  overcome.  Another  young  woman,  when  five  months  gone, 
was  suddenly  seized  with  such  an  aversion  for  her  apartment,  that  after  many 
fruitless  efforts,  and  notwithstanding  all  the  force  of  her  reason,  she  had  to  be 
left  in  the  country  for  the  remainder  of  her  pregnancy. 

I  shall  pass  over  those  intellectual  disorders  known  as  puerperal  mania.  The 
strange  and  sometimes  criminal  actions  of  which  they  appear  to  have  been  the 
cause,  belong  much  more  properly  to  legal  medicine ;  but  I  cannot  avoid  men- 
tioning a  peculiar  tendency  to  sadness,  which  is  mentioned  by  Burns,  and  of 
which  I  have  observed  two  cases.  Certain  individuals,  who  are  usually  of  a  gay 
disposition,  suddenly  become  sad  and  morose ;  refuse  all  the  enjoyments  tendered 
to  them,  and  entertain  the  belief  that  they  will  not  survive  their  labor,  with  a 
tenacity  that  nothing  can  overcome.  A  young  American  lady,  recommended  to 
my  care  by  M.  Rayer,  exhibited  a  profound  melancholy  for  the  last  six  weeks  of 
her  pregnancy.     Although  surrounded  by  her  family,  she  declined  all  the  plea- 


312  GENERATION. 

sures  of  the  capital.  She  wept  unceasingly  over  her  inevitable  end,  which  was 
so  near  at  hand,  and  was  constantly  expressing  her  distress  at  being  obliged  to 
leave  all  whom  she  loved.  She  had  a  happy  labor,  and  from  the  next  day  her 
usual  gaiety  was  resumed. 

§  2.  Vertigo,  Giddiness,  Syncope.       , 

These  disorders  may  be  due  to  great  nervous  susceptibility  increased  by  chlo- 
rosis, or,  what  is  still  rarer,  to  plethora.  In  the  latter  case,  venesection  is  the 
best  remedy.  But  frequently,  the  general  signs  of  plethora  are  wholly  wanting; 
thus  some  delicate,  nervous  women  are  subject  to  faintings,  from  the  most  trifling 
cause,  when  they  are  pregnant ;  any  strong  moral  impulses,  such  as  joy,  or  anger, 
and  sometimes  even  an  odor  that  is  a  little  too  penetrating,  or  the  sight  of  an 
unpleasant  object  or  person,  may  give  rise  to  this  condition.  Gardien  relates  an 
instance,  where  the  simple  movements  of  the  child  produced  swoonings;  and  I 
have  attended  a  lady  who  fainted  three  or  four  times  a  week,  during  the  second, 
third,  and  fourth  months  of  her  gestation,  without  any  satisfactory  cause  being 
discovered  for  it. 

Ordinarily,  the  syncope  attacks  the  woman  when  standing,  and  she  at  once 
experiences  a  ringing  in  her  ears,  vertigo,  dimness  of  vision,  weakness  in  the 
knees,  and  she  has  scarcely  time  to  sit  down,  before  she  faints  away.  Some 
females,  however,  are  warned  of  the  attack  by  the  occurrence  of  yawnings,  and  a 
sensation  of  heat  in  the  precordial  region;  soon  after,  the  extremities  become 
cold,  the  face  grows  pallid,  and  is  covered  with  a  cold  sweat;  the  senses  and  in- 
tellectual faculties  are  almost  lost,  the  pulse  and  respiration  have  nearly  ceased, 
though  a  total  loss  of  the  intelligence  and  sensibility  is  very  rare.  For  my  own 
part,  I  have  never  seen  any  woman  in  this  latter  state,  since  nearly  all  those 
whom  I  have  carefully  questioned  on  the  subject,  have  stated  that  they  had  a 
confused  idea  of  what  was  passing  around  them;  and  therefore,  if  there  really 
be  any  instances  of  a  complete  abolition  of  the  faculties,  they  certainly  are  not 
so  frequent  as  the  authors  would  have  us  believe. 

While  the  syncope  lasts,  we  should  employ  the  ordinary  means,  such  as  am- 
monia, vinegar,  cold  water,  &c.  &c.  The  tonics  combined  with  antispasmodics 
have  been  recommended  for  its  prevention ;  for  instance.  Van  Swieten  highly 
extols  the  use  of  orange-peel  with  canella,  or  lemon-rind  and  canella,  in  the  pro- 
portion of  two  or  three  drachms  to  three  pounds  of  sherry  wine,  of  which  three 
or  four  tablespoonsful  are  to  be  taken  daily.  Chambon  has  employed  an  infusion 
of  peach  blossoms  with  success. 

The  attacks  of  fainting,  though  generally  short,  are  sometimes  quite  pro- 
longed. In  the  latter  case,  they  are  frequently  accompanied  or  followed  by  some 
hysterical  symptoms,  as  sense  of  oppression,  hypogastric  pain,  constriction  of  the 
fauces,  and  sometimes  true  hysterical  convulsions.  In  the  case  of  a  young  lady, 
a  patient  of  M.  Kayer's,  these  symptoms  occurred  almost  every  evening  after 
dinner,  during  the  last  three  months  of  her  pregnancy.  They  had  no  serious 
consequence,  unless  a  threatening  of  premature  labor  towards  the  end  of  the 


DISEASES    OF    PREGNANCY.  313 

eighth  month  be  so  regarded,  •which,  however,  yielded  to  a  small  bleeding  and 
opiate  injections. 

§  3.  Pruritus  op  the  Vulva.     Itching  op  the  Skin. 

Before  closing  this  article,  we  wish  to  say  one  word  about  a  very  singular  affec- 
tion; I  allude  to  the  excessive  itching  which  manifests  itself  in  the  early  periods 
of  pregnancy,  and  is  located  in  the  external  genital  organs.  This  annoyance  was 
so  insupportable  in  a  young  married  lady  under  my  care,  that  she  could  not 
refrain  from  continual  scratching,  and  the  general  irritation  resulting  therefrom 
almost  threw  her  into  convulsions. 

In  another  instance,  a  young  girl,  who  wished  to  conceal  her  pregnancy,  was 
so  tormented  by  this  disease,  that  it  was  absolutely  impossible  to  hide  her  dis- 
tress from  the  observation  of  her  family;  and  when  I  examined  her,  I  found  the 
internal  face  of  the  labia  externa,  and  the  nymphoe,  both  swollen  and  inflamed 
from  the  constant  scratching;  the  nympha  on  the  right  side  had  been  so  long, 
and  so  strongly  dragged  upon,  that  it  had  acquired  twice  the  usual  length  at 
least.  Generally  speaking,  the  use  of  frequent  bathing,  and  of  the  vegeto-mineral 
lotions  applied  five  or  six  times  a  day,  will  calm  the  itchings ;  and  as  it  is  often 
greatly  aggravated  by  walking,  perfect  rest  is  of  course  indicated.  Some  advan- 
.  tage  is  often  to  be  derived  from  a  fine  compress  dipped  in  oil  of  sweet  almonds, 
and  then  placed  in  the  vulvar  fissure ;  or  still  better,  if  the  compress  be  soaked 
in  lead  water. 

Dewees  states  that  he  examined  a  young  lady  who  complained  of  this  exces- 
sive itching  in  the  genital  parts,  and  he  found  the  internal  face  of  the  vulva,  as 
also  the  inferior  part  of  the  vagina  covered  by  numerous  ajjhthae ;  and  that  the 
application  of  a  strong  solution  of  borax,  four  or  five  times  a  day,  caused  them 
all  to  disappear  in  the  course  of  twenty-four  hours. 

Dr.  Meigs  has  always  found  the  following  preparation  useful : — 

B  Borax,        .  ......      ^ij. 

Sulph.  of  morphia,      .....  gr.  ivss. 

Dist.  rose  water,  ......      f3viii. 

Apply  three  times  a  day  to  the  affected  parts,  by  means  of  a  sponge  or  piece 
of  linen,  taking  care  to  wash  the  parts  beforehand  with  soap  and  water,  and  to 
dry  them  well  afterwards. 

These  itchings  are  not,  however,  always  confined  to  the  genital  parts.  M. 
Maslieurat-Lagemart  has  published  a  remarkable  case  of  a  lady,  who,  in  eight 
successive  pregnancies,  was  afilicted  with  itchings  so  violent  as  to  produce  pre- 
mature labors.  On  four  occasions,  they  began  in  the  sixth  month,  twice  at  eight 
months  and  a  half,  and  twice  in  the  seventh  month.  They  appeared  almost  in- 
stantly over  the  entire  cutaneous  surface ;  the  legs,  thighs,  genital  parts,  the 
whole  trunk,  the  neck,  face,  scalp,  were  all  affected;  nothing  escaped  but  the 
palms  of  the  hands,  and  even  they  were  invaded  at  a  later  period.  So  severe 
were  they,  that  the  violent  rubbings  of  the  poor  sufferer  excoriated  the  skin. 
Hardly  was  she  delivered  when  they  vanished  entirely.     The  skin  retained  its 


314  GENERATION. 

natural  transparency,  color,  and  whiteness,  throughout.  Simple  and  alkaline 
baths,  ammoniacal  and  camphorated  frictions  to  the  spine,  preparations  of  opium, 
bismuth,  valerian,  hyoscyamus,  belladonna,  and  bleeding,  were  all  employed  with- 
out advantage. 

Three  cases  of  general  itching  which  I  have  had  occasion  to  treat,  yielded 
quite  promptly  to  alkaline  baths.  (Five  ounces  of  carbonate  of  potash  to  an  entire 
bath.) 

ARTICLE   VII. 

Beside  the  numerous  functional  disorders  just  studied,  some  pregnant  women 
suffer,  in  various  parts  of  the  body,  pains  whose  intimate  cause  is  imperfectly 
understood,  and  to  which  they  sometimes  call  the  attention  of  the  physician. 
Some  of  these  pains  appear  to  be  seated  in  the  abdominal  parietes,  the  lumbar 
region,  the  groins,  and  the  internal  part  of  the  thighs;  others,  again,  appear  to 
aflFect  more  especially  the  walls  of  the  uterus,  or  the  annexes  of  that  organ. 

§  1.  Abdominal,  Lumbar,  and  Inguinal  Pains. 

These  pains,  which  are  sometimes  confined  to  a  quite  limited  space  of  the  ab- 
dominal parietes,  do  not  often  appear  before  the  latter  months  of  gestation,  and 
seem  to  result  from  the  extreme  distension  of  the  walls  of  the  abdomen.  Such, 
at  least,  is  the  most  generally-received  opinion.  They  ai-e  frequently  felt  at  the 
lower  part  of  the  breast,  near  the  upper  insertions  of  the  abdominal  muscles,  or 
less  often,  in  the  inguinal  folds  near  their  inferior  attachments.  The  pains  are 
much  increased  by  motion,  the  least  pressure,  and  sometimes,  also,  by  the  move- 
ments of  the  child,  if  violent.  As  already  stated,  they  are  generally  limited  in 
extent,  sometimes  not  affecting  a  space  larger  than  a  silver  dollar,  the  parts  sur- 
rounding being  entirely  free  from  pain.  Baths,  and  ointments  containing  opium 
or  belladonna,  appear  to  me  the  only  remedies  to  be  used  against  them,  though 
they  usually  persist  in  spite  of  treatment  until  after  delivery.  I  have  never  dis- 
covered the  advantage  usually  attributed  to  bleeding  from  the  arm  in  these  cases. 

Since  lumbar  and  inguinal  pains,  occurring  in  the  first  half  of  gestation,  may 
be  the  preludes  of  an  abortion  near  at  hand,  they  claim  special  attention,  and 
will  be  treated  of  in  the  next  chapter.  At  this  early  period  they  are  almost 
uniformly  the  sympathetic  expression  of  uterine  disorder,  itself  due  to  a  local 
congestion,  though  perhaps  still  oftener  to  a  special  irritability  of  the  womb. 
They  then  resemble  precisely  the  lumbar  and  inguinal  pains  which  are  so  often 
experienced  by  young  girls  affected  with  dysmenorrhoea  or  amenorrhoea,  and  are 
effectually  overcome  by  opiates,  small  revulsive  bleedings,  and  sometimes,  also, 
in  very  nervous  women  by  warm  bathing.  If,  as  is  often  the  case,  the  pains 
seem  to  be  increased  by  sexual  intercourse,  too  long  a  walk,  or  riding  in  a'  car- 
riage, it  were  useless  to  say,  that  abstinence  from  all  these  causes,  and  rej^ose  in 
the  horizontal  posture,  are  the  first  indications  to  be  fulfilled. 

These  pains  most  commonly  appear  toward  the  end  of  pregnancy,  but  their 
cause,  that  especially  of  the  lumbar  pains,  is  very  obscure.     Dragging  upon  the 


DISEASES     OF    PKEGNANCY.  315 

broad  ligaments,  compression  of  the  lumbar  nerves,  extreme  distension  of  the 
uterus,  and  engorgement  of  the  pelvic  and  uterine  vessels,  have  been  successively 
adduced  in  explanation ;  but  though  the  relief  obtained  from  bleeding,  in  some 
cases,  would  seem  to  show  that  they  might  sometimes  be  caused  by  local  plethora, 
there  is  no  evidence  of  any  such  influence  as  is  attributed  to  the  other  causes 
mentioned. 

The  inguinal  pains  have  generally  been  referred  to  traction  upon  the  round 
ligaments.  I  do  not  say  that  this  traction  may  not  produce  them,  but  I  am  con- 
vinced, that  toward  the  end  of  pregnancy,  they  are  oftener  due  to  the  pressure 
of  the  uterus  upon  that  region,  in  the  vertical  as  well  as  in  the  sitting  posture. 
They  generally  disappear,  indeed,  in  the  horizontal  position,  and  the  best  means 
of  relieving  the  patients  is  to  support  the  abdomen,  and  at  the  same  time  raise 
it  a  little  by  means  of  a  well-made  corset,  or  of  a  large  abdominal  belt,  the  cen- 
tral portion  of  which  embraces  the  sub-umbilical  region,  and  whose  two  ends  are 
attached  to  the  back  part  of  the  corset. 

The  pains  in  the  internal  parts  of  the  thighs,  the  numbness  and  cramps  of 
both  legs,  though  more  commonly  of  one  only,  are  usually  attributed  to  pressure 
of  the  head  on  the  sacral  nerves.  But,  as  Tyler  Smith  remarks,  since  they 
mostly  occur  at  night,  when  the  women  are  in  the  horizontal  posture,  or  whilst 
■  they  are  sitting,  in  both  which  positions  the  pressure  should  be  much  less  than 
whilst  standing,  it  seems  very  probable  that  compression  of  the  nerves  is  not  the 
cause.  Perhaps  we  may  accept  the  idea  of  the  English  accoucheur,  that  like  the 
corresponding  affections  in  cholera,  they  are  connected  with  some  irritation  or 
difficulty  of  the  large  intestine,  or  with  a  morbid  condition  of  the  uterus.  It 
would  not  be  the  only  instance  of  visceral  irritation  producing  spasmodic  contrac- 
tion of  the  muscles  of  animal  life  by  reflex  action. 

According  to  this  hypothesis,  the  best  means  of  preventing  the  recurrence  of 
the  cramp  is  to  keep  the  bowels  free,  and  allay  the  irritability  of  the  womb  as 
much  as  possible  by  baths,  opiates,  &c.  The  surest  means  of  counteracting  it  is 
to  contract  voluntarily,  the  very  moment  it  appears,  the  antagonistic  muscle  of 
the  affected  one ;  thus,  the  thigh  should  be  strongly  extended  when  the  flexor 
muscles  are  contracted,  and  the  foot  should  be  flexed  on  the  leg  when  the  cramp 
affects  the  muscles  of  the  calf. 

The  lumbar  pains  may  sometimes  be  alleviated  by  baths  and  alcoholic  and  aro- 
matic frictions  upon  the  spine,  besides  being  useful  by  encouraging  the  patient. 
We  have  already  stated  that  bleeding  from  the  arm  sometimes  relieves  them 
materially, 

§  2.  Uterine  Pains. 

1.  Beside  the  uterine  pains  which  sometimes  accompany  the  outset  of  a  disor- 
dered pregnancy,  also  beside  those  which  seem  to  herald  the  approach  of  labor  in 
the  latter  weeks  of  gestation,  females  experience,  at  variable  periods  and  inter- 
vals, pains  which  are  sometimes  very  acute,  and  evidently  seated  in  the  walls  of 
the  uterus  itself.  It  is  impossible  to  determine  the  cause  and  nature  of  these 
pains;  for  though  they  may  be  attributed,  in  some  rare  instances,  to  partial  spasm 


"316  GENERATION. 

of  the  muscles  of  the  uterus,  or  to  a  more  or  less  extensive  inflammation,  most 
frequently  nothing  of  the  kind  is  to  be  discovered.  Sometimes  they  are  limited 
to  a  single  circumscribed  point,  whilst  at  others  they  affect  the  entire  womb.  In 
the  first  case  they  are  continuous;  in  the  second,  they  are  irregularly  intermit- 
tent, and  their  recurrence,  or  rather  their  paroxysm,  appears  to  coincide  with  a 
motion  of  the  female,  pressure  upon  the  abdomen,  an  attack  of  coughing,  or  sud- 
den movements  of  the  child.  At  the  same  time  the  uterine  tumor  may  almost 
always  be  felt  to  become  denser  and  harder,  in  short,  a  true  contraction  takes 
place,  which  continues  as  long  as  the  paroxysm  lasts.  If,  struck  with  this  con- 
dition of  the  body  of  the  womb,  an  examination  be  made  per  vagina m,  the 
cervix  will  be  found  unchanged,  having  undergone  no  alteration  which  could 
excite  solicitude  on  account  of  the  long-continued  previous  contractions.  Usually, 
there  is  very  slight  general  reaction,  and  little  or  no  fever. 

When  the  pain  is  both  circumscribed  and  moderate,  emollient  and  narcotic 
applications  may  be  found  sufficient ;  but  when  more  severe,  it  will  be  necessary 
to  prescribe  the  most  absolute  repose,  injections  with  camphor  and  laudanum, 
baths,  maniluvia,  and  even  bleeding  from  the  arm.  It  generally  yields  to  these 
measures  when  properly  employed,  though,  unfortunately,  it  returns  with  some 
individuals  very  frequently.  I  have,  at  this  moment,  a  young  lady  under  care, 
who  is  at  the  eighth  month  of  her  pregnancy,  and  who  has  had  five  attacks 
within  three  months,  two  of  them  lasting  for  twenty-four  hours.  The  first  time 
she  was  bled ;  but  as  her  general  condition  seemed  to  contraindicate  a  repetition 
of  this  measure,  and  she  was  very  averse  to  bathing,  I  was  obliged  to  content  my- 
self with  prescribing  rest  and  opiate  injections.  Now,  there  is  every  prospect  of 
her  reaching  her  full  term. 

2.  The  sensibility  of  the  uterus  is  sometimes  singularly  increased  by  constant 
and  violent  motions  of  the  foetus.  Some  children,  indeed,  seem  endowed  with 
such  activity  that  they  are  hardly  ever  quiet,  and  their  continual  movement 
becomes  a  cause  of  irritation  to  the  womb,  which,  by  reacting  upon  the  whole 
economy,  may  produce  insomnia,  general  excitement,  and  nervous,  and  some- 
times even  convulsive  movements.  I  have  seen  two  instances  of  these  disordered 
motions  of  the  child ;  especially  was  it  marked  in  the  case  of  the  wife  of  one  of 
my  professional  brethren.  This  poor  lady  was  delivered  at  term,  notwithstand- 
ing she  had  been  almost  entirely  deprived  of  sleep  during  the  eighth  and  ninth 
months.  Burns  says,  that  patients  under  these  circumstances  are  delivered 
rather  before  the  ninth  month.  The  bleeding  and  opiates  which  he  recommends 
may  indeed  lessen  the  irritability  of  the  uterus,  but  evidently  can  have  no  power 
to  diminish  the  activity  of  the  motions  of  the  child,  which  is  the  first  cause  of 
the  uterine  pains. ^ 

'  Dr.  Tyler  Smith  endeavors  to  show,  in  a  very  interesting  memoir,  that  the  active  motions 
of  the  child  amount  to  almost  nothing,  and  that  the  sensations  perceived  by  the  mother 
and  accoucheur,  hitherto  attributed  to  the  muscular  contractions  of  the  child,  result  simply 
from  partial  contraction  of  the  muscular  fibres  of  the  uterus.  Notwithstanding  the  seductive 
character  of  the  reasons  adduced  by  Dr.  Smith,  we  hold  to  the  generally-received  opinions, 
though  entirely  disposed  to  think  that  the  views  of  the  English  accoucheur  may  be  ajiplicable 
to  the  exceptional  cases  of  which  we  are  speaking. 


DISPLACEMENTS     OF    THE    UTERUS.  317 

3.  Some  authors  state  that  metritis,  or  metro-peritonitis,  are  possible  during 
pregnancy,  but  they  are  so  rare  tliat  it  has  never  fallen  to  my  lot  to  see  them. 
Besides,  they  seem  to  me  to  belong  to  the  same  category  as  all  the  acute  aflFec- 
tions  which  may  arise  during  pregnancy;  and  though  the  usual  gravity  of  the 
prognosis  be  heightened  by  the  condition  of  the  female,  the  treatment  would  be 
the  same  as  after  delivery. 

To  complete  the  pathology  of  pregnancy,  it  would  be  necessary  to  treat  of  con- 
vulsions, hemorrhage,  thrombus  of  the  vulva,  ruptures  of  the  uterus,  &c.  But 
as  these  accidents  or  complications  may  occur  during  pregnancy,  labor,  and  even 
after  delivery,  we  think  it  better,  in  order  to  avoid  repetitions,  to  defer  the  com- 
plete account  of  them  to  the  fourth  part  of  the  work,  in  which  the  reader  will  be 
enabled  to  study  all  the  phases  of  the  puerperal  condition. 


CHAPTER  II. 

OF   DISPLACEMENTS   OF   THE    UTERUS    CONSIDERED   IN   REFERENCE   TO 
THE   ACCIDENTS   TIIEY   MAY   CAUSE   DURING   PREGNANCY. 

AKTICLE   I. 

OF   PROLAPSUS    UTERI. 

We  have  already  seen,  in  studying  the  situation  of  the  uterus  at  the  different 
periods  of  gestation,  that  at  first  this  organ  sinks  lower  in  the  excavation,  and 
that  its  orifice  approaches  the  vulva.  Now  this  first  degree  of  depression  may  be 
considered  as  physiological,  but  it  cannot  pass  beyond  that  without  giving  rise  to 
some  accident  or  other.  Hence,  laying  aside  all  causes  foreign  to  pregnancy,  the 
uterus  descends  the  more  in  the  earlier  months  of  gestation  in  proportion  to  the 
larger  size  of  the  pelvis,  and  the  greater  relaxation  of  the  ligaments.  In  some 
women  it  rests  on  the  floor  of  the  pelvis,  whilst  in  others,  the  neck,  or  even  the 
body  may  protrude  through  the  vulva  and  become  visible  externall}'. 

We  secj  therefore,  that  either  a  simple  descent  or  an  incomplete  or  complete 
prolapsus  may  occur  during  pregnancy,  as  well  as  in  the  non-pregnant  condition. 
The  complete  prolapsus,  that  in  which  the  entire  body  of  the  uterus  is  external 
to  the  genital  parts  and  hangs  between  the  thighs,  is  extremely  rare.  It  were 
wrong,  however,  to  deny  its  possibility,  since  this  is  proved  by  a  case  reported  by 
Yimmer. 

These  displacements  may  occur  either  slowly  or  suddenly,  though  the  female 
may  have  had  nothing  of  the  kind  previously;  sometimes,  however,  they  are  but 
the  continuation  or  exaggeration  of  a  pre-existing  prolapsus.  Although  the  pro- 
gressive development  of  the  uterus  generally  removes  the  incomplete  prolapsus 
about  the  fourth  or  fifth  month,  by  causing  the  organ  to  rise  above  the  superior 


318  GENERATION. 

strait,  the  displacement,  in  some  cases  where  the  pelvis  is  spacious,  may  continue, 
and  even  increase,  notwithstanding  the  progress  of  gestation.  I  have,  quite 
recently,  had  under  care  at  the  Clinique,  a  very  remarkable  case  of  incomplete 
prolapsus,  in  which  the  entire  neck  of  the  uterus  projected  beyond  the  external 
parts,  the  whole  excavation  being  occupied  by  the  lower  part  of  the  body  dis- 
tended by  the  foetal  head.  The  displacement  continued  until  delivery  without  any 
serious  accident  supervening.^     It  had  existed  for  several  years. 

'  The  following  are  some  of  the  details  of  this  interesting  case.  Marie ,  aged  twenty- 
seven  years,  entered  the  hospital  October  18th,  1849.  She  was  then  at  the  beginning  of  the 
ninth  month  of  her  pregnancy.  Four  years  previously,  she  became  pregnant  for  the  first 
time,  and  when  near  delivery,  she  both  felt  and  saw  a  small  red  tumor,  of  about  the  size  of 
a  walnut,  escape  through  the  vulva.  It  projected  but  slightly,  incommoded  the  patient  but 
little,  and  did  not  interfere  with  the  labor  at  all,  since  the  latter  was  accomplished  quite 
rapidly.  After  her  confinement,  she  continued  to  feel  the  same  tumor,  less  prominent,  in- 
deed, than  during  pregnancy,  projecting  and  disappearing  according  as  she  was  quiet  or  took 
long  and  fatiguing  walks.  Under  the  latter  circumstances  she  suflered  much  from  sensations 
of  dragging  in  the  groins  and  upper  part  of  the  thighs.  She  was  habitually  and  obstinately 
constipated,  and  sometimes  had  great^difficulty  in  urinating. 

Two  years  ago,  the  same  person  became  pregnant  the  second  time,  and  during  the  first 
three  months  the  tumor  became  gradually  more  projecting,  and  hung  very  low. — so  low,  she 
says,  that  a  midwife,  after  having  returned  the  parts,  applied  a  pessary,  which  produced 
discomfort,  and  was  retained  but  two  days.  Eight  days  after  the  introduction  of  the  pessary, 
she  miscarried,  at  about  three  months  and  a  half  to  four  months.  The  midwife  who  attended 
her  could  not  extract  the  placenta,  and,  two  days  afterwards,  a  physician  endeavored  to  de- 
liver it,  first  with  the  hand,  and  afterwards  with  forceps,  but  could  obtain  only  some  frag, 
ments. 

She  recovered  entirely;  the  tvunor  remaining  within  whilst  quiet  in  her  chamber,  but  ap- 
pearing externally  after  much  walking. 

Becoming  pregnant  for  the  third  time,  the  tumor  did  not  incommode  her  much  more  than 
usual  during  the  first  three  months,  but  after  the  fourth,  it  projected  much  more  from  the 
vulva,  and  towards  the  three  last  months  it  was  impossible  to  restore  it  for  several  days, 
even  after  observing  the  most  absolute  repose  in  bed.  At  present,  the  patient  being  eight 
months  and  a  half  gone,  the  following  may  be  observed: 

A  cylindrical  tumor,  two  inches  in  length,  projects  from  the  vulva ;  it  is  five  inches  in  cir- 
cumference, and  rather  larger  and  harder  at  its  lower  than  at  its  upper  extremity.  Its  exter- 
nal surface  is  marked  at  the  union  of  the  two  upper  thirds  with  the  lower  one  by  a  whitish 
circle,  dividing  two  surfaces  of  different  color  and  appearance.  The  superior  is  of  a  rosy 
hue  and  smooth,  being  only  the  internal  surface  of  the  vagina  inverted  from  above  down- 
wards, wliich  thus  forms  the  external  surface  of  the  tumor.  The  inferior  portion  is  of  a 
deeper  red  color,  and  presents  wrinkles  or  folds,  directed  from  above  downwards,  and  from 
within  outwards,  and  separated  on  the  median  line  by  apparently  longitudinal  fibres.  These 
folds  are  merely  the  arbor  vitae  of  the  neck  inverted  from  below  upwards,  so  that  the  inter- 
nal surface  of  the  cavity  of  the  neck  has  become  a  part  of  the  external  surface  of  the  tumor 
to  the  extent  of  five-eighths  of  an  inch.  The  somewhat  swollen  lower  extremity  of  this 
tumor  presents  an  opening,  with  wrinkled  edges,  resembling  the  drawn  mouth  of  a  purse, 
and  into  which  the  finger  enters  with  ease.  This  is  the  cavity  of  the  neck,  forming  a  canal 
two  inches  and  three  quarters  in  length,  through  which  the  membranes  and  a  hard  body, 
recognized  as  the  head  of  the  foetus,  may  be  felt.  The  internal  orifice  is  quite  largely 
dilated,  that  is,  nearly  to  the  size  of  a  one  franc  piece.  The  entire  head  is  discovered  to  be 
in  the  excavation,  and  altogether  behind  the  symphysis  pubis,  by  which  it  seems  to  be 
arrested. 


DISPLACEMENTS    OF    THE    UTERUS.  319 

In  some  cases,  the  displacement  increases  considerably,  and  either  as  an  effect 
of  its  own  weight,  or  in  consequence  of  exertion  or  violent  exercise;  the  lower 

If  it  be  attempted  to  enter  the  vagina,  at  the  same  time  traversing  the  circumference  of 
the  upper  part  of  the  tumor,  a  cul-de-sac  is  reached,  at  a  depth  of  from  two  inches  and  three 
quarters  to  three  inches  and  a  quarter  on  the  sides,  from  two  and  a  half  inches  to  three 
inches  and  a  quarter  behind,  and  from  only  two  to  two  and  a  half  in  front,  wlien  the  exa- 
mination is  stopped  by  the  walls  of  the  urethra,  which  are  thickened  and  curved,  as  it  were, 
posteriorly. 

This  cul-de-sac  is  formed  by  the  vagina  turned  inside  out  from  above  downwards;  and 
any  etfort  to  push  it  upwards  is  soon  arrested  by  the  fcetal  head,  which  is  plunged  into  the 
excavation,  and  rests  upon  the  floor  of  the  pelvis. 

The  patient  suffers  from  obstinate  constipation,  and  sometimes  only  from  difficulty  in  pass- 
ing urine,  which  escapes  by  jets. 

To  recapitulate,  we  find:  1.  A  descent  of  the  womb,  which  seems  to  be  retained  in  the 
pelvis  only  by  the  floor  of  the  latter,  and  the  pubic  arch  and  symphysis,  against  which  it 
rests ;  the  rectum  and  urethra  are  also  compressed  ;  2.  Prolapsus  of  the  neck  of  the  uterus 
outside  of  the  vulva,  carrying  with  it  the  vagina,  which  covers  its  upper  part  like  the  inverted 
finger  of  a  glove,  and  which  is  itself  inverted  from  below  upward  to  the  extent  of  five- 
eighths  of  an  inch,  so  that  its  internal  surface  forms  the  external  surface  of  its  lower  extre- 
mity; this  extremity  of  the  neck  forms  the  expanded  and  wrinkled  portion  of  the  tumor; 
3.  Constipation  and  difficulty  in  urination  caused  by  pressure. 

■  The  tumor  increased  about  three  quarters  of  an  inch  in  size,  from  the  20th  of  October  to 
the  3d  of  November;  but  its  volume  was  much  greater  in  consequence  of  the  osdematous 
condition  of  the  prolapsed  parts. 

After  some  fruitless  efforts  to  reduce  the  prolapsus,  I  concluded  that  it  W'ould  be  best  not 
to  try  any  further,  but  to  limit  treatment  to  evacuation  of  the  bowels  by  mild  laxatives, — the 
patient  being  unable  to  receive  enemata, — a  bath  every  two  or  three  days,  and  frequent 
lotions  and  injections.  Assisted  by  the  horizontal  posture,  these  measures  relieved  the  patient 
of  her  sufferings  completely. 

At  noon,  on  the  3d  of  November,  the  waters  came  away  without  pain,  after  efforts  at  defe- 
cation. The  internal  orifice  of  the  cervix  was  of  the  size  of  a  one  franc  piece  ;  the  neck  was 
rather  longer  than  before  the  3d,  and  rather  softer.  During  the  last  ten  days,  the  patient 
felt  her  abdomen  become  harder  from  time  to  time,  but  without  experiencing  the  least  pain. 

From  noon  until  10  P.  M.  the  pains  were  very  weak  and  distant.  From  10  o'clock  to  3 
A.M.  (of  the  4th),  they  became  greater,  more  powerful  and  frequent.  Finally,  the  labor  ter- 
minated at  3  A.  M.  the  4th  of  November,  after  a  labor  of  fifteen  hours,  if  the  time  be  reckoned 
from  the  rupture  of  the  membranes  and  discharge  of  the  waters,  and  only  of  five  hours,  if 
counted  from  10  P.  M.,  at  which  time  there  was  no  change  in  either  the  length  or  dilatation 
of  the  neck,  though  then  it  was  that  the  pains  became  well  marked  and  regular. 

The  following  are  the  principal  phenomena  which  accompanied  the  expulsion  of  the 
ftEtus.  At  the  commencement  of  labor,  the  neck  remained  external  precisely  as  before,  and 
when  the  head  came  to  be  expelled,  it  dilated  visibly,  and  was  the  last  obstacle  which  this 
part  had  to  overcome.  No  resistance  was  offered  by  the  vulva,  which  was  traversed  before 
the  external  orifice  of  the  neck  of  the  uterus. 

The  child,  which  was  a  male,  was  born  alive.  Its  weight  and  dimensions  were  as 
follows: 

Weight,  .......  5i  lbs.  (Troy). 

Total  length,  .  .  .  .  .  .       1  ft.  6  inches. 

From  the  crown  to  the  umbilicus,  .  .  .  0  ft.  9       " 

From  the  umbilicus  to  the  heel,         .  .  .  .      0  ft.  9       " 


320  GENERATION. 

part  of  the  body  of  the  uterus  projects  beyond  the  vulva,  the  upper  part  of  the 
organ  being  still  within  the  pelvis. 

The  disorders  resulting  from  this  displacement  vary  in  intensity  according  to 
its  extent  and  the  stage  of  pregnancy  at  which  it  occurs.  When  the  pelvis  is 
too  spacious,  the  excess  of  size  affecting  chiefly  the  excavation,  whilst  the  straits 
preserve  their  normal  dimensions,  the  uterus  may  remain  much  longer  in  the 
lesser  pelvis  than  is  usual  in  well-formed  women.  It  then  incommodes  the 
neighboring  parts,  pressing  upon  and  irritating  the  rectum  and  the  bladder;  the 
patient  suffers  from  a  feeling  of  weight  at  the  anus,  and  painful  tractions  in  the 
groins,  lumbar  regions,  and  umbilicus.  A  more  or  less  abundant  and  foetid  dis- 
charge also  comes  on;  the  woman  can  neither  stand  nor  walk  without  suffering, 
and  she  falls  gradually  into  a  state  of  marasmus. 

When  the  gestation  is  more  advanced,  and  the  womb  increased  in  size,  or  even 
if  less  voluminous,  but  more  depressed,  the  symptoms,  such  as  complete  reten- 
tion of  the  urine,  very  obstinate  constipation,  kc,  are  still  worse ;  finally,  the 
pressure  of  the  uterus  on  other  organs  may  react  on  itself,  and  the  consequent 
irritation  thus  prove  a  cause  of  abortion. 

When  the  retention  of  the  urine  is  complete,  either  the  catheter  should  be  at 
once  resorted  to,  or  the  womb  be  pressed  up  by  one  or  two  fingers  previously 
introduced  into  the  vagina ;  but  even  this  assistance  will  not  be  necessary,  if  the 
woman  lies  down  and  elevates  her  hips  considerably  whenever  she  wants  to 
urinate.  All  these  symptoms,  however,  disappear  about  the  fifth  mouth,  when 
the  uterus,  on  account  of  its  great  development,  can  no  longer  remain  in  the 
excavation,  and  therefore  rises  above  the  superior  strait. 

In  cases  of  simple  and  incomplete  prolapsus,  some  authors  recommend  the 
introduction  of  a  pessary,  in  order  to  sustain  the  uterus,  and  prevent  its  prolapsing 
completely.  I  regard  the  pessary  as  always  useless  and  often  dangerous.  Rest 
in  bed,  and  proper  cleanliness,  seem  to  me  capable  of  preventing  the  precipita- 
tion of  the  organ,  and  of  alleviating  the  painful  irritations  which  the  displace- 
ment produces. 

Certain  instances  of  success  seem  to  authorize  attempts  at  reduction  in  cases  of 
incomplete  and  complete  prolapsus  occurring  at  an  advanced  stage  of  pregnancy. 
In  both  circumstances,  I  think  that  these  attempts  should  be  moderate,  since 
they  appear  to  me  likely  to  compromise  the  gestation.  When  the  prolapsus  is 
complete,  the  danger  to  which  the  woman  is  exposed  by  the  nature  of  the  dis- 
placement itself  would  certainly  authorize  rather  greater  perseverance ;  but  it  is 

Occipito-frontal  diameter,  .  .  .  .  0  ft.  4  inches. 

Occipito -mental        "  .  .  .  .  .      0  ft.  5       " 

Bi-parietal  «  .  .  .  .  0  ft.  3|     " 

Sub-occipito-bregmatic  diameter,  .  .  .  .      0  ft.  3(^     " 

The  day  following  the  labor,  the  cervix  projected  to  the  same  extent  outside  the  vulva, 
and  the  parts  were  rather  more  flaccid;  the  engorgement  being  dissipated,  the  neck  was 
returned  within  the  vagina;  the  patient  continued  in  the  horizontal  position,  and  a  month 
after  left  the  Ciinique  without  the  neclc  having  appeared  at  the  vulvar  opening. 


DISPLACEMENTS    OF    THE     UTERUS.  321 

easy  to  sec  that  in  the  latter  months  it  will  rarely  be  possible  to  return  the  uterus 
within  the  pelvis. 

When  the  reduction  is  impossible,  the  uterine  tumor  should  be  supported  by  a 
proper  bandage,  and  the  female  confined  to  the  horizontal  position. 

In  women  who  have  had  a  falling  of  the  womb  before  impregnation,  there  is 
reason  to  fear  that  it  may  persist  and  augment  during  the  first  three  or  four 
months  of  gestation,  in  consequence  of  the  great  laxity  of  the  ligaments;  and  it 
is  therefore  prudent  to  advise  such  persons  to  keep  the  horizontal  position  during 
all  this  time,  and  not  to  permit  them  to  get  up  until  after  the  fifth  month. 
After  the  delivery,  they  should  again  remain  in  bed  six  weeks  or  two  months  at 
least;  for  by  such  precautions,  not  only  may  the  patient  escape  the  dangers 
attendant  on  a  prolapsus  uteri  during  the  earlier  periods,  but  sometimes  even  a 
radical  cure  of  the  disease  she  had  before  the  gestation  took  place  may  be  eficcted. 

ARTICLE  II. 

FAULTY   DIRECTIONS    OF   THE   UTERUS. 

The  mobility  of  the  uterus  in  the  pelvis,  which  is  still  observable  in  the  early 
stages  of  pregnancy,  notwithstanding  its  augmentation  in  volume,  exposes  it  to 
another  variety  of  displacement,  that  is  not  so  common  as  the  preceding,  but 
more  disastrous  in  its  consequences.  Thus,  in  some  instances,  the  womb  seems 
to  execute  a  see-saw  movement,  by  which  its  long  vertical  axis  is  brought  into  a 
nearly  horizontal  line  in  the  excavation,  in  such  a  way  that  the  fundus  remains 
either  a  little  more  elevated,  or  else  somewhat  more  depressed  than  the  neck. 
This  displacement  is  called  retroversion^  when  the  fundus  uteri  is  carried  back- 
wards into  the  hollow  of  the  sacrum,  and  anteversion  when  it  is  directed  towards 
the  symphysis  pubis.  These  two  varieties  may  occur  in  different  degrees;  but 
the  displacement  will  be  much  more  considerable  in  retroversion  than  in  ante- 
version,  on  account  of  the  anterior  concavity  of  the  sacrum ;  the  former  is  also 
more  frequent  and  serious  than  the  latter. 

Both  kinds  of  displacement  may  occur  at  any  stage  of  the  pregnancy,  though 
in  the  latter  months,  anteversion  is  much  more  common  than  retroversion,  the 
possibility  of  the  latter  having  even  been  denied  by  most  authors.  Again,  in 
the  latter  part  of  gestation,  the  uterus  may  incline  more  or  less  to  the  right  or 
the  left,  so  as  to  constitute  what  have  been  termed  lateral  obliquities. 

§  1.  Retroversion. 

This  accident  generally  takes  place  some  time  during  the  first  three  or  four 
months,  more  usually  in  the  third,  according  to  Noegele.  Smellie,  however,  has 
observed  a  case  of  it  at  the  fifth  month,  and  William  Bartlett  states  that  he  has 
known  it  to  occur  twice,  with  an  interval  of  ten  days,  in  the  case  of  a  lady  who 
had  reached  the  seventh  month  of  her  pregnancy. 

The  displacement  may  come  on  slowly,  or  take  place  suddenly ;  in  the  former 
case,  it  seems  due  to  the  slight,  though  continuous  pressure  of  the  viscera  on  the 

21 


322  GENERATION. 

fundus  uteri,  and  on  its  anterior  part.  The  following  is  a  case  in  point :  A 
woman,  says  M.  Martin,  of  Lyons,  was  taken  in  her  third  month,  after  a  violent 
strainin"-  effort,  with  pains,  accompanied  by  loss  of  blood ;  at  first,  the  os  tincac 
was  found  in  the  centre  of  the  vagina ;  but  the  patient  renewed  her  efforts,  and 
then  the  uterus  became  completely  retroverted,  that  is,  the  neck  was  placed  be- 
hind the  pubis,  and  a  little  to  the  right,  and  the  fundus  of  the  organ  rested 
ao-ainst  the  sacrum.  In  this  instance,  the  retroversion  evidently  resulted  from 
the  conjoint  influence  of  the  uterine  contractions,  and  the  expulsory  efforts  of  the 
abdominal  muscles.     (Martin,  Memoires,  p.  142.) 

It  may  also  result  from  habitual  constipation.  The  accumulation  of  fcecal 
matters  in  the  sigmoid  flexure  of  the  colon  and  the  upper  part  of  the  rectum, 
forms  a  tumor,  which  presses  continually  upon  the  already  slightly  retroverted 
fundus  of  the  womb,  until  it  finally  renders  the  displacement  complete.  Tumors 
adherino-  to  the  upper  and  posterior  part  of  the  organ,  may  produce  the  same 
result,  by  dragging  down  the  parts  to  which  they  are  attached,  in  consequence  of 
their  weight.  When  the  retroversion  takes  place  suddenly,  a  similar  eff"ect  is 
produced  by  the  same  mechanism,  only  a  more  vigorous  and  energetic  impulsion 
is  then  requisite ;  and  such  an  impulsion  is  usually  given  by  a  rapid,  violent  con- 
traction of  the  muscles ;  thus,  after  a  severe  retching,  or  vomiting,  or  after  the 
strainings  at  stool,  in  women  who  are  habitually  constipated,  or  in  urinating,  in 
cases  of  retention,  the  womb  is  often  found  displaced. 

M.  Moreau  relates  an  instance  of  a  woman  who  lifted  a  weight  of  fifty  pounds, 
for  the  purpose  of  placing  it  on  the  balance,  when  she  was  immediately  attacked 
by  pains  in  the  hypogastrium,  vomiting,  syncope,  &c. ;  on  his  arrival,  he  found 
the  uterus  completely  turned  backwards ;  but  all  these  symptoms  disappeared 
immediately  after  the  reduction  was  efi'ected.  A  fall  backwards,  or  blows,  or  a 
strong  pressure  below  the  navel,  have  very  frequently  caused  the  same  result. 
(Na32;ele.)  In  one  of  Hunter's  cases,  the  retroversion  appeared  soon  after  a 
severe  fright. 

Where  the  displacement  is  effected  slowly,  the  woman  is  but  little  incommoded 
at  first;  and  the  necessity  for  reduction  is  only  apparent  after  it  has  become  con- 
siderable. Originally,  there  are  only  some  painful  dragging  sensations  in  the 
groins  and  lumbar  regions  j  a  feeling  of  weight  and  pressure  on  the  neck  of  the 
bladder;  some  vesical  tenesmus,  and  a  little  diflaculty  in  the  emission  of  urine. 
But  when  the  uterus  attains  a  certain  degree  of  development,  all  these  pheno- 
mena increase,  and  we  are  then  obliged  to  interpose  the  resources  of  our  art ;  for 
when  matters  reach  this  state,  the  womb  becomes  wedged,  as  it  were,  in  the 
middle  of  the  pelvis,  and  even  more  firmly  so  afterwards,  because  its  volume 
augments  rapidly ;  for  not  only  does  the  foetus  continue  its  growth,  but  also  the 
uterine  walls  become  engorged,  tumefied,  and  inflamed,  and  the  symptoms  caused 
by  this  inflammation  are  added  to  those  previously  existing;  and,  further,  as  the 
space  then  occupied  and  filled  up  by  the  uterus  is  larger  than  the  superior  strait, 
the  reduction  becomes  very  difficult,  or  even  impossible.  Hunter  relates  a  case 
in  which  the  reduction  could  not  be  made,  and  the  woman  died  in  consequence ; 


DISPLACEMENTS     OF    THE     UTERUS.  323 

and  at  the  autopsical  examination  it  was  found  necessary  to  cut  through  the  sym- 
physis, in  order  to  disengage  the  womb  from  the  excavation. 

When  the  displacement  takes  place  suddenly,  all  these  symptoms  are  speedily 
manifested,  and  should  it  happen  at  an  early  stage,  they  are  shortly  carried  to 
the  highest  degree,  or  even  may  soon  prove  fatal,  for  their  persistence  may  give 
rise  to  so  great  a  distension  of  the  bladder,  as  to  produce  its  rupture.*  Again, 
the  accumulation  of  fecal  matters  in  the  intestine,  occasions  so  imperious  a  feeling 
of  tenesmus,  that  the  female  gives  way  to  the  most  immoderate  strainings;  and 
the  pain  caused  by  the  displaced  and  inflamed  uterus,  may  create  a  convulsive 
agitation  of  the  abdominal  muscles  and  the  vaginal  walls,  so  great  as  to  cause  a 
rupture  of  the  vagina,  and  an  escape  of  the  fundus  of  the  uterus  from  the 
vulva;  as  happened  in  the  case  communicated  to  M.  Dubois,  by  M.  Mayor. 

The  vaginal  examination,  in  such  cases,  will  enable  us  to  detect  the  particular 
variety  of  displacement  which  causes  the  symptoms,  for  the  finger  encounters  a 
tumor  just  \vithin  the  vagina  that  fills  the  whole  excavation,  which  is  the  pos- 
terior surface  of  the  womb.  In  passing  over  this  surface,  which  is  of  greater  or 
less  extent  according  to  the  stage  of  pregnancy,  the  finger  reaches  the  fundus  of 
the  uterus,  which  it  finds  directed  toward  the  anterior  surface  of  the  sacrum,  and 
in  more  serious  cases  toward  the  point  of  the  coccyx.  Pursuing  the  examination 
,  anteriorly,  the  neck  is  discovered  to  be  turned  directly  forward,  toward  the  middle 
of  the  posterior  surface  of  the  pubis,  and  sometimes  even  raised  above  the  upper 
edge  of  the  symphysis.  Sometimes,  however,  the  neck  is  very  accessible  to  the 
touch,  although  the  retroversion  is  carried  to  the  greatest  extent.  This  is  owing 
to  the  fact  of  the  cervix  being  bent  round  on  the  body,  like  the  beak  of  a  retort. 
In  this  case,  the  uterus  was  retroflexed  before  being  overset  backward. 

In  retroversion,  a  rounded  tumor,  varying  in  size  with  the  volume  of  the  dis- 
placed organ,  is  found  in  the  vagina.  This  tumor  spreads  out  more  behind  than 
in  front,  whereby  the  posterior  vaginal  wall  is  depressed  whilst  the  anterior  is 
distended  and  elevated.  Sometimes  the  perineum  is  prominent,  and  the  vulva 
swollen,  the  rectum  is  pressed  down  and  almost  obliterated  by  the  tumefied 
organ ;  and  the  anus  often  dilated  and  bulged  outwards. 

A  particular  variety  of  retroversion  has  been  described  by  M.  Martin,  of  Lyons, 
in  which  the  os  tincae  protrudes  from  the  vulva,  and  the  fundus  uteri  is  pushed 
to  the  side  of  the  sacrum  ;  the  uterine  neck,  being  curved  like  the  spout  of  a 
ewer,  is  situated  below  and  a  little  in  front  of  the  pubis ;  the  body  of  the  organ  is 
retained  in  the  sacral  excavation,  and  lies  close  to  the  perineum.  But,  after  care- 
fully reading  his  description,  I  do  not  think  it  can  be  justly  considered  as  a  new 

'  The  greatly-distended  bladder  may  then  doubtless  form  a  very  considerable  tumor, 
capable  of  increasing  the  retroversion  mechanically,  and  of  opposing  the  reduction.  But  the 
very  intimate  adhesions  by  which  the  anterior  and  posterior  surfaces  of  the  uterus  are  con- 
ne<ted  with  the  posterior  and  inferior  walls  of  the  bladder,  tend  especially  to  augment  the 
dilficLilties.  The  abnormal  size  of  the  latter  organ  keeps  it  very  high  in  the  pelvis,  and  the 
neck  of  the  uterus  evidently  can  only  be  brought  downwards  and  backwards,  after  the 
relieved  bladder  has  itself  descended  into  the  e.\cavation. 


324  GENERATION. 

example  of  retroversion.  I  believe  it  was  merely  a  ftdlinir  of  tlie  veomb,  which 
had  existed  prior  to  pregnancy,  and  had  been  aggravated  by  this  latter  condition; 
there  was  at  the  same  time  an  anteflexion  of  the  neck,  which  explains  how  the 
curve  in  the  latter,  described  by  M.  Martin,  might  be  formed  below  and  in  front 
of  the  pubis,  from  the  depressed  body  forcing  it  beyond  the  vulva. 

A  retroversion  could  scarcely  be  confounded  with  simple  prolapsus ;  for,  in  the 
former,  the  vaginal  wall  is  always  situated  between  the  finger  and  the  tumor,  aad 
the  neck  is  high  up  behind  the  pubis,  whilst,  in  a  prolapsus,  the  cervix  is  always 
the  most  dependent  part,  and  the  tumor  can  be  perfectly  isolated  from  the  vagina; 
in  the  latter  case,  the  reduction  is  generally  easy,  but  it  is  usually  quite  difficult, 
sometimes  even  impossible,  in  the  former.  Further,  the  symptoms  of  retrover- 
sion are  ordinarily  much  more  severe  than  those  of  prolapsus. 

Finally,  anteflexion  of  the  uterus  consists,  as  is  well  known,  in  a  bending  of 
the  body  upon  the  neck,  so  as  to  form  with  each  other  a  more  or  less  obtuse 
angle  with  the  opening  directed  in  front.  If  the  attention  be  fixed  exclusively 
upon  the  direction  of  the  orifice,  the  anteflexion  may  be  mistaken  for  a  retrover- 
sion, since,  in  both  cases,  the  orifice  is  directed  toward  the  pubis.  The  error  may 
be  avoided  by  ascertaining:  1.  The  absence  of  the  fundus  of  the  womb  from  the 
hollow  of  the  sacrum;  2.  The  angle  opening  anteriorly,  which  the  body  forms 
with  the  neck. 

As  a  general  rule,  tho  prognosis  in  these  displacements  is  very  grave;  it  varies, 
however,  with  the  period  of  pregnancy,  the  volume  of  the  uterus,  the  alteration 
in  the  neighboring  parts,  and  the  violence  of  the  attendant  symptoms. 

Cccteris  paribus,  a .  retroversion  is  usually  more  unfavorable  than  an  antever- 
sion ;  because,  in  retroversion,  the  constipation  and  retention  of  urine,  which 
thus  far  have  been  considered  as  comparatively  unimportant,  soon  become  aggra- 
vating circumstances  of  the  disease.  In  fact,  the  bladder  can  only  enlarge  and 
ascend  into  the  abdominal  cavity,  by  pushing  the  uterine  neck  upwards  and  to- 
wards the  front;  and  hence,  its  body  acting  on  the  uterus  by  its  size  and  weight, 
necessarily  increases  the  displacement.  The  stercoraceous  matters  accumulated 
in  the  rectum,  above  the  part  in  contact  with  the  fundus  uteri,  act  in  a  similar 
manner;  and,  again,  all  the  woman's  expulsory  efi'orts  have  a  constant  tendency 
to  further  depress  the  fundus,  after  the  displacement  has  once  commenced.  In 
anteversion,  on  the  contrary,  all  the  causes  just  enumerated  operate  in  a  favorable 
manner.  Thus,  the  distended  bladder  constantly  has  a  tendency  to  press  back 
the  body  of  the  womb,  which  is  then  carried  forwards,  and  the  accumulated  mat- 
ters of  the  large  intestine  pressing  from  above  downwards  on  the  posterior  part  of 
the  neck,  contribute  to  the  same  end. 

Treatment. — After  having  emptied  the  bladder  and  rectum,  and  combated  the 
inflammatory  symptoms  by  the  appropriate  means,  the  accoucheur  should  proceed 
at  once  to  reduce  the  uterus  to  its  natural  position,  and  secure  it  there.  The 
best  position  for  the  female  to  assume  is  one  in  which  all  the  muscles  are  thrown 
into  a  state  of  relaxation ;  two  fingers  are  then  to  be  introduced  in  the  vagina, 
with  which  the  body  is  first  to  be  pushed  up,  after  which  the  index  should  be 
hooked  over  the  neck  so  as  to  depress  it. 


DISPLACEMENTS*  OF    THE     UTERUS.  325 

The  reduction  may  sometimes  be  eflPected  on  a  single  trial,  but  more  often  we 
are  compelled  to  repeat  the  attempt  after  an  interval  of  a  few  minutes;  and  just 
at  the  instant  of  the  resumption  of  its  ordinary  position  by  the  womb,  a  noise  is 
heard,  in  some  instances,  like  the  click  of  a  spring.  It  must  not  be  supposed, 
however,  that  this  operation  is  always  an  easy  one.  For  the  difficulty  in  using 
the  catheter,  so  often  experienced,  the  impossibility  of  emptying  the  rectum,  and 
especially  the  voluminous  tumor  formed  behind  the  uterus  by  the  fteces  collect- 
ing in  the  sigmoid  flexure  of  the  colon;  the  violent  strainings  made  by  the  patient 
under  such  circumstances,  and  the  size  of  the  tumor,  and  its  adhesions  to  sur- 
rounding parts,  are  so  many  embarrassing  circumstances  to  the  practitioner. 
Although  it  is  very  seldom  that  we  cannot  succeed  in  introducing  the  catheter, 
by  time  and  patience,  yet,  in  some  cases,  this  has  been  found  altogether  impos- 
sible ;  indeed,  much  prudence  is  requisite  in  the  measures  then  adopted,  and  if 
they  all  prove  useless,  a  moderate  pre.'^sure  made  over  the  hypogastriura  may, 
perhaps,  slowly  compress  the  bladder,  and  thus  luake  the  woman  urinate,  so  to 
speak,  by  exudation. 

The  retroverted  fundus  sometimes  compresses  the  rectum  to  such  a  degree  that 
an  injection  cannot  be  made  to  enter  the  large  intestine. 

Such  cases  demand  some  precaution  in  the  administration  of  the  enemata. 
There  may  be  a  collection  of  indurated  matters  above  the  fundus  of  the  retro- 
verted uterus,  in  which  case  it  is  evident,  that  as  the  latter  compresses  the  upper 
part  of  the  rectum,  an  injection  given  in  the  usual  manner  cannot  reach  high 
enough  to  bring  away  the  fseces  accumulated  in  the  descending  colon.  It  then 
becomes  necessary  to  use  a  long  gum  elastic  tube,  which  may  be  inserted  to  the 
extent  of  seven  or  eight  inches.  This  simple  expedient  has  often  disencumbered 
the  intestine  of  matters  which  an  ordinary  injection  could  not  have  reached,  with 
the  efi"ect  of  producing  spontaneous  reduction. 

Even  with  the  use  of  the  tube  just  recommended,  the  injections  are  some- 
times ineffectual.  In  such  cases,  if  the  palpation  and  the  abdominal  percussion 
lead  us  to  suspect  a  considerable  accumulation  of  fecal  matters  in  the  descending- 
colon,  we  should  exhibit  purgatives  by  the  mouth.  Again,  the  necessary  intro- 
duction of  the  hand  into  the  vagina,  to  eifect  the  reduction,  is  at  times  so  pain- 
ful to  the  female,  that,  notwithstanding  all  persuasions  to  the  contrary,  she  gives 
way  to  the  most  violent  bearing-down  efibrts,  which  neutralize  those  of  the 
operator.  If  baths,  or  emollient  and  narcotic  injections  should  not  assuage  this 
acute  sensibility,  the  advice  of  Dewees  might  be  taken,  and  bleeding  practised 
to  the  extent  of  producing  syncope ;  still  better,  in  my  opinion,  would  be  the 
administration  of  chloroform  before  the  operation. 

The  abnormal  adhesions  that  are  occasionally  established  between  the  uterus 
and  adjacent  parts,  will  certainly  add  another  to  the  serious  difficulties  just  men- 
tioned ;  but  even  this  should  not  give  rise  to  despair.  Amussat  reports  a  case 
where  he  distinctly  felt  some  bridles  in  the  bottom  of  the  vagina,  and  to  the  left 
of  the  tumor,  into  which  he  could  hook  the  forefinger,  but  after  a  careful  exami- 
nation he  acquired  the  conviction  that  the  uterus  was  free  on  the  right  side. 
He  then  renewed  his  attempts,  by  acting  in  such  a  way  as  to  turn   the  uterus 


326  GENERATION. 

from  the  opposite  side  towards  that  where  the  adhesions  existed,  that  is,  from 
right  to  left,  and  he  thereby  succeeded  in  replacing  the  organ  in  its  natural  posi- 
tion. But  if,  after  having  adopted  all  suitable  precautions,  the  simple  procedure 
just  described  should  not  succeed,  one  of  the  following  plans  should  then  be 
resorted  to,  namely,  to  act  simultaneously  by  the  vagina  and  rectum,  as  some 
have  advised ;  but  the  most  simple  plan,  however,  is  that  of  31.  Evrat,  quoted  by 
M.  Moreau,  as  follows  :  The  woman  must  lie  upon  her  side,  and  the  accoucheur 
then  takes  a  rod  eight  or  ten  inches  long,  covered  at  one  end  by  a  tampon  of 
linen  smeared  over  with  some  fatty  matter,  which  he  introduces  into  the  rectum, 
so  as  to  press,  through  the  recto-vaginal  septum,  the  fundus  uteri  from  below 
upwards,  whilst  the  two  fingers  passed  into  the  vagina  hook  the  neck,  and  simul- 
taneously draw  it  downwards  and  backwards.  The  force  necessary  for  this 
reduction  is  very  variable,  though  in  effecting  it  we  need  not  be  restrained  by 
the  fear  of  producing  an  abortion,  for,  even  if  this  were  to  result  from  such 
efforts,  the  dangers  to  the  mother  would  be  far  less  than  from  the  continuance 
of  the  retroversion.  In  a  case  of  this  kind,  M.  Plalpin,  after  having  emptied  the 
bladder,  and  endeavored  unsuccessfully  to  reduce  the  uterus,  came  to  the  conclu- 
sion that  the  only  mode  of  curing  the  patient  was  by  the  employment  of  an 
instrument  that  would  bear  equally  on  all  parts  of  the  displaced  womb ;  and  he 
imagined  that  the  pelvis  could  be  filled  up  with  a  bladder,  and  thus  all  the  con- 
tained organs  be  pressed  up  together  into  the  abdomen.  With  this  view,  he 
placed  an  empty  one  between  the  fundus  uteri  and  the  rectum,  and  then  by  cau- 
tiously distending  it,  he  actually  succeeded  in  pushing  the  fundus  upwards. 
{Archiv.  Gen.,  Sept.  1840,  page  88.) 

Attributing,  as  they  did,  the  difficulty  of  reduction  to  the  pressure  of  the 
viscera  upon  the  anterior  surface  of  the  uterus.  Hunter,  Boyer,  and  others,  have 
recommended  that  the  patient  should  be  placed  in  such  a  position  that  the  weight 
of  the  intestines  may  be  supported  by  the  upper  part  of  the  abdomen.  Acting 
upon  this  suggestion,  M.  Godefroy  adopts  the  following  position  :  the  patient 
rests  her  head  and  hands  upon  the  floor,  whilst  the  anterior  part  of  the  thighs 
and  legs  repose  upon  the  edge  of  the  bed,  where  they  are  supported  by  assistants. 
The  surgeon  then  acts  either  through  the  vagina  or  the  rectum  upon  the  fundus 
of  the  uterus  in  such  a  way  as  to  effect  the  reduction.  In  three  very  grave  cases, 
success  was  complete.      (.Journ.  des  Conn.  Med.  Chir.,  August,  1846.) 

This  position  is  very  fatiguing,  painful,  and  disagreeable  to  the  patient.  I 
would,  therefore,  much  prefer,  in  these  difficult  cases,  simply  to  place  the  female 
on  her  knees  in  bed,  with  the  upper  part  of  the  body  supported  on  the  elbows. 
I  have  thus  been  able,  in  two  cases,  to  reduce  retroflexions  which  had  resisted 
every  other  means. 

In  an  obstinate  case,  we  might  resort  to  a  procedure  recently  employed  by 
Amussat,  with  a  prospect  of  success ;  that  is,  to  place  the  female  in  the  position 
for  operating  for  stone,  and  then  introduce  one  or  two  fingers  into  the  rectum, 
and  gently  press  up  the  uterine  tumor,  by  following  the  concavity  of  the  sacmm, 
at  first  directly  upwards,  and  then  alternating  from  right  to  left  and  left  to  right, 
so  as  to  raise  the  whole  surface  of  the  uterus ;  but  if  the  finger  or  fingers  placed 


DISPLACEMENTS     OF    THE    UTERUS.  327 

in  the  rectum  cannot  reach  so  high,  the  thumb  should  be  put  into  the  vagina  so 
as  to  elevate  the  perineum,  in  order  that  the  former  may  penetrate  still  further ; 
and,  lastly,  to  get  higher  yet,  an  assistant  might  press  against  the  elbow,  or  the 
accoucheur  himself  could  sustain  it  with  his  own  thigh  or  body.  M.  Amussat 
declares  that  he  has  twice  succeeded  in  this  manner  in  making  a  reduction  that 
had  previously  been  ineffectually  tried  by  several  other  practitioners. 

Finally,  what  is  to  be  done  where  the  reduction  is  impossible  ?  Abandon  the 
patient  to  the  resources  of  nature,  says  Merriman  ;  but  would  not  that  devote  her 
to  a  certain  death,  in  case  the  inflammatory  phenomena  did  not  determine  an 
abortion  ?  and  since  a  miscarriage  is  inevitable  under  the  most  fortunate  circum- 
stances, would  it  not  be  advisable  to  bring  it  on,  rather  than  to  leave  the  patient 
exposed  for  a  long  time  to  the  dangei's  which  threaten  her?  Indeed,  most  phy- 
sicians are  of  this  opinion,  and  I  should  not  hesitate,  therefore,  to  rupture  the 
membranes  by  a  sound  passed  through  the  neck  of  the  womb.  But,  sometimes, 
the  neck  is  so  high  up  that  it  is  wholly  inaccessible ;  and  then,  a  puncture  of  the 
uterus  itself  must  be  resorted  to.  This  latter  operation  has  been  performed 
both  by  the  vagina  and  by  the  rectum,  but  I  should  think  the  first  preferable. 
It  is,  without  any  doubt,  a  dernier  resort,  but  it  ought  always  to  be  chosen 
rather  than  the  symphysiotomy  recommended  by  Gardien,  and  some  other  ac- 
coucheurs. 

After  the  reduction  (when  that  has  been  possible),  the  patient  must  remain  in 
the  horizontal  position  until  towards  the  sixth  month  of  pregnancy,  and  must 
carefully  avoid  all  straining,  whether  in  urinating  or  at  stool.  These  simple  pre- 
cautions are  all-sufficient,  and  generally  render  the  introduction  of  a  pessary  use- 
less; which  latter,  however,  Baudelocque  considers  indispensable  in  most  cases. 
Occasionally,  the  incontinence  of  urine,  brought  on  by  the  pressure  which  the 
neck  of  the  bladder  has  suffered  from  the  neck  or  fundus  uteri,  may  still  continue 
some  time  after  the  reduction ;  and  then,  if  the  ordinary  simple  means  do  not 
cause  its  disappearance,  we  may  resort  to  the  warm  mineral  waters  of  Cauterets, 
Bareges,  or  Balaruc;  to  frictions  with  the  tincture  of  cantharides,  and  blisters 
on  the  hypogastrium,  together  with  tonics  and  astringents  administered  internally. 

Retroversion  is,  for  the  most  part,  confined  to  the  first  half  of  pregnancy,  the 
possibility  even  of  such  a  displacement  at  an  advanced  stage  having  been  denied. 
Some  well-observed  cases  seem  to  me  to  prove  that  it  may  occur,  and  we  shall 
see  hereafter  that  this  difference  of  opinion  is  due  to  a  false  interpretation  of  the 
word  retroversion.  However,  as  this  faulty  direction,  so  much  to  be  deprecated 
in  the  early  stages,  produces  no  serious  disorder  toward  the  end  of  gestation,  but 
exerts  its  disturbing  influence  only  during  labor,  we  shall  treat  of  it  in  the  fourth 
part  of  the  volume. 

§  2.  Anteversion. 

Antevcrsion  is  very  rare  in  the  early  stages  of  gestation,  and  probably  on  this 
account,  has  been  passed  over  by  most  authors  who  have  studied  the  disorders  of 
pregnancy.  The  manner  in  which  the  uterus  is  developed,  the  peculiar  form  of 
the  anterior  and  posterior  boundaries  of  the  pelvis,  and  the  normal  direction  of 


328  GENERATION. 

the  organ,  are  so  many  circumstances,  which,  just  in  proportion  as  they  facilitate 
retroversion,  render  the  occurrence  of  antevcrsion  difficult.  Besides,  the  influ- 
ence which  a  distended  rectum  and  bladder  have  in  the  production  and  increase 
of  the  posterior  displacement,  would  tend  to  restore  the  womb  to  its  natural  posi- 
tion, should  any  circumstance  efioct  a  commencement  of  anteversion. 

Notwithstanding  these  favoi'able  conditions,  anteversion  has  been  observed  by 
Chopart  at  two  months,  by  Madame  Boivin  at  three  months,  and  finally  by  Ash- 
well.  The  case  of  the  latter,  being  unknown  in  France,  we  shall  give  an  analysis 
of  it. 

Mrs.  M ,  thirty-three  years  of  age,  and  habitually  very  constipated,  fell, 

during  the  first  month  of  her  pregnancy,  whilst  ascending  a  pair  of  stairs. 
Though  there  was  no  hemorrhage,  she  had  a  spell  of  faintness  which  lasted 
nearly  an  hour.  For  five  or  six  weeks,  there  was  a  feeling  of  weight  at  the 
pubis,  micturition  was  frequent  and  painful,  but  there  was  no  obstruction  to 
defecation.  I  examined  her  for  the  first  time  at  the  end  of  the  second  month. 
The  cervix  was  in  its  normal  position,  but  the  strongly-inclined  fundus  formed  a 
round  solid  tumor  between  the  bladder  and  the  anterior  part  of  the  vagina. 
Pressure  with  the  finger  upon  the  angle  of  inflexion  caused  pain.  The  neck 
was  elongated,  and  larger  and  harder  than  usual.  I  endeavored,  inefi'ectually,  to 
efi"ect  reduction  by  pressing  upon  the  fundus  of  the  womb  with  the  finger,  whilst 
the  neck  was  drawn  downward  and  forward  by  the  index  of  the  right  hand.  At 
the  sixth  month,  the  husband  found  that  the  anteflexion  had  almost  entirely  dis- 
appeared, and  although  the  lady  still  sufi'ered  some  pain  in  the  latter  months,  she 
was  delivered  without  difiiculty. 

Although  the  author  describes  this  as  a  case  of  anteflexion,  it  is  evident  that 
there  was  also  anteversion,  as  is  proved  by  the  normal  position  of  the  neck,  and 
especially,  by  the  spontaneous  disappearance  of  the  displacement  at  the  fourth 
month.  I  see,  indeed,  no  reason  why  an  anteflexion  should  disappear  suddenly 
at  this  stage  of  pregnancy. 

Anteversion  is,  therefore,  possible,  in  the  early  months,  though  it  occurs  more 
frequently  in  the  second  half,  and  especially  towards  the  end  of  the  pregnancy. 
At  that  time,  the  fundus  of  the  womb,  which  is  naturally  inclined  forwards,  is 
supported  by  the  abdominal  muscles  only;  now  if  these  resist  slightly,  as  often 
happens  when  women  have  had  several  children,  the  physiological  inclination 
has  a  constant  tendency  to  increase.  The  axis  of  the  uterus  may  thus  become 
nearly  horizontal,  or  even  be  depressed  still  lower,  until  the  fundus  falls  upon  the 
thighs  and  knees.  The  neck,  which  is  carried  very  far  upwards  and  backwards, 
sometimes  gets  above  the  sacro-vertebral  angle,  and  is  reached  by  the  finger  with 
the  greatest  difficulty;  the  impossibility  of  attaining  it  has  occasionally  given 
rise  to  a  belief  of  the  existence  of  imperforation. 

Beside  the  signs  furnished  by  the  touch  and  examination  of  the  abdomen, 
some  functional  disorders  may  be  produced  by  anteversion  at  different  stages  of 
pregnancy,  whose  cause  should  not  be  mistaken  when  called  upon  to  treat  them. 
In  the  early  months,  the  sensation  as  of  a  heavy  weight  at  the  pubis,  frequent, 
and  sometimes  painful  micturition  and  defecation,  are  almost  the  only  rational 


OF    ABORTION.  329 

signs.  In  the  latter  months,  the  weight  of  the  uterine  tumor,  which  is  carried 
strongly  forwards,  occasions  pains  and  draggiugs  in  the  thighs  and  groins  •  the 
extreme  distension  of  the  skin  of  the  abdomen,  also  produces  acute  pain,  and 
the  pressure  to  which  the  bladder  is  subjected,  is  the  cause  of  vesical  tenesmus, 
with  dysuria  or  strangury.  Finally,  in  the  worst  cases,  walking  is  rendered  diffi- 
cult, and  often  impossible. 

The  prognosis  is  not  generally  serious.  For,  when  the  anteversion  occurs  in 
the  early  months,  the  development  of  the  uterus  may  restore  it;  when  it  occurs 
in  the  second  half  of  gestation,  it  may  produce  premature  labor,  though  it  usually 
occasions  merely  the  inconveniences  just  spoken  of,  and  never  gives  rise  to  acci- 
dents in  any  degree  serious,  except  during  labor.     (See  Dystocia.) 

Reduction  may  be  attempted  in  the  early  months,  but  has  hitherto  always 
failed;  too  great  perseverance  would  be  at  the  risk  of  abortion.  The  most  pru- 
dent course,  therefore,  provided  resistance  is  encountered,  is  to  intrust  the  reduc- 
tion to  the  subsequent  progress  of  the  pregnancy.  If  the  discomfort  and  weight 
are  too  fatiguing,  they  may  be  relieved  by  the  horizontal  decubitus. 

At  a  more  advanced  stage,  a  body  bandage,  or  a  sort  of  corset  or  belt  for  the 
abdomen,  well  adapted  to  the  size  and  form  of  the  belly,  will  afford  much  relief. 
When  the  abdomen  is  pendent,  the  abdominal  belt  may  be  kept  up  by  suspenders. 

ARTICLE   III. 

§  3.  Lateral  Obliquities. 

In  describing  the  physiological  phenomena  of  pregnancy,  we  spoke  of  obliqui- 
ties of  the  uterus,  and  pointed  out  their  probable  causes.  They  are  rarely  car- 
ried to  any  great  extent,  and  are  never  the  occasion  of  serious  accidents.  Only 
by  tending  to  produce  an  unfavorable  presentation  of  the  child,  and  by  retarding 
the  dilatation  of  the  neck,  can  they  have  any  unpleasant  effect  upon  the  labor. 
Therefore,  the  present  is  not  the  proper  time  to  speak  of  them  further. 


CHAPTER    III. 


OF    ABORTION. 


The  term  abortion  has  been  applied  to  the  expulsion  of  the  foetus  from  the 
womb,  where  this  occurs  at  a  period  of  pregnancy  when  the  product  of  concep- 
tion is  not  yet  viable ;  that  is  to  say,  an  abortion  may  take  place  at  any  time 
between  the  commencement  of  pregnancy  and  the  end  of  the  sixth  mouth. ^ 

'  We  place  the  period  of  viability  at  the  seventh  month,  though  well  aware  that  some  cases 
have  been  reported  where  foetuses  born  at  six  or  five,  or  even  four  months,  have  lived  ;  but 
those  instances,  some  of  which  have  not  all  the  authenticity  desirable,  are  too  rare  to  invali- 
date the  general  law. 


330  GENERATION. 

The  ancients  applied  the  term  effluxio  to  this  accident,  if  it  happened  before  the 
seventh  day. 

In  a  recent  and  very  remarkable  article  by  M.  Guillemot,  this  author  adu)its 
three  varieties  of  abortion,  founded  on  the  period  of  its  occurrence  :  thus,  ovular 
abortion  is  the  title  he  gives  when  it  takes  place  before  the  twentieth  day ;  em- 
hryonic  if  prior  to  the  third  month,  and/ce^a?  from  the  latter  date  up  to  the  sixth 
month  of  gestation. 

Persons  out  of  the  profession,  further  designate  abortion  under  the  title  of 
miscarriage  (^fausne  couclie). 

Abortions  are  much  more  frequent  in  the  first  two  or  three  months  than  at  any 
other  period.  The  great  vascularity  of  the  uterine  mucous  membrane,  become 
the  decidua,  and  the  ease  with  which  effusions  of  blood  may  take  place  into  the 
space  which  originally  exists  between  the  chorion  and  the  reflected  portion  of 
this  same  deciduous  membrane,  sufficiently  explain  the  frequency  of  hemorrhage, 
and  consequently  of  abortion,  in  the  early  months.  In  making  this  remark,  I  am 
not  ignorant  that  Madame  Lachapclle  has  given  a  different  view,  but  it  was 
because  her  position  at  the  Maternity  rarely  furnished  her  with  opportunities  of 
observing  abortions  prior  to  the  fourth  or  fifth  month,  for  females  do  not  usually 
go  to  the  hospitals  on  account  of  the  miscarriages  of  the  first  five  or  six  weeks  of 
gestation ;  and  though  other  persons  have  since  adopted  her  opinion,  it  is  doubt- 
less owing  to  the  difficulty  of  diagnosis,  and  to  the  errors  of  females  themselves, 
who,  supposing  they  have  only  a  simple  retardation  of  the  menses,  allow  an  abor- 
tion to  pass  away  in  the  early  stages  unperceived. 

Morgagni  and  Desormeaux  supposed  that  abortions  of  foetuses  belonging  to 
the  female  sex  are  more  numerous  than  of  males,  and  I  do  not  know  whether  the 
"vulgar  opinion  opposed  to  this  is  true  or  false ;  but  certain  it  is,  that  at  term  the 
boys  exceed  the  girls  in  the  proportion  of  sixteen  to  fifteen,  which  would  seem 
to  prove  that  female  abortions  are  the  most  numerous ;  and  besides,  it  is  possible, 
that  the  difficulty  of  distinguishing  the  sex  in  the  earlier  periods  of  intra-uterine 
life  may  have  had  some  influence  in  creating  the  popular  error. 

The  history  of  abortion  evidently  includes  the  study  of  the  causes  producing  it, 
the  symptoms  and  consequences  which  may  arise,  the  signs  by  which  it  may  be 
detected,  and  the  most  suitable  indications  for  preventing  or  opposing  it. 

ARTICLE   I. 

CAUSES. 

Considered  in  relation  to  its  determining  causes,  abortion  may  be  divided  into 
the  sponlaneous  and  accidental. 

The  term  provoked  has  also  been  used,  where  the  abortion  has  resulted  either 
from  criminal  efforts,  or  from  the  measures  adopted  by  the  scientific  physician 
with  a  laudable  object. 

The  causes  of  sjwntaneous  abortion  may  arise :  1,  from  the  constitution  and 


OF    ABORTION.  331 

general  health  of  the  mother;  2,  from  diseases  of  the  ovum;  3,  from  the  condi- 
tion of  the  uterus  and  its  appendages. 

1.  Women  of  a  plethoric  habit,  and  having  copious  menstrual  discharges,  arc 
greatly  exposed  to  abortion  during  the  early  months  of  gestation ;  in  fact,  we 
have  already  alluded  to  those  hemorrhagic  molimens  that  appear  in  them  at  every 
monthly  period.  Again,  nervous  or  very  irritable  women,  those  who  are  strongly 
affected  by  moral  impressions,  such  as  anger,  chagrin,  &c. ;  females  of  a  seden- 
tary habit,  who  are  always  shut  up  in  the  shops,  as  well  as  those  that  follow  an 
indolent  life,  passing  their  time  at  balls  or  soirees,  and  in  light  reading,  also  abort 
very  frequently.  The  surrounding  atmospheric  conditions  are  not  wholly  without 
influence  in  the  production  of  abortion ;  in  fact,  we  may  refer  to  this  cause  those 
epidemic  miscarriages  spoken  of  by  most  authors.  Mountainous  countries,  where 
the  air  is  bleak,  are  considered  as  being  favorable  to  their  production ;  for,  ac- 
cording to  the  report  of  Saucerotte,  the  women  inhabiting  the  summit  of  the 
Vosges  are  very  subject  to  abortion,  and  they  arc  in  the  constant  habit  of  descend- 
ing into  the  adjacent  plains  to  avoid  this  accident. 

Acute  diseases  occurring  in  the  course  of  pregnancy,  abdominal  or  thoracic 
affections,  and  recent  cutaneous  diseases,  often  give  rise  to  miscarriage.  Syphilis 
in  the  mother  has  the  most  disastrous  influence  upon  the  progress  of  gestation, 
and  even  the  mercurial  treatment  does  not  always  secure  from  abortion.  Some 
writers  think  that  the  administration  of  mercury  endangers  the  life  of  the  foetus. 
Their  opinion  is,  however,  rejected  by  most  modern  writers  upon  syphilis,  almost 
all  of  whom  regard  the  antivenereal  treatment  begun  at  the  outset  of  pregnancy, 
as  the  best  means  of  preventing  abortion.  The  numerous  fiets  which  have  come 
under  our  own  observation,  have  changed  our  opinion  upon  this  point,  and  we 
now  think  it  most  prudent  to  begin  the  treatment  as  soon  as  possible. 

The  convulsive  diseases  may  occasion  miscarriage  either  by  provoking  uterine 
contractions,  or  by  directly  destroying  the  child.    (See  Eclampsia.) 

§  2.  Diseases  of  the  Ovum. 

Circumstances,  which  are  often  unknown  to  us,  may  arrest  the  development  of 
the  foetus ;  for  instance,  it  may  be  affected  in  the  mother's  body,  by  those  acute 
diseases  which  at  times  beset  it  after  birth ;  and  such  affections,  though  not 
always  fatal  to  the  new-born  infant,  are  the  more  disastrous  to  the  intra-uterine 
foetus  as  they  occur  the  nearer  to  the  period  of  fecundation.  We  may  add,  the 
presence  of  several  children  as  a  cause  dependent  on  the  child ;  in  fact,  we  have 
elsewhere  seen  that  the  excessive  distension  produced  by  a  twin  pregnancy,  fre- 
quently brings  on  premature  contractions.  However,  the  uterus  is  rarely  deve- 
loped enough  prior  to  the  sixth  month  to  provoke  such  an  accident,  for  this  seldom 
happens  until  a  more  advanced  stage,  and  then  it  no  longer  appertains  to  abortion 
properly  so  called. 

Some  diseases  of  the  parents  may  affect  the  child ;  for  example,  a  vitiated 
spermatic  fluid,  such  as  that  from  a  father  debilitated  by  debauchery  or  old  age, 
or  corrupted  by  a  syphilitic  taint,  communicates  to  the  new  being  a  principle 
which  does  not  fail  sooner  or  later  to  destroy  it.     M.  Guillemot  attributed  the 


382  GENERATION, 

numerous  miscarriages  of  a  young  lady  who  consulted  bim  to  this  cause ;  for  her 
husband,  although  of  a  suitable  age,  exhibited  all  the  characters  of  premature 
decrepitude.  Having  become  a  widow,  she  remarried,  was  several  times  enceinte, 
and  all  her  pregnancies  terminated  happily  at  full  term. 

The  mother,  also,  may  transmit  her  diseases  to  the  child.  Nothing,  indeed, 
is  more  common  than  to  find  children  presenting,  a  few  weeks  after  birth,  evident 
traces  of  the  venereal  infection  received  from  the  mother  during  intra-uterine 
life,  and  hence  we  may  conceive  that  this  hereditary  taint  may  prove  fatal  to  the 
foetus  whilst  still  within  the  womb. 

Small-pox  is  also  sometimes  communicated  from  the  mother  to  the  foetus,  and 
causes  its  death.  It  is  remarkable  that  several  circumstances  seem  to  prove,  that 
the  infection  frequently  does  not  take  place  until  after  the  mother's  recovery. 

In  some  cases,  the  body  of  the  mother  is  but  the  conductor  of  a  contagious 
principle,  whose  influence  it  is  itself  incapable  of  receiving.  Thus,  during  an 
epidemic  of  small-pox,  Ebel  had  charge  of  a  woman  who  experienced  uncom- 
fortable sensations,  and  felt  her  child  move  with  violence  fifteen  days  before  labor. 
The  infant  was  born  with  variolous  pustules  in  full  suppuration.  Kessler  and 
Wartson  have  known  women,  who  had  formerly  been  affected  with  small-pox,  to 
give  birth  to  children  presenting  pustules.  Some  years  ago,  a  woman  in  the 
wards  of  Professor  Fouquier,  was  delivered  of  a  dead  child  affected  with  small- 
pox, although  she  had  herself  been  vaccinated.  Finally,  the  illustrious  Mauri- 
ceau  relates  that  his  mother,  when  in  the  last  stage  of  her  pregnancy,  had  the 
misfortune  to  lose  the  eldest  of  her  three  sons  by  small-pox,  to  whom,  notwith- 
standing her  condition,  she  was  unceasing  in  her  attentions;  and  that  at  his 
birth,  which  occurred  the  day  after  the  death  of  his  eldest  brother,  he  presented 
four  or  five  pustules  of  small-pox. 

The  placenta  may  be  atrophied  or  hypertrophied,  or  may  become  inflamed;  its 
tissue  may  degenerate,  harden,  ossify,  and  form  an  hydatid  mass  or  a  fatty  tumor; 
and  it  is  not  very  uncommon  to  find  some  purulent  collections  in  its  substance, 
though  a  number  of  sanguineous  ones  are  much  more  frequently  met  with,  the 
volume  of  which  varies  from  the  size  of  a  pea  to  that  of  a  large  nut.  The  clots 
contained  in  those  cavities  exhibit  all  the  degrees  of  transformation  which  the 
blood  passes  through,  whenever  it  escapes  into  the  substance  of  the  tissues. 

This  disease,  designated  by  M.  Cruveilhier  as  placental  apopkxij,  is  repro- 
duced at  different  periods,  and  the  collections,  by  increasing  in  number,  ultimately 
invade  the  greatest  part  of  the  placental  mass,  thereby  interrupting  the  focto- 
placental  circulation,  and  speedily  cjiusing  the  death  of  the  foetus.  Similar  effu- 
sions of  blood  may  also  take  place  between  the  divers  membranous  layers  that 
constitute  the  envelope  of  the  ovum.  For  instance,  Dcneux  has  found  such  in 
the  cavity  of  the  decidua  itself,  between  the  reflected  lamina  and  the  chorion 
(the  cavity  recently  described  by  M.  Jacquemier),  as  also  between  the  chorion 
and  the  amnion. 

As  regards  the  insertion  of  the  placenta  over  the  neck,  I  can  scarcely  believe 
that  it  could  produce  an  abortion,  and  hence  I  imagine  that  the  cases  cited  in 
support  of  that  view  have  been  misinterpreted ;  the  insertion  has  been  considered 


OF    ABORTION.  333 

as  tbe  cause  of  the  accident  in  those  instances,  when  it  certainly  was  nothing 
more  than  a  simple  coincidence.  M.  D'Outrepont  has  advanced  the  torsion  of 
the  umbilical  cord  as  a  cause  determining  the  death  of  the  foetus ;  for  the  state 
of  compression,  says  he,  resulting  therefrom,  may  impede  the  circulation.  The 
embryos  had  been  dead  for  a  long  time,  in  all  the  cases  of  that  kind  observed  by 
him. 

Again,  it  may  be  asked,  if  the  umbilical  cord  is  too  short,  could  it  drag  off  or 
detach  the  placenta,  or  even  be  ruptured  itself?  Now,  to  the  facts  bearing  on 
this  point,  reported  by  Mauriceau,  Stein,  &c.,  M.  Guillemot  adds  the  following : 
The  foetus  was  about  three  months  old,  the  umbilical  cord  was  tightly  stretched 
and  even  half  separated  near  its  origin  at  the  navel ;  two  folds  of  it  encircled  the 
neck,  and  some  deep  marks  were  left  on  this  part  from  their  pressure.  The  cir- 
culation, he  continues,  was  therefore  interrupted  in  the  cord  by  the  tension  and 
compression  it  sustained;  and  the  strangling  of  the  child's  neck  also  contributed 
to  its  death.  M.  Deneux  has  furnished  a  case  of  a  rupture  of  the  umbilical 
vein,  and  effusion  of  its  blood  into  the  tissue  of  the  cord  itself;  he  found  there 
a  clot,  equalling  a  small  nut  in  volume,  which  had  interrupted  the  circulation  in 
the  umbilical  vessels  by  its  pressure. 

Lastly,  the  diseases  of  the  membranes,  and  of  the  umbilical  vesicle,  also  prove 
a  frequent  cause  of  abortion,  especially  in  the  early  stages  of  embryonic  life ;  for 
in  more  than  two  hundred  products  of  conception,  that  had  not  passed  beyond 
the  third  month,  M.  Velpeau  generally  found  an  alteration  of  some  part  of  the 
ovum. 

§  3.  Diseases  of  the  Womb  and  its  Appendages. 

The  causes  dependent  on  the  uterus  are  referable  either  to  a  particular  state  of 
that  organ,  or  to  a  peculiar  habit  of  the  body,  the  influence  of  which  is  reflected 
back  on  the  womb.  The  following  are  given  as  causes  of  abortion  dependent  on 
this  source  :  An  excessive  rigidity  of  the  uterine  fibres,  and  their  consequent 
resistance  to  dilatation ;  an  unusual  contractility  and  sensibility  of  the  organ, 
and  too  great  a  laxity  and  weakness  in  the  uterine  neck.  I  willingly  admit  that, 
in  certain  females,  the  excessive  sensibility  of  the  uterine  fibre  will  scarcely  sup- 
port, without  reaction,  the  strange  modifications  it  must  undergo  during  gestation ; 
but,  I  do  not  equally  comprehend  that  species  of  opposition,  which  some  authors 
seem  desirous  of  establishing,  between  the  resistance  on  the  part  of  the  uterine 
walls  and  the  expansive  force  of  the  ovum.  What,  indeed,  can  an  ovule,  a  few 
lines  in  diameter,  effect  against  the  thick  walls  of  the  womb  ?  or,  what  action 
can  it  possibly  have  on  the  uterine  neck,  that  will  explain  the  influence  which 
has  been  accorded  to  this  pretended  laxity  of  the  cervix,  on  the  frequency  of 
abortions  ?  The  truth  is,  the  ovum  and  uterus  are  developed  simultaneously, 
but  by  forces  peculiar  to  each.  Therefore,  although  abortions  are  more  frequent 
in  primiparae,  where  the  females  have  been  married  too  young  or  too  old ;  and, 
although  certain  women  abort  in  all  their  pregnancies  at  nearly  the  same  period, 
we  must  not  on  that  account  attribute  these  accidents  to  too  great  a  resistance  of 
the  body,  or  to  an  extreme  laxity  of  the  neck ;  for  these  repeated  miscarriages, 


334  GENERATION. 

■when  not  owing  to  the  hemorrhagic  tendency  before  alluded  to,  are  far  more 
naturally  explained  by  the  excessive  irritability  of  the  womb.  The  organ  has  to 
habituate  itself,  as  it  were,  to  its  new  functions ;  a  proof  of  which  is,  that,  in 
many  females,  the  accident  is  repeated  a  number  of  times,  but  each  time  at  a 
more  advanced  period ;  so  that,  about  the  fourth  or  fifth  pregnancy,  they  go  on 
till  full  terra.  Hence,  those  uterine  congestions,  which  are  so  often  produced  in 
plethoric  women  by  the  menstrual  periodicity,  and  that  excess  of  sensibility  as 
well  as  of  irritability  observed  in  nervous  females,  are  the  only  two  predisposing 
causes  that  I  consider  as  belonging  to  the  uterus  proper,  and  even  they  are  mere 
exaggerations,  as  will  be  seen,  of  the  physiological  condition.  Where  abortions 
are  often  produced  by  the  influence  of  either  of  these,  they  are  designated  as 
periodical. 

But,  independently  of  these  two  causes,  we  must  evidently  take  into  account 
all  the  diseases  of  the  uterus,  whether  acute  or  chronic,  whose  action  is  discerni- 
ble ;  thus,  the  various  tumors  which  may  grow  in  the  substance  of  its  walls,  or 
may  contract  adhesions  with  them  and  the  foreign  bodies  developed  in  its  cavity, 
also  ulcerations,  whether  syphilitic  or  otherwise,'  which  are  so  frequently  found 
upon  the  cervix,  are  so  many  predisposing  causes,  which  may  both  hinder  and 
oppose  its  free  enlargement ;  and  lastly,  let  us  add  the  various  displacements  of 
the  uterus,  such  as  prolapsus,  lateral  obliquities,  or  anteversion  and  retroversion, 
as  acting  in  the  same  manner. 

On  the  part  of  the  appendages,  all  the  chronic  diseases  to  which  they  are 
subject;  the  adhesions,  deformities,  displacements,  and  their  divers  degenera- 
tions; the  organic  alterations  of  the  tubes,  fibrous,  polypous,  or  other  productions 
seated  in  the  uterine  tissue  or  neighboring  parts ;  unnatural  adhesions  of  the 
broad  or  the  round  ligaments,  tubes,  or  ovaries ;  in  a  word,  everything  that  can 
impede  the  easy  and  free  development  of  the  womb,  must  be  regarded  as  occa- 
sional causes  of  abortion.  (3Iadame  Boivin,  Reclicrches  sur  unc  cause  peu  connue 
d'avortenient.) 

Finally,  an  inflammation  of  the  adjacent  organs,  particularly  the  bladder, 
rectum,  &c.,  may,  through  the  irritation  thereby  communicated  to  the  uterus, 
bring  on  its  contractions.  Moreover,  the  existence  of  any  voluminous  tumor  in 
the  abdomen  must  necessarily  incommode  the  development  of  this  organ  ;  also  the 
compression  of  the  hypogastrium,  that  some  women  produce  by  the  use  of  corsets, 
may  have  the  same  effbct. 

According  to  Peu,  we  must  add  to  these  various  sources  of  inconvenience, 
contraction  of  the  pelvis  opposing  the  distension  of  the  womb,  and  sometimes  its 
elevation  above  the  superior  strait ;  more  especially  when  the  narrowness  of  the 
latter  coincides  with  the  regular,  or  even  an  increased  size  of  the  excavation. 

4.  Besides  the  causes  just  enumerated,  that  have  been  designated  by  most 
writers  as  the  predisposing  ones,  but  which,  perhaps,  would  be  more  appropriately 
called  slow-acting  causes,  there  are  yet  some  others  that  might  be  termed  acci- 
dental causes ;  such  as  those  which  operate  from  without,  and  make  their  influ- 

'  See  the  following  chapter,  in  which  the  effect  of  these  ulcerations  upon  the  progress  of 
gestation  is  studied. 


OF    ABORTION.  335 

ence  more  promptly  felt.  The  latter  are  very  numerous ;  indeed,  on  reading  the 
published  cases,  we  find  that  authors  have  considered  all  the  moral  and  physical 
excitements  that  women  are  subject  to,  as  so  many  causes  of  abortion.  In  most 
of  the  recorded  instances,  we  can  readily  satisfy  ourselves  that  the  observers  have 
attached  too  much  importance  to  these  occasional  causes  of  its  production ;  for, 
generally  speaking,  it  would  have  occurred  without  them,  only,  perhaps,  a  little 
later;  and  even  here  the  expulsion  of  the  foetus  is,  in  truth,  owing  to  the  slow 
and  gradual  action  of  the  predisposing  cause.  However,  there  are  some  acci- 
dental causes  whose  influence  is  indisputable.  For  instance,  falls,  excessive 
fatigue,  too  frequent  coition,  and  severe  contusions,  have,  in  some  instances,  pro- 
duced immediately  a  loss  of  blood,  followed  by  abortion. 

Falls  and  contusions  may  act  in  two  ways;  either  by  bruising  or  violently  irri- 
tating the  mother's  organs,  or  by  wounding  the  foetus,  and  determining  its  death. 
The  latter  has  been  denied  by  some  persons ;  but  to  the  instances  now  known  to 
science,  I  will  add  the  following  from  my  own  observation.  A  young  woman,  six 
months  pregnant,  struck  her  abdomen  violently  against  a  table  while  walking  in 
the  dark  in  her  chamber;  during  the  night,  the  motions  of  the  child  were  for  a 
time  quite  tumultuous,  then  they  diminished,  and  on  the  following  morning 
could  not  be  perceived  at  all.  Two  days  afterwards  she  was  delivered  of  a  dead 
child,  which  presented  an  ecchymosis  on  its  back  as  large  as  the  palm  of  my 
hand. 

Burdach  speaks  of  a  woman  who  received  a  blow  upon  the  lower  part  of  the 
abdomen,  when  in  the  sixth  month  of  her  pregnancy,  and  who  was  delivered  of 
a  child  the  bones  of  one  of  whose  legs  and  of  a  forearm  had  been  fractured,  and 
united  at  an  acute  angle. 

I  shall  not  enumerate  here  the  various  circumstances  that  have  been  considered 
as  occasional  causes ;  but,  by  way  of  showing  how  their  importance  has  been 
overrated,  I  will  merely  remark  that,  although  certain  women,  who  are  constitu- 
tionally predisposed  to  miscarriages,  may  abort  in  consequence  of  a  trifling  fright, 
or  the  odor  of  a  badly-snuflfed  candle,  yet  there  are  others,  on  the  contrary,  who 
will  sufi'er  the  most  acute  moral  impressions,  and  the  most  violent  physical  shocks, 
without  any  accident  whatever  resulting  therefrom ;  and  nothing  would  be  more 
easy  than  to  bring  foi'ward  numbers  of  cases  in  support  of  this  proposition ;  the 
following,  however,  may  be  sufllcient :  I  had  an  opportunity  of  observing,  at  the 
Hotel  Dieu,  when  acting  as  an  ''interne"  in  the  obstetrical  wards,  a  young  girl 
in  the  fifth  month  of  pregnancy,  who,  being  rendered  desperate  by  the  desertion 
of  her  lover,  cast  herself  into  the  Seine,  from  the  Pont  Neuf,  yet,  notwithstand- 
ing so  violent  a  shock,  the  gestation  pursued  its  regular  course.  Again,  M. 
Gendrin  speaks  of  a  young  lady  who  was  thrown  from  a  chaise  over  the  horse's 
head  by  the  animal  falling  in  his  career.  This  lady  was  then  five  months  preg- 
nant, but  the  accident  did  not  prevent  her  from  reaching  her  full  term. 

I  was  consulted,  in  Sept.  1845,  by  a  young  lady,  who  was  evidently  six  or 
seven  months  advanced.  Her  physician  had  suspected  an  inflammatory  engorge- 
ment of  the  womb,  and  during  the  third  or  the  fourth  month  this  gentleman  had 
applied  fifteen  leeches  on  the  neck  of  the  uterus  itself;  and,  strange  to  say,  not 


GENERATION. 

only  was  this  application  unattended  by  any  accident,  but  the  patient  seemed 
relieved  of  the  distress  and  pain  in  the  hypogastrium.  And,  lastly,  is  it  neces- 
sary to  refer  here  to  all  the  manipulations,  and  all  the  violent  remedies,  that 
some  distracted  women  make  use  of  in  vain  to  procure  an  abortion  ? 

5.  The  third  order  of  causes  still  remaining  for  our  examination,  are  the  means 
of  producing  abortion.  These  must  be  distinguished  according  to  the  proposed 
object;  that  is,  whether,  in  producing  an  abortion,  the  indication  be  to  relieve 
the  woman  as  well  as  the  infant,  if  the  latter  is  well  developed,  from  the  dangers 
that  threaten  them  (and  we  shall  treat  of  the  means  to  be  employed  in  such  cases 
when  we  speak  of  the  indications  presented  by  the  mother's  vices  of  conforma- 
tion), or  whether,  contrary  to  all  the  laws  of  morality,  the  design  is  to  destroy 
the  foetus  in  the  body  of  its  mother,  for  the  sole  purpose  of  concealing  the  traces 
of  an  illegitimate  pregnancy.  But  we  have  nothing  whatever  to  say  concerning 
the  measures  resorted  to  by  criminal  hands  in  such  cases,  for,  unfortunately,  they 
are  too  well  known. 

ARTICLE   11. 

SYMPTOMS    OF   ABORTION. 

The  signs  of  abortion  vary  with  the  period  of  its  occurrence,  and  also  with  its 
determining  cause.  Thus,  when  it  happens  in  the  early  days  of  gestation,  it  is 
att»nded  by  but  very  few  remarkable  phenomena;  and,  in  general,  the  pain  is  so 
trifling  that  the  patient  scarcely  suffers  more  than  from  a  difficult  menstruation. 
The  first  uterine  contraction  are  sufficient  to  produce  the  complete  separation  of 
the  ovum,  the  adhesions  of  which  are  still  very  feeble;  and  it  escapes  either  in 
mass  or  in  shreds,  usually  surrounded  by  fluid  or  half-coagulated  blood,  and, 
being  mistaken  for  a  clot,  it  often  passes  away  unnoticed,  most  women  then  sup- 
posing that  they  have  only  had  a  slight  postponement  of  their  menses,  followed 
by  a  more  difficult  and  abundant  flow  than  usual. 

At  a  more  advanced  stage,  the  symptoms  are  much  better  marked,  but  still 
vary  with  the  cause  of  the  abortion.  For  instance,  when  this  accident  has  been 
produced  under  the  influence  of  bad  health  in  the  mother,  or  of  chronic  dis- 
eases, or  those  causes  that  operate  slowly,  by  altering  the  genital  organs,  or  the 
ovum  and  its  membranes,  the  following  symptoms  are  ordinarily  observed, 
namely :  shiverings  succeeded  by  heat,  anorexia,  nausea,  thirst,  spontaneous  lassi- 
tude, palpitations,  cold  extremities,  pallor,  sadness,  depression  of  spirits,  tume- 
faction and  lividity  of  the  eyelids,  want  of  brilliancy  in  the  eyes,  a  sense  of 
sinking  at  the  epigastrium,  of  cold  about  the  pubis,  of  weight  near  the  anus  and 
vulva,  pain  in  the  loins,  vesical  tenesmus,  frequent  ineffectual  desires  to  urinate, 
and  a  weakness  and  flaccidity  of  the  breasts,  from  which  a  serous  fluid  sometimes 
exudes.  These  phenomena  may  be  considered  as  the  precursors  of  an  abortion ; 
for,  when  they  have  lasted  for  some  time,  the  pains  in  the  loins  become  more  and 
more  acute,  extend  round  to  the  hypogastrium,  and  are  renewed  at  short  inter- 
vals, finally  assuming  all  the  characteristics  of  the  regular  uterine  contractions. 
During  these  pains,  if  the  uterus  is  sufficiently  high  up  to  be  easily  distinguished 


OF    ABORTION.  337 

above  the  pubis,  it  will  be  felt  to  harden  sensibly,  whilst  at  the  same  time  a 
sanious  discharge  takes  place  from  the  vagina,  afterwards  becoming  sanguinolent, 
and  eventually  replaced  by  liquid  or  grumous  blood.  If  the  woman  be  then 
examined  per  vaginam,  the  neck  will  be  found  partly  dilated,  the  dilatation 
advancing  progressively  with  the  frequency  of  the  pains  ;  the  membranes  begin 
to  protrude,  then  engage,  and  ultimately  rupture ;  the  waters  escape,  and  the 
foetus  and  placenta  are  successively  expelled.  Usually  in  those  cases  in  which  the 
cause  has  operated  slowly,  whether  dependent  on  diseases  of  the  mother  or  affec- 
tions of  the  ovum,  the  foetus  dies  before  the  labor,  or  at  least  during  the  first  pains. 

When  the  abortion  is  a  consequence  of  the  occasional  violent  causes,  it  usually 
has  quite  another  coui"se.  Thus,,  in  some  instances,  the  expulsion  of  the  ovum 
closely  follows  the  accident ;  a  woman  slips  in  descending  a  staircase,  and  falls 
violently  on  her  seat ;  when  she  rises,  her  clothes  are  flooded  with  blood,  for  an 
ovum  of  six  weeks  has  been  driven  out,  together  with  a  large  quantity  of  fluid 
blood.  This,  however,  is  more  apt  to  occur  in  the  beginning  of  pregnancy;  for, 
at  a  more  advanced  period,  some  interval  always  elapses  between  the  accident 
and  the  consequent  abortion.  The  phenomena  then  observed  vary,  according  to 
whether  the  cause  has  affected  the  mother's  organs,  or  has  directly  influenced  the 
foetus  itself. 

In  the  former  case,  the  mother  experiences,  at  the  time  of  the  accident,  a  sharp 
pain,  either  about  the  loins,  or  else  in  some  part  of  the  abdomen ;  after  the  lapse 
of  a  few  days,  during  which  the  pain  has  diminished,  or  even  entirely  ceased,  it 
is  violently  renewed,  and  followed  almost  immediately  by  uterine  pains  and  con- 
tractions, a  slight  dilatation  of  the  neck,  some  discharges  of  serosity  from  the 
vagina,  at  first  reddish,  then  sanguinolent,  and  lastly  pure  blood. 

Finally,  if  the  travail  continue,  the  foetus  is  expelled  as  usual,  and  often  living. 

The  expulsion  is  almost  always  effected  very  slowly,  and  the  progress  of  the 
labor  is  far  from  being  as  regular  as  at  term.  The  resistance  occasioned  by  the 
length  and  hardness  of  the  cervix  at  this  period  sufliciently  explain  the  extreme 
slowness  of  its  dilatation,  and  even  when  the  latter  is  sufficient,  the  contractile 
powers  of  the  uterus  are  yet  so  feeble  that  the  ovum  may  remain  engaged  in  the 
orifice  for  several  days,  and  even  project  into  the  upper  part  of  the  vagina,  before 
being  expelled  completely. 

When  the  cause  has  acted  directly  upon  the  foetus,  either  mechanically,  as  by 
a  violent  blow  or  concussion,  or  physiologically,  by  destroying  to  a  greater  or  less 
extent  its  vascular  connections  with  the  uterus,  the  subsequent  course  of  affairs 
is  different,  for  here  the  phenomena  which  announce  the  death  of  the  product  of 
conception  are  the  first  to  be  manifested.  After  the  few  hours  necessary  to  dissi- 
pate the  agitation  and  fears  caused  by  the  commotion  she  has  experienced,  the 
woman  ♦feels  no  pain  nor  inconvenience ;  everything  is  calm,  and  seems  to  resume 
its  natural  order;  but,  after  the  lapse  of  a  few  days,  sometimes  only  eight  or  ten, 
the  movements  of  the  foctu?,  which  had  up  to  this  time  maintained  their  usual 
force  and  frequency,  become  weaker,  are  separated  by  longer  intervals,  and  finally 
become  imperceptible.  From  this  moment,  the  uncomfortable  sensations  and 
digestive  disorders,  which  had  annoyed  the  patient  from  the  outset  of  pregnancy, 

22 


338  GENERATION. 

disappear  as  though  by  magic ;  the  swelling  of  the  breasts  and  prickling  sensa- 
tions which  had  affected  them,  also  diminish  or  cease  entirely.  A  miscarriage  is 
then  inevitable,  for  the  ovum  is  a  foreign  body  in  the  uterine  cavity,  and  soon 
irritates  the  walls  of  the  organ  by  its  presence ;  the  latter  contracts,  and  the 
expulsion  is  generally  effected  about  eight  to  nine  days  after  the  accident.  In 
this  case,  the  process  advances  in  a  more  regular  manner,  because  the  womb  has 
had  time  to  prepare  itself  for  the  act.  However,  this  term  is  not  uniform,  it 
being  not  at  all  uncommon  for  the  dead  foetus  to  remain  much  longer  in  the 
womb ;  two  or  three  weeks,  or  a  month,  for  example.  I  saw  a  woman  at  La 
Clinique,  in  whom  the  child's  death  was  clearly  ascertained,  though  she  did  not 
abort  until  sis  weeks  afterwards.  Cases  are  also  recorded  of  the  embrj-o  remain- 
ing in  the  womb  until  the  ninth  month. 

The  development  of  the  contractions  is  solicited  by  the  derangement  which 
this  condition  of  death  gradually  produces  in  the  placental  circulation ;  indeed, 
the  quantity  of  blood  arriving  in  the  placenta  often  diminishes  by  degrees,  and 
ultimately  becomes  almost  null ;  but  this  is  not  always  the  case,  since,  in  some 
instances,  the  circulation  continues,  and  the  placenta  enlarges, — attains  even  to 
double  the  volume  of  that  at  term,  and  after  its  expulsion  exhibits  the  same  de- 
gree of  integrity.  Lastly,  in  other  cases,  says  M.  Guillemot,  the  placenta  retains 
its  vitality  and  grows;  but,  at  the  same  time,  assumes  unusual  forms,  and  a  sin- 
gular structure,  exhibiting  a  cavity  in  which  remains  of  the  foetus  are  hardly  to 
be  found. 

Where  a  long  time  thus  ensues  between  the  period  of  the  child's  death  and 
that  of  its  expulsion,  there. is,  in  general,  less  danger  from  hemorrhage  than  if  the 
premature  labor  had  taken  place  immediately.  In  these  abortions,  less  blood  is 
usually  lost  than  in  the  labors  which  come  on  naturally,  after  the  most  favorable 
gestations ;  which  is  probably  owing  to  the  fact  that  the  child's  death  diminishes 
the  activity  of  the  uterine  circulation,  especially  that  of  the  utero-placental  ves- 
sels, which  must  then  become  obliterated  in  a  great  measure,  and  consequently 
can  furnish  but  little  blood  at  the  time  when  the  placenta  is  separated. 

Further,  the  general  phenomena  experienced  by  the  mother  after  the  death  of 
the  foetus  are  very  singular  in  these  cases.  If  the  gestation  is  somewhat  advanced, 
everything  passes  off  absolutely  as  if  the  expulsion  of  the  embryo  had  occurred, 
only  excepting  the  discharge  of  the  lochia;  thus,  in  the  course  of  forty-eight  to 
sixty  hours  after  its  death,  the  breasts  swell  up,  the  phenomena  of  milk  fever  are 
manifested,  and  the  lacteal  secretion  is  fully  established,  after  which  the  breasts 
again  subside,  and  the  usual  order  is  resumed.  As  a  general  rule,  the  prolonged 
retention  of  a  dead  infant  does  not  produce  any  disastrous  result  to  the  mother, 
and  I  suspect  that  writers  have  greatly  exaggerated  on  this  point ;  they  say, 
indeed,  that  the  woman  becomes  depressed,  uneasy,  and  of  a  fretful  temper;  that 
she  experiences  lassitude,  alternations  of  heat  and  cold,  oppression  at  the  epigas- 
trium, headache,  syncope,  palpitations  of  the  heart;  her  face  is  pale,  the  eyes 
dull  and  surrounded  by  a  livid  circle,  the  breath  fetid,  pulse  frequent  and  irregu- 
lar; in  a  word,  all  these  general  phenomena  of  a  slow  fever  have  been  considered 
by  them  as  so  many  rational  signs  of  the  child's  death.     But  these  symptoms  are 


OF    ABORTION.  339 

certainly  absent  in  the  majority  of  cases ;  for  most  women,  after  we  have  suc- 
ceeded in  cahning  their  fears,  experience  nothing  of  the  kind,  and  I  have  known 
many  of  them  to  carry  a  dead  child  for  several  months  without  even  suspecting 
it,  and  some  even  to  congratulate  themselves  upon  the  amelioration  of  their  gene- 
ral condition,  in  consequence  of  the  sudden  disappearance  of  the  sympathetic 
disorders  of  pregnancy.  At  an  indeterminate  period,  labor  comes  on,  and  the 
abortion  is  effected. 

By  examining  the  dead  foetus,  we  may  learn  why  its  prolonged  sojourn  in  the 
uterine  caA'ity  has  been  wholly  innoxious  to  the  mother.  In  fact,  the  infant  is 
not  putrefied,  as  is  proved  by  its  having  no  bad  odor;  the  solid  parts  undergo  a 
peculiar  transformation,  and  the  body  is  somewhat  analogous  in  appearance  to  one 
that  has  been  soaked  for  a  long  time  in  water.' 

'  A  child  putrefied  in  the  womb  presents  so  different  an  aspect  Trom  one  that  has  under- 
gone the  same  process  in  the  open  air,  that  it  is  only  necessary  to  observe  this  particular 
condition  once  or  twice,  never  to  mistake  it  afterwards. 

Imagine  the  little  defunct  stretched  on  a  table;  the  flaccidity  of  its  soft  parts  is  then  so 
very  striking,  that  the  head  becomes  flattened  under  the  influence  of  its  own  weight,  what- 
ever position  may  be  given  to  it;  the  soft  parts  on  the  thorax  exhibit  the  form  of  the  ribs; 
the  front  of  the  chest  is  very  much  flattened,  the  abdomen  sunken,  and  nearly  hollow  about 
the  navel,  and  forming  two  large  rounded  projections  on  the  flanks;  even  the  extremities 
exhibit  the  same  state  of  collapse.  The  discoloration  of  the  skin  is  particularly  remarkable, 
although  often  confined  to  the  abdomen,  at  least  when  the  sojourn  of  the  foetus  in  the  womb 
has  not  been  very  long.  The  skin  of  this  part  has  a  brownish-red  shade,  without  the  least 
appearance  of  a  greenish  hue.  This  tint  is  less  marked  on  the  chest,  neck,  head,  and  limbs  • 
nevertheless,  it  exists  there  also.  But  this  is  not  the  brownish  hue  that  often  succeeds  a 
green  putrefaction  ;  it  is  a  much  clearer  reddish-brown.  The  cord  is  no  longer  twisted,  but 
it  forms  a  true  fleshy  cylinder,  of  a  reddish  color,  soft,  and  saturated  with  a  brown  fluid. 
The  epidermis  is  detached  from  a  considerable  part  of  the  surface,  and  may  be  easily  sepa- 
rated from  those  places  where  it  is  still  adherent,  thus  leaving  the  humid  dermis  exposed 
which  is  as  glutinous  as  if  it  were  lubricated  by  a  mucous  fluid;  and  then  the  true  skin  has 
a  bright  rose  color.  The  epidermis  on  the  feet  and  hands  is  white  and  thick,  and  looks  as  if 
it  had  been  corrugated  by  cataplasms.  The  subcutaneous  cellular  tissue  is  infiltrated  with 
a  reddish  serosity,  which  is  also  seen  between  the  muscles,  and  sometimes  in  the  substance 
of  the  muscular  tissue  itself.  The  bones  of  the  head  are  feebly  held  together,  their  perios- 
teum may  be  readily  detached,  and  they  are  movable  on  each  other.  The  cellular  tissue 
underneath  the  hairy  scalp  is  infihrated  with  a  thick  serosity,  resembling  currant  jelly  in 
appearance.  Finally,  whenever  we  attempt  to  move  or  raise  the  fa-tus,  it  slips  through  the 
hands  just  like  a  fish  that  lives  for  some  time  out  of  water,  in  consequence  of  the  fluid  muci:s 
covering  its  surface.     (Devergie,  Med.  Legale) 

This  description,  although  perfectly  accurate  as  regards  the  fcetus  that  dieset  an  advanced 
stage,  does  not  equally  apply  when  the  death  happens  in  the  earlier  months.  For,  according  to 
the  judicious  remark  of  M.  Martin,  of  Lyons,  the  mode  of  alteration  varies  with  the  period 
of  pregnancy  at  which  the  child  dies.  Thus,  in  the  early  stage  of  its  formation,  when  its 
organization  has  but  little  consistence,  and  approaches  the  mucilaginous  state,  it  dissolves  in 
the  waters  of  the  amnios,  which  then  become  thicker  and  assume  the  characters  of  a  gummy 
solution,  and  no  further  trace  of  the  embryo  is  found  in  the  amniotic  cavity.  But,  at  a  period 
somewhat  later,  that  is,  from  the  second  to  the  fifth  month,  it  withers  away,  becomes  shri- 
veled and  dried  up,  and  looks  like  a  little  mummy  of  a  yellow  color,  or  like  a  fojtus  preserved 
for  a  long  lime  in  alcohol.  Not  unfrequently,  the  placenta  likewise  participates  in  this  state 
of  de.-^iccation,  the  liquor  amnii  disappearing  and  being  replaced  by  a  thick  and  apparently 
an  earthy  humor,  wliicli  incrusts  the  foetus.     {Memoires  de  Med.  et  de  Chir.  Prat.,  page  96.) 


340  GENERATION. 

But  it  happens  otherwise  when,  the  foetus  being  dead,  the  membranes  are  rup- 
tured, and  the  expulsion  is  delayed ;  for  then,  a  rapid  putrefaction  sets  in,  as  a 
consequence  of  the  contact  of  the  child  with  the  external  air.  A  high  fever, 
characterized  by  the  symptoms  of  a  veritable  infection,  developes  itself;  a  dark 
fetid  liquid  oozes  from  the  genital  parts,  mixed  with  shreds,  in  a  state  of  putre- 
faction; and  if  the  uterine  contractions  do  not  speedily  relieve  the  organism  from 
this  source  of  infection,  the  patient  may  rapidly  succumb  under  its  deleterious 
influence.  Finally,  when  the  abortion  is  brought  on  by  the  existence  of  two 
children,  the  twins  are  nearly  always  expelled  simultaneously ;  although  we  have 
occasionally  known  the  woman  to  abort  of  one  child  in  a  multiple  pregnancy, 
whilst  the  other  continued  to  crow. 


ARTICLE   III. 

DIAGNOSIS. 

Judging  from  the  numerous  signs  just  given,  the  diagnosis  of  an  abortion 
ought  to  be  very  easy ;  but,  unfortunately,  these  signs  are  not  very  clearly  marked 
until  the  accident  is  inevitable,  and,  consequently,  when  it  is  a  matter  of  indif- 
ference to  the  patient  whether  the  physician  makes  out  a  clear  diagnosis  or  not. 

It  is,  therefore,  in  the  beginning  of  such  symptoms,  especially,  that  we  should 
endeavor  to  recognize  their  true  nature,  because  then  only  can  our  art  succeed  in 
arresting  their  progress ;  but  this  is  exceedingly  difficult. 

The  diagnosis  of  abortion  involves  the  solution  of  several  questions.  Is  the 
woman  pregnant?  And,  supposing  the  pregnancy  to  be  determined,  are  the 
symptoms  those  of  a  simple  uterine  congestion,  or  of  a  commencing  abortion  ? 
Lastly,  is  the  abortion  inevitable  ? 

1.  Is  the  Wo7nan  Prejnant? — This  first  question  is  quite  readily  resolved 
after  the  fourth  month  of  gestation,  though  before  that  period  it  is  almost  always 
unanswerable.  All  practitioners  of  obstetrical  experience  are  aware  of  the  diffi- 
culties which  often  involve  it.  Thus,  a  woman  in  good  health  has  her  courses 
suddenly  suppressed  for  several  months  without  any  appreciable  cause,  the  breasts 
swell,  and  the  body  increases  in  size ;  in  a  word,  she  experiences  several  of  the 
phenomena  properly  regarded  as  rational  signs  of  pregnancy  j  then,  all  at  once, 
at  the  return  of  the  third  or  fourth  menstrual  period,  some  symptoms  of  conges- 
tion of  the  uterus  appear,  last  for  several  days,  and  are  soon  followed  by  a  slight 
flow  of  blood.  How,  then,  shall  we  determine  whether  the  pains  felt  by  the 
patient,  and  the  discharge  of  blood  from  the  vulva,  are  owing  to  a  return  of  the 
interrupted  menses,  or  to  an  approaching  abortion  ?  The  pains  attendant  on 
difficult  menstruation,  especially  after  a  suspension  of  several  months,  resemble 
greatly,  both  in  situation  and  intermittence,  those  of  abortion.  According  to 
Madame  Lachapelle,  in  abortion,  the  uterine  orifice  is  open,  the  hemorrhage 
precedes  the  pains,  and  the  latter  persist  notwithstanding  the  abundance  of  the 
discharge ;  whilst  in  difficult  menstruation  the  orifice  is  closed,  the  pains  are  felt 


OF    ABORTION.  341 

before  the  hemorrhage  appears,  and  they  diminish  or  even  cease  entirely  when 
the  discharge  is  well  established.    The  contrary,  however,  not  unfrequently  occurs. 

Doubtless,  a  strict  investigation  of  the  circumstances  which  accompanied  and 
followed  the  suppression  of  the  menses,  and  an  examination  of  the  uterus,  might 
lead  to  an  opinion  as  to  the  probable  state  of  the  case ;  but  what  experienced 
physician  does  not  know  how  deceptive  are  all  these  rational  signs,  when  we  take 
in  consideration  the  tendency  to  exaggerations  of  the  females,  who  so  readily 
believe  what  they  wish  or  what  they  fear,  as  also  how  nearly  the  congestion 
which  precedes  and  accompanies  the  suspended  menstruation,  places  the  uterus 
in  the  same  physical  conditions  as  in  a  commencing  pregnancy  ? 

Does  the  blood  escape  from  the  genital  parts  as  a  clot  ?  It  has  been  hoped 
that  the  shape  of  the  latter  might  furnish  a  reliable  sign. 

It  has  been  stated,  that  the  clot  driven  from  the  unimpregnated  womb  exhibits 
a  triangular  form,  corresponding  to  that  of  the  cavity  where  the  blood  coagulated, 
which  never  happens  when  a  product  of  conception  is  present ;  but  this  may  fail, 
as  the  clot  is  mostly  changed  in  its  shape  by  traversing  the  neck ;  and,  on  the 
other  hand,  in  abortion,  the  blood  may  collect  and  coagulate  in  the  vagina,  and 
the  coagulum  exhibit  the  indicated  character. 

But,  if  the  coagulum  be  still  in  the  cervix  uteri,  and  supposing  the  finger  is 
able  to  reach  this  point,  how  can  we  distinguish  whether  the  foreign  body  felt 
there  is  a  clot  or  an  ovum  ?  For  this  purpose,  HoU  has  laid  down  the  following- 
signs  :  If  the  finger  introduced  into  the  orifice  perceives  the  mass  to  become 
tense  during  the  contraction,  to  augment  in  volume  and  advance  towards  the 
vulva,  it  is  an  ovum  engaged  in  the  os  uteri ;  and  if  it  were  a  clot,  it  might  be 
recognized  by  its  fibrinous  structure ;  besides,  during  the  pain,  its  exterior  sur- 
face would  not  be  more  tense,  nor  more  smooth,  and  it  would  not  appear  forced 
down,  but  rather  compressed ;  finally,  as  the  ovum  resembles  a  soft  bladder,  its 
inferior  extremity  is  rather  rounded  than  pointed,  while  the  coagulated  mass  is 
more  resistant  and  solid,  is  less  compressible,  and  has,  in  general,  the  form  of  a 
cone,  the  enlarged  extremity  of  which  is  above  and  the  apex  below. 

Finally,  if  we  should  then  attempt  to  move  the  uterus  in  its  totality  by  press- 
ing on  this  mass,  it  might  be  easily  effected  if  there  were  a  clot  concerned,  whilst 
the  parictes  of  the  ovum  would  yield,  and  would  not  transmit  the  motion  to  the 
organ  which  envelopes  it,  and  with  which  it  is  then  but  feebly  adherent. 

The  question  is  therefore  by  no  means  simple,  yet  it  is  important  to  know 
whether  pregnancy  really  exists,  for  as  the  appearance  of  the  menses  is  then  of 
very  rare  occurrence,  especially  when  they  are  absent  in  the  early  months,  a  flow 
of  blood  should  be  treated  as  a  serious  accident,  which,  on  the  contrary,  would 
be  promoted,  if  attributable  to  a  return  of  the  courses.  Notwithstanding  these 
uncertainties,  there  may  be  a  union  of  circumstances,  such  as  to  allow  of  at  least 
a  probable  diagnosis.  Thus,  if  a  woman  who  has  been  habitually  regular,  finds 
her  catamenia  to  stop  suddenly  and  unaccountably;  if  this  suppression  is  followed 
by  other  rational  signs  of  pregnancy ;  if  the  pains  continue  notwithstanding  the 
discharge  of  blood ;  if  they  appear  as  an  effect  of  any  violence  whatsoever,  or  if 
they  present  anything  unusual  as  respects  either  intensity  or  duration,  it  may  be 


342  GENERATION. 

concluded  that  abortion  is  imminent.  The  diagnosis  becomes  more  certain  if  the 
blood  flows  more  profusely  than  in  ordinary  menstruation,  if  it  is  accompanied 
with  sharper  pains  in  the  hypogastrium  than  is  usual,  if  coagula  are  expelled,  and 
if  the  orifice  is  sufficiently  dilated  to  admit  the  extremity  of  the  finger. 

2.  Pregnancy  existing,  may  the  symptoms  be  attributed  to  simple  congestion 
of  the  uterus,  or  should  they  be  regarded  as  the  first  tokens  of  a  threatened  abor- 
tion ?  Though  it  is  very  difficult  to  decide  this  question  within  the  first  three  or 
four  months,  and  at  the  beginning  of  the  accident,  its  solution  is  happily  of  little 
importance  as  regards  the  treatment,  the  measures  indicated  by  simple  conges- 
tion being  equally  applicable  to  the  prevention  of  miscarriage. 

When  symptoms,  which  in  all  appearance  were  due  to  simple  congestion,  have 
yielded  to  proper  treatment,  the  physician  is  often  required  to  answer  a  question 
whose  rigorous  solution  is  always  impossible,  namely,  the  abdominal  and  lumbar 
pains  being  allayed,  and  all  the  other  alarming  symptoms  removed,  is  the  patient 
therefore  out  of  danger  of  miscarriage  ?  In  the  majority  of  cases,  we  can  tell 
nothing  about  it,  for  it  is  impossible  to  know  whether  the  congestion  has  been 
arrested  in  time  to  prevent  a  rupture  of  bloodvessels,  and  an  effusion  between  the 
placenta  and  uterus,  or  whether  the  separation  of  the  placenta  is  extensive  enough 
to  have  destroyed  the  foetus  immediately;  even  supposing  the  child  to  be  still 
living,  we  cannot  ascertain  the  degree  of  separation  of  the  placenta,  nor  foresee 
the  efi"ect  which  a  partial  destruction  of  its  maternal  attachments  may  have  upon 
the  foetus.  Very  frequently,  indeed,  the  latter,  by  being  cut  off  from  a  conside- 
rable part  of  its  means  of  respiration,  is  placed  in  the  condition  of  an  adult  whose 
lungs  are  in  great  measure  destroyed,  and  whose  respiration  and  nutrition  being 
insufficient,  gradually  wastes  away,  so  the  child  often  does  not  perish  until  after 
the  lapse  of  eight  days,  two  weeks,  and  frequently  even  not  until  the  next  men- 
strual period ;  this,  too,  without  the  appearance  of  any  new  symptom  to  explain 
its  unlooked-for  death.  The  physician  cannot  therefore  be  too  reserved  in  his 
diagnosis,  as  regards  the  possible  consequences  of  such  accidents. 

3.  Finally,  supposing  the  abortion  begun,  can  we  hope  to  arrest  the  symptoms  ? 
The  intensity  of  the  pains,  their  constant  direction  from  the  umbilicus  towards 
the  coccyx,  the  previous  duration  of  the  discharge,  and  the  amount  of  blood 
already  lost,  softening  and  dilatation  of  almost  the  entire  neck,  and  even  of  the 
internal  orifice,  and  projection  of  the  membranes  during  the  contraction,  doubt- 
less indicate  a  very  unfavorable  prognosis,  though  they  should  not  destroy  all  hope. 
All  these  symptoms  conjointly,  have  in  fact  been  known  to  yield  to  appropriate 
treatment,  everything  to  resume  the  natural  state,  and  the  pregnancy  to  go  on 
as  usual.  Some  authors,  even,  state  that  the  rupture  of  the  membranes  and 
discharge  of  the  amniotic  fluid,  does  not  render  abortion  inevitable.  This  last 
assertion,  however,  seems  to  me  to  be  at  least  very  contestable,  for  it  is  infinitely 
probable,  not  to  say  certain,  that  in  the  cases  alluded  to  there  has  been  a  mistake 
in  reference  to  the  true  origin  of  the  waters  lost  by  the  patient.  It  appears  to 
me  that  a  rupture  of  the  ovum  must  inevitably  give  rise  to  abortion;  and  Desor- 
meaux  has  certainly  confounded  cases  of  hydrorrhoea  with  the  true  discharge  of 
the  amniotic  fluid. 


OF    ABORTION.  343 

A  young  lady,  who  had  already  been  so  unfortunate  as  to  miscarry  in  her  first 
pregnancy,  to  be  delivered  of  a  dead  child  in  the  second,  and,  finally,  to  have 
lost  a  little  girl  of  six  months,  had  advanced  three  months  and  a  half  in  a  fourth 
pregnancy.  After  returning  from  mass,  in  a  church  very  near  her  dwelling, 
there  was  a  sudden  discharge  of  fluid  from  the  genital  organs,  to  an  amount 
estimated  by  the  patient  at  about  a  tumblerful.  On  first  seeing  her,  I  thought 
abortion  inevitable.  Then,  upon  a  careful  examination  of  the  uteras,  it  seemed 
to  me,  that  notwithstanding  the  loss  which  had  occurred,  the  organ  presented  its 
usual  size,  a  certain  elasticity,  a  peculiar  suppleness,  showing  that  some  fluid 
must  still  remain  within  the  amniotic  cavity;  there'was  nothing  peculiar  in  the 
state  of  the  cervix;  no  flow  of  blood;  neither  was  there  pain  before,  during,  or 
after  the  discharge  of  water.  In  acquainting  the  patient  with  the  fears  which  I 
entertained,  I  also  assured  her  that  all  hope  was  not  lost,  and  that  the  circum- 
stances just  mentioned  presented  collectively  features  which  do  not  usually  apper- 
tain to  ruptures  of  the  ovum  itself.  Absolute  quiet,  a  small  bleeding  from  the 
arm,  opiate  enemata,  and  hand-baths,  to  be  repeated  morning  and  evening,  were 
directed.  No  new  symptoms  supervened,  and  the  development  of  the  uterus 
continued.  For  the  first  two  days,  there  was  still  a  very  small  discharge  of  water. 
At  four  months  and  a  half,  and  also  without  appreciable  cause,  there  was  a  sud- 
den escape  of  five  or  sis  spoonfuls  of  a  fluid  similar  to  the  preceding.  After 
this,  nothing  of  the  kind  occurred  until  the  end  of  her  pregnancy,  which  termi- 
nated very  happily. 

Abortion  is  really  inevitable  only  when  the  foetus  has  ceased  to  live,  or  when 
the  separation  of  the  placenta  and  the  rupture  of  the  utero-placental  vessels  are 
so  extensive  that  the  remaining  utero-placental  attachments  are  unequal  to  the 
support  of  the  foetal  respiration. 

In  order  to  estimate  the  probable  degree  of  disturbance  of  the  utero-placental 
relations  which  has  taken  place,  much  more  regard  must  be  had  to  the  amount 
of  the  discharge,  than  to  its  duration.  A  simple  exudation,  or  a  moderate  flow 
of  blood,  may  continue  for  several  days  or  weeks,  since  it  may  originate  in  the 
rupture  of  very  few  vessels;  I  have  known  it  last  for  six  weeks  and  two  mouths, 
without  compromising  the  pregnancy ;  but  that  the  patient  should  lose  a  consi- 
derable amount  of  fluid  or  coagulated  blood  in  a  short  time,  the  placenta  must  be 
separated  to  a  considerable  extent,  and  abortion  almost  necessarily  ensues. 

There  is  still  another  peculiarity  not  mentioned  by  authors,  which  appears  to 
me  of  importance,  inasmuch  as  it  cuts  off"  almost  all  hope  of  arresting  the  pro- 
gress of  the  symptoms ;  I  allude  to  a  particular  form  of  the  neck.  When  the 
patient  has  been  for  a  short  time  only  pregnant,  we  know  that  it  is  always  easy  to 
distinguish  the  neck  of  the  uterus  from  its  body;  in  the  great  majority  of  cases, 
we  may  even  feel  the  angle  which  separates  them.  Now,  when  the  contractions 
have  lasted  for  a  certain  time,  they  have  gradually  dilated  the  internal  orifice ; 
the  cavity  of  the  neck  has  become  confounded  with  that  of  the  body,  and  when 
the  finger  in  the  vagina  is  passed  over  the  entire  lower  segment  of  the  uterus, 
the  neck  can  no  longer  be  distinguished  from  it ;  a  well-defined  limit  between 
them  is  no  more  to  be  detected,  and  all  that  belongs  to  the  neck  of  the  womb  has 


344  GENERATION. 

the  shape  of  a  pear,  the  larger  part  being  continuous  with  the  body  of  the  organ, 
and  the  lower  extremity  corresponding  with  the  external  orifice.  Whenever  I 
have  met  with  this  condition  of  things,  abortion  has  taken  place. 

It  is  impossible  to  ascertain  certainly  in  the  early  months,  whether  the  foetus 
be  living  or  dead.  I  must,  however,  mention  a  peculiarity  which  in  my  estima- 
tion is  of  great  value  in  reference  to  this  question,  namely,  the  sudden  cessation 
of  the  vomitings,  salivation,  or  any  other  sympathetic  functional  disorder  of 
pregnancy.  When,  after  an  accident,  vomiting  and  salivation  cease,  there  is 
cause  to  fear  that  the  child  is  dead,  the  persistence  of  these  discomforts  being  on 
the  contrary  a  favorable  sign.  Happily,  though  the  uncertainty  upon  this  point 
makes  an  exact  prognosis  impossible,  it  in  no  wise  affects  the  treatment.  When- 
ever, indeed,  a  collective  examination  of  the  general  and  local  symptoms  leads  to 
the  supposition  that  the  child  is  living,  and  that  we  may  hope  to  arrest  the  pro- 
gress of  the  accident,  we  should  act  as  though  we  were  certain. 

We  see,  therefore,  that  in  the  first  third  of  gestation  the  diagnosis,  at  the  best, 
can  be  only  probable. 

At  a  more  advanced  stage  of  gestation,  the  diagnosis  is  much  more  certain. 
First,  because  we  can  then  generally  ascertain  the  development  of  the  uterus 
without  difficulty;  then,  again,  pains  are  more  energetic;  the  blood  flows  in 
greater  abundance,  and  the  dilatation  of  the  os  uteri  is  more  easily  detected ;  but 
it  becomes  still  more  certain,  when  the  death  of  the  foetus  can  be  verified  in  a 
positive  manner.  Now,  the  following  are  the  signs  of  this  occurrence  :  1.  The 
abdomen  diminishes,  instead  of  increasing,  in  volume ;  2.  The  breasts  shrink 
away;  the  woman  experiences  dragging  sensations  about  her  loins,  and  an  unusual 
weight  in  the  hypogastrium,  as  of  an  inert  body,  which  falls  towards  the  side  on 
which  she  lies  from  the  mere  law  of  gravity;  3.  If  the  movements  of  the  infant 
had  before  been  perceptible,  they  now  cease  to  be  so;  4.  Lastly,  the  most  valuable 
evidence  is  that  furnished  by  auscultation,  for  an  impossibility  of  hearing  the 
sounds  of  the  foetal  heart  after  the  fifth  month  is  an  almost  certain  sign  of  the 
child's  death.  I  will  go  so  far  as  to  say,  that  it  is  the  only  one;  for  all  the  others 
may  be  observed,  and  yet  the  foetus  be  living.  Unfortunately,  the  pulsations  of 
the  heart  are  not,  generally,  perceptible  before  the  fourth  month  of  pregnancy. 

ARTICLE   IV. 

PROGNOSIS.  • 

The  prognosis  of  abortion  is  necessarily  variable,  according  to  the  time  of  its 
occurrence  and  the  cause  which  has  produced  it.  As  regards  the  foetus,  it  is 
always  mortal,  since  the  expulsion  takes  place  before  the  product  of  conception 
is  fitted  for  an  extra-uterine  life,  though  I  am  well  aware  that  cases  are  reported 
of  children,  born  prior  to  the  period  of  viability  fixed  by  law,  which  have  lived ; 
but  these  examples,  even  were  they  authentic,  are  too  rare  to  invalidate  the 
general  proposition  just  laid  down. 

As  regards  the  mother,  the  prognosis  is  said  to  be  more  grave  than  that  of 


OF    ABORTION.  345 

labor  at  term,  but  this  proposition,  which  has  been  advocated  since  the  days  of 
Hippocrates,  requires  explanation,  and  should  not  be  received  without  some  re- 
striction ;  for  the  prognosis,  considered  in  relation  to  immediate  consequences,  is 
certainly  less  serious  in  a  case  of  abortion  than  in  a  natural  labor;  but  the  remote 
effects  are  undoubtedly  more  disastrous  in  the  former  case.  Thus,  the  acute 
diseases  which  attack  lying-in  women,  are  more  frequent  after  labor,  whilst  the 
chronic  disorders  of  the  genital  organs  which  appear  in.  advanced  age,  are  more 
common  in  females  who  have  often  aborted,  than  in  those  who  have  always  been 
delivered  at  term.*  Again,  it  is  highly  important  to  notice  the  unfavorable 
influence  that  one  abortion  seems  to  have  over  subsequent  pregnancies,  for  when- 
ever a  woman  has  had  a  miscarriage,  she  is  more  predisposed  than  others  to  a 
similar  accident,  and  hence  grejit  precautions  should  always  be  taken  to  pre- 
vent it. 

The  period  at  which  an  abortion  occurs,  also  influences  the  prognosis,  although 
we  cannot  exactly  say,  with  Desormeaux,  that  it  is  more  serious  for  the  patient 
in  the  advanced  stages  of  gestation.  Doubtless,  as  before  stated,  it  scarcely  con- 
stitutes an  indisposition  in  the  first  or  even  the  second  month ;  but  in  the  third 
or  fourth,  the  expulsion  of  the  foetus  demands  a  certain  dilatation  of  the  os  uteri, 
and  tolerably  energetic  contractions ;  for  the  neck  and  body  of  the  uterus  have 
not  as  yet  undergone  the  modifications  necessary  to  such  an  efi'ort,  and  the  deli- 
very of  the  after-birth  often  presents  difliculties  less  frequently  met  with  at  a 
more  advanced  stage  of  gestation ;  whence  I  conclude,  that  an  abortion  is  then 
more  grave  and  painful  to  the  patient,  as  also  more  dangerous,  than  in  the  fifth 
or  the  sixth  month. 

Lastly,  the  prognosis  varies  with  the  cause  of  the  accident.  Thus,  the  most 
serious  of  all  is  an  abortion  brought  on  either  by  medicines  administered  inter- 
nally or  by  manipulations ;  while  a  miscarriage  determined  by  slow  and  gradual 
influences  is  usually  attended  with  less  danger  than  one  caused  by  external  vio- 
lence or  some  powerful  moral  commotion.  In  this  latter  case,  the  hemorrhage 
which  precedes,  accompanies,  or  follows  the  abortion,  is  nearly  always  much  more 
disastrous.  Lastly,  when  it  occurs  in  the  course  of  an  acute  inflammation  of  an 
important  organ,  or  during  the  existence  of  an  acute  disease  of  the  skin,  it  is 
exceedingly  dangerous. 

ARTICLE    V. 

DELIVERY   OF   THE   AFTER-BIRTH. 

The  spontaneous  expulsion  or  the  extraction  of  the  placenta  presents  very 
diff'erent  phenomena  according  to  the  period  when  the  abortion  takes  place;  and, 
in  this  respect,  it  is  highly  important  to  distinguish  the  accident  in  the  first  two 
months  from  that  of  the  third  and  fourth,  as  also  from  that  of  the  fifth  and  sixth; 

'  Would  it  be  unreasonable  to  suppose,  that  the  cause  of  the  greater  exposure  of  women 
who  have  had  numerous  miscarriages  to  chronic  diseases,  may  be  due  to  their  having  borne 
the  germ  of  the  latter  for  a  long  period,  and  that  this  itself  may  have  produced  the  primary 
abortions?     Which,  here,  has  been  the  cause,  and  which  the  elTect?     (Blot.) 


346  GENERATION. 

for  the  ovum  is  usually  expelled  entire  in  the  first  and  second  months,  but  in  the 
two  latter  the  expulsion  of  the  placenta  is  accomplished  nearly  in  the  same  way 
as  at  term ;  and  we  shall  consider  it  more  particularly  hereafter.  But  in  the 
third  and  fourth  months  it  is  altogether  different,  because  the  placenta,  which  is 
already  voluminous,  has  contracted  at  this  perio(^  numerous  and  very  intimate 
adhesions  with  the  womb,  which  has  not,  as  yet,  acquired  all  the  contractility  of 
tissue  that  it  possesses  at  term ;  consequently  the  premature  contractions,  although 
sufi&ciently  energetic  to  rupture  the  ovum,  are  not  adequate  to  the  destruction  of 
the  utero-placeutal  adhesions.  Hence,  under  the  influence  of  such  contractions, 
the  amniotic  sac,  being  pressed  on  all  sides,  yields  near  the  neck,  the  waters 
escape,  the  little  foetus  is  expelled,  and  the  very  delicate  umbilical  cord  breaks 
easily;  at  the  same  time  a  certain  quantity  of  liquid  or  coagulated  blood  is  poured 
out,  and  very  often  the  small  foetus  is  lost  in  the  midst  of  the  coagula  that 
accompany  its  discharge.  Then  the  uterus,  being  partially  evacuated,  retracts, 
the  neck  closes  up,  and  the  symptoms  disappear ;  nevertheless,  the  placenta  and 
membranes  are.  still  undelivered,  and  may  remain  in  the  womb  for  eight,  ten,  or 
twelve  days,  or  even  longer.  Dr.  Advena,  of  Labischin,  reports  an  instance 
where  the  after-birth  was  not  expelled  till  three  months  subsequent  to  the  abor- 
tion, this  latter  having  occurred  at  the  fifth  month  of  pregnancy.  (Journal  de 
Chirurgie,  Aug.  1843.) 

The  complete  closure  of  the  neck  evidently  makes  the  introduction  of  the 
finger  impossible,  so  that  every  attempt  made  for  this  purpose  would  prove  fruit- 
less. Ergot  may,  indeed,  be  administered  with  the  object  of  exciting  contrac- 
tions, though  1  have  never  seen  it  have  any  good  effects  when  given  under  these 
circumstances.  To  wait,  at  the  same  time  watching  carefully,  is  all  that  can  be 
done. 

The  symptoms  which  may  then  result  from  a  retention  of  the  placenta  are  very 
variable,  and  should  be  carefully  studied. 

1.  Very  frequently,  nothing  at  all  unusual  is  observed  for  a  few  days  following 
the  miscarriage.  The  general  health  is  good;  the  patient,  believing  herself 
entirely  cured,  gradually  resumes  her  ordinary  occupations,  when  all  at  once,  and 
without  any  known  cause,  some  intermittent  pains  are  felt  in  the  hypogastrium, 
and  a  little  blood  escapes  from  the  vulva.  The  woman  often  neglects  these 
primary  symptoms,  but  they  persist  and  augment  in  intensity,  thereby  constrain- 
ing her  attention  to  them ;  for  the  placenta  has  become  a  foreign  body  in  the 
womb,  and,  irritating  the  uterine  walls  by  its  presence,  excites  their  contractions; 
these  break  up  the  utero-placental  adhesions,  and  the  after-birth  is  almost  free  in 
the  uterine  cavity.  This  separation  is  always  accompanied  by  hemorrhage,  which 
is  at  times  very  abundant,  because  the  os  uteri  dilates  with  so  much  difficulty,  to 
permit  the  foreign  body  to  escape,  that  the  latter,  by  remaining  in  the  womb, 
encourages  a  hemorrhage  by  irritating  the  organ  and  preventing  the  complete 
contraction  of  its  walls ;  insomuch  that,  if  art  does  not  seasonably  interpose,  life 
itself  may  be  endangered  by  the  great  amount  of  the  discharge.  What  is  still 
worse,  if  the  physician  did  not  happen  to  be  present  at  the  time  of  the  miscar- 
riage, if  he  had  not  carefully  examined  all  the  clots  himself,  the  attendants  will 


OF    ABORTION.  847 

not  fail  to  tell  him  that  the  after-birth  and  the  child  were  expelled  together,  and, 
should  he  pay  any  regard  to  their  statements,  he  may  possibly  overlook  the  cause 
of  the  accident  altogether.  I  have  been  summoned  several  times  to  such  cases, 
and  have  invariably  been  told  by  the  persons  questioned  that  the  placenta  was 
delivered.  Consequently,  the  accoucheur  should  rely  exclusively  on  his  own 
personal  examination  in  such  cases.  He  must  absolutely  touch  the  female,  when 
be  will  usually  find  the  os  uteri  to  be  partially  dilated,  and  a  portion  of  the  pla- 
centa hanging  in  its  orifice.  It  then  is  only  necessary  to  seize  this  portion  with 
the  two  fingers,  for  its  extraction  is,  in  general,  quite  easy.  In  case  of  necessity, 
Levret's  abortion-forceps,  or  Duges'  placenta-crotchet,  might  be  used  for  this 
purpose.' 

Sometimes  the  adhesions  of  the  placenta  are  so  numerous  that  it  is  impossible 
to  destroy  them,  and  extract  the  latter,  even  with  Levret's  forceps.  It  is  then 
possible,  by  strong  pressure  upon  the  hypogastrium,  to  depress  the  womb,  so  that 
the  forefinger  of  the  other  hand  can  be  passed  into  its  cavity,  and  glided  between 
the  placenta  and  the  uterine  walls.  Lastly,  if  this  does  not  succeed,  the  tampon 
must  be  resorted  to,  and  the  ergot  be  administered  at  once;  for  the  conjoint  use 
of  these  measures  rarely  fliils  to  arrest  the  hemoi'rhage,  and  bring  on  a  suflicient 
degree  of  conti'action  to  expel  the  secundines. 

Such  are  the  measures  which  should  be  resorted  to,  whenever  the  hemorrhage 
becomes  dangerous  either  by  its  duration  or  abundance.  When,  however,  it  is 
arrested,  especially  when  the  placenta  is  partially  engaged  beneath  the  orifice, 
and  seems  to  prevent,  by  its  presence  there,  further  discharge,  we  should  wait, 
and  be  very  careful  how  we  attempt  to  extract  it  immediately.  The  engagement 
of  the  placenta  in  the  cavity  of  the  neck,  maintains  in  the  latter  a  degree  of  dila- 
tation likely  to  facilitate  its  complete  expulsion,  and  beside  exciting,  as  a  foreign 
body,  the  sensibility  of  that  part,  also  excites,  or  at  least  keeps  up,  the  contrac- 
tions of  the  fundus  of  the  womb.  Tractions  upon  the  engaged  portions  might 
tear  the  placental  mass  at  the  point  of  constriction  by  the  retracted  internal  ori- 
fice. Now,  immediately  after  this  partial  extraction,  the  neck  would  resume  its 
former  condition,  the  internal  orifice  would  close  more  or  less  completely,  and 
render  impossible  the  removal  of  the  portion  of  placenta  remaining  in  the  cavity 
of  the  body  of  the  uterus. 

2.  But  matters  do  not  always  pass  ofi"  so  happily,  and  a  retention  of  the  pla- 
centa may  give  rise  to  the  most  serious  accidents.  In  fact,  it  sometimes  remains 
in  the  uterine  cavity  after  having  been  separated  wholly,  or  in  part,  and  soon 
undergoes  decomposition,  just  as  though  it  were  exposed  to  the  air;  the  lochia 
become  fetid;  the  uterine  walls,  being  in  contact  with  the  substances  in  course 

'  This  is  a  blunt  Look,  formed  of  a  loop  of  iron  or  silver  wire,  of  a  line  or  more  in  dia- 
meter. The  loop  is  narrow  in  proportion  to  the  thickness  which  it  is  desired  the  hook 
should  have,  never,  however,  exceeding  an  inch  and  a  half  in  width.  It  is  curved  near  its 
extremity,  so  as  to  form  a  hook  of  the  size  required.  The  remainder  of  the  loop,  which 
serves  as  a  handle,  receives  the  curvature  necessary  to  facilitate  the  introduction  and  use  of 
the  instrument.  It  is  directed  into  the  womb  by  a  few  fingers,  when  it  receives  the  sofi  mass 
in  its  concavity,  and  is  then  slowly  drawn  out.     (Did.  Med.  et  Chir.,  en  15  volumes.) 


3'18  GENERATION, 

of  putrefaction,  absorb  a  portion  thereof,  and,  as  a  consequence,  fever  is  deve- 
loped, together  with  all  the  symptoms  of  a  putrid  infection.  In  these  distressing 
cases,  we  should  evidently  relieve  the  womb  from  those  foul  materials  that  infect 
the  whole  economy ;  but,  unfortunately,  the  neck  of  the  uterus  is  completely 
closed,  and  an  introduction  of  the  finger  thereby  rendered  impossible.  Often, 
indeed,  it  is  exceedingly  difficult  to  make  the  extremity  of  a  canula  enter  for  the 
purpose  of  throwing  detergent  injections  into  the  uterine  cavity,  and  we  are 
then  compelled  to  await  the  complete  expulsion  of  the  excessively  fetid  sanious 
matters  resulting  from  the  decomposition  of  the  placenta.  In  such  cases,  M. 
Velpeau  speaks  favorably  of  the  use  of  ergot.  This,  indeed,  is  a  remedy  that 
might  be  used,  but  from  which,  nevertheless,  we  should  not  expect  too  much. 

A  lady,  thirty-five  years  of  age,  whom  I  suspected  to  be  pregnant,  although 
she  would  not  believe  it,  felt  a  discharge  from  the  parts  after  a  suspension  of  the 
menses  for  two  months  and  a  half,  which  she  at  first  mistook  for  a  return  of  her 
courses,  but  which,  after  riding  out  in  a  carriage,  was  suddenly  converted  into  a 
profuse  flooding.  Having  been  summoned  immediately,  I  found  the  os  uteri 
slightly  dilated,  and  I  forthwith  employed  various  measures  adapted  to  the  arrest 
of  the  discharge,  and  among  others  the  ergot.  The  hemorrhage  gradually  dimi- 
nished, and  at  ten  o'clock,  p.  M.  (six  hours  subsequent  to  the  invasion  of  the 
symptoms)  it  had  entirely  ceased.  During  the  first  five  days  the  patient  did  very 
well,  but  on  the  sixth  I  thought  I  detected  a  slight  odor  in  the  lochia,  and  at 
three  o'clock  in  the  afternoon  a  violent  chill  came  on,  which  lasted  an  hour. 
From  this  moment  all  the  phenomena  of  absorption  were  manifested.  I  imme- 
diately administered  forty  grains  of  the  ergot,  but  without  efi'ect,  for  nothing 
came  away ;  and,  notwithstanding  the  enlightened  efforts  of  Messrs.  Chomel  and 
Moreau,  who  were  several  times  called  in  consultation,  this  unfortunate  lady  died 
on  the  tenth  day  following  the  appearance  of  the  first  symptoms.  At  the  jpost- 
morteni  examination,  we  found  the  uterine  tissue  softened,  and  its  cavity  filled 
by  the  putrefied  and  still  adherent  placenta,  which  we  could  not  separate  without 
tearing. 

3.  It  may  further  happen  that  the  placenta,  maintaining  its  vascular  adhesion 
with  the  internal  surface  of  the  organ,  continues  to  be  developed  after  the  child's 
death,  the  cord  and  foetus  become  atrophied,  and  then  completely  destroyed ;  or, 
indeed,  the  ovum  may  rupture,  and  the  little  product  escape,  leaving  the  mem- 
branes behind.  These  envelopes  may  undergo  various  modifications,  but  the 
most  common  is  the  morbid  product  known  as  a  mole.  It  has  been  generally 
conceded,  since  the  reseai'ches  of  M.  Velpeau  on  the  subject,  that  the  hydati- 
form  or  other  moles  which  are  expelled  from  the  uterine  cavity,  are  merely  the 
remains  of  an  altered  product  of  conception. 

4.  Lastly,  there  is  yet  another  mode  of  termination,  admitted  by  Noegele, 
Osiander,  &c.  I  allude  to  the  absoi-ption  of  the  placenta  retained  in  the  cavity 
of  the  womb;  for  although  such  an  absorption  has  been  observed,  even  after  deli- 
very at  term,  yet  most  of  the  reported  cases  refer  especially  to  miscarriages. 
(See  Delivery  of  the  After-birth.) 


OF    ABORTION.  349 

ARTICLE  VI. 

TREATMENT   OF   ABORTION. 

The  treatment  of  abortion  consists  in  preventing  it,  in  favoring  the  expulsion 
of  the  ovum  when  this  is  inevitable,  and  in  remedying  the  various  accidents  that 
may  complicate  it. 

1.  Preventive  3Ieasiires. — When  the  miscarriage  is  dependent  on  the  woman's 
bad  constitution,  or  on  a  lesion  of  the  genital  organs,  we  must  endeavor  to  combat 
and  destroy  this  pernicious  predisposition,  more  especially  in  the  intervals  be- 
tween the  gestations.  I  shall  say  nothing  at  this  time  of  the  means  of  modifying 
the  general  vices  of  the  constitution,  since  they  necessarily  vary  with  the  nature 
of  the  affection.  It  is  particularly  important,  however,  to  bear  in  mind  the  dis- 
astrous influence  of  syphilis,  whether  the  fxther  or  the  mother  be  infected  with 
it,  over  the  life  of  the  foetus ;  and  we  should  persuade  them  to  submit  to  a  mer- 
curial course. 

When  it  happens  that  several  abortions  have  resulted  in  consequence  of  some 
displacement  of  the  uterus,  the  latter  should  be  remedied  by  the  appropriate 
measures;  for  instance,  in  the  commencement  of  pregnancy,  the  woman  should 
avoid  all  fatigue  and  every  violent  effort ;  and  it  is  even  advisable  for  her  to 
remain  in  the  recumbent  position  until  the  uterus  rises  above  the  superior  strait. 

We  award  the  proper  value  to  the  influence  attributed  by  Desormeaux  to  the 
supposed  rigidity  and  excess  of  sensibility  or  contractility  in  the  uterine  fibre,  as 
well  as  to  the  excessive  weakness  or  relaxation  in  the  fibres  of  the  neck.  But 
whilst  interpreting  the  action  of  those  causes  in  a  different  manner,  we  believe, 
with  him,  that  bathing,  general  bleeding,  opiate  injections,  and  a  regulated  course 
of  living,  are  the  means  best  suited  to  moderate  this  great  irritability  of  the 
organ ;  and  that  a  tonic  and  strengthening  regimen,  aided  by  the  ferruginous 
preparations,  cold  baths,  and  the  chalybeate  mineral  waters,  will  be  the  most 
usefully  employed  in  those  cases  where  the  general  debility  of  the  patient  may 
have  seemed  to  exercise  some  influence  over  her  former  abortions. 

Plethoric  women,  who  usually  have  profuse  menstrual  discharges,  and  who 
may  have  previously  suffered  from  abortion  at  the  periods  of  menstruation,  all  of 
which  had  been  preceded  by  the  symptoms  of  general  or  local  plethora,  and  all 
followed  by  more  or  less  copious  discharges,  should  be  subjected  before  fecunda- 
tion to  a  restricted  regimen ;  and  during  gestation,  they  should  avoid  all  moral 
and  physical  excitements,  and  should  remain  in  bed  eight,  ten,  or  even  twelve 
days  at  every  monthly  term ;  besides,  they  ought  to  be  bled  several  times  during 
the  earlier  periods  of  pregnancy,  more  especially  just  before  the  time  for  the 
menses  to  appear.* 

'  The  physician  often  meets  with  much  opposition  from  persons  out  of  the  profession 
when  he  proposes  a  preventive  bleeding  in  the  early  stages  of  gestation.  Particularly, 
should  any  accident  happen  shortly  afterwards,  they  would  not  fail  to  reproach  him  with  it. 
This,  however,  is  no  just  reason  for  not  acting  according  to  his  convictions,  or  for  yielding  in 
cases  where  he  believes  it  really  useful ;  now  experience  has  fully  proved  that,  in  such  in- 
stances as  those  we  have  described,  it  is  one  of  the  best  preventive  measures. 


360  GENERATION. 

These,  more  than  other  pregnant  women,  should  renounce  the  use  of  corsets, 
which,  independently  of  the  restraint  they  make  on  the  development  of  the 
breasts,  oppose  the  free  return  of  blood,  by  interfering  more  or  less  with  the 
abdominal  and  thoracic  circulation,  and  thereby  favor  congestion  of  the  inferior 
organs. 

Feeble,  cachectic  females,  who  are  impaired  by  former  diseases,  and  those 
whose  tissues  are  soft,  and  their  circulation  languid,  or  who,  from  being  habitu- 
ally irregular,  are  affected  with  chronic  leucorrhoca,  are  often  attacked  by  hemor- 
rhages during  pregnancy  which  ultimately  lead  to  an  abortion. 

In  such  patients  the  face  is  pale,  the  pulse  soft,  small,  and  irritable,  the  tongue 
white,  digestion  painful,  the  intestines  torpid,  and  the  extremities  cold.  The 
least  exercise  fatigues  them,  sometimes  even  exhausts  their  strength.  The 
fatigue  is  often  accompanied  by  a  sensation  of  weight,  of  painful  draggings  in 
the  groins  and  lumbar  regions,  and,  should  they  remain  standing  for  any  length 
of  time,  the  uterus  seems  to  require  some  support,  as  it  appears  just  on  the  point 
of  escaping  by  the  vagina  or  rectum.  Even  in  the  earliest  stages  they  feel 
something  like  a  weight  in  the  lesser  pelvis,  always  pressing  on  the  most  depen- 
dent part. 

Now  the  best  mode  of  preventing  such  a  condition,  is  to  prescribe  a  tonic  regi- 
men, together  with  the  ferruginous  and  bitter  preparations.  Canella,  in  powder, 
has  been  recommended;  and  Sauter  highly  extols  the  use  of  powdered  savine; 
he  asserts,  that  he  has  succeeded  in  correcting  this  pernicious  predisposition  in 
pregnant  women,  who  had  previously  had  several  miscarriages,  by  administering 
fifteen  grains  of  the  powder  three  times  a  day,  continuing  it  for  three  or  four 
months;  by  this  remedy  he  has  arrested  flooding  and  prevented  abortion,  and 
many  patients  can  attribute  the  fact  of  having  children  born  at  full  term  to  the 
employment  of  this  precious  drug. 

White,  of  Manchester,  has  particularly  recommended  cold  bathing,  especially 
sea-bathing,  to  be  often  repeated,  both  before  and  during  pregnancy. 

The  accoucheur  must  therefore  search  in  the  history  of  former  miscarriages  for 
the  indications  to  guide  him  in  the  use  of  preventive  measures;  and  it  is  like- 
wise very  important  that  he  should  make  himself  acquainted  with  all  the  accom- 
panying circumstances. 

Pregnant  women  are  very  often  constipated,  and  this  constipation  frequently 
becomes  the  cause  of  periodic  abortions,  by  the  irritation  it  produces;  hence,  it 
should  be  prevented  by  the  use  of  some  simple  injections,  with  the  addition  of 
one  or  two  tablespoonfuls  of  linseed  oil,  regularly,  every  other  day,  for  two  weeks 
before  the  period  when  the  abortion  occurred  last  time,  and  they  ought  to  be 
continued  for  two  weeks  after  it. 

But  whatever  may  have  been  the  predisposing  cause  whose  influence  was 
exerted  in  the  previous  pregnancies,  there  is  one  very  important  precaution,  the 
neglect  of  which  mioiht  render  all  others  useless.  In  all  cases  where  abortion 
has  occurred  several  times,  it  is  indispensable  that  the  organ  should  remain  un- 
disturbed, and  the  husband  be  recommended  to  allow  from  six  to  eight  months, 
or  even  a  year  to  elapse,  without  the  wife  being  exposed  to  become  pregnant. 


OF    ABORTION.  351 

When  this  accident  has  already  occurred  a  number  of  times  in  former  preg- 
nancies, it  is  always  indispensable  for  the  woman  to  abstain  altogether  from  inter- 
course with  her  husband,  for  all  sources  of  irritation  must  evidently  be  withdrawn 
from  the  womb.  Again,  if  the  foetus  was  expelled  dead  in  the  preceding  gesta- 
tions, and  this  death  had  been  caused  by  some  lesion  of  the  ovum,  it  is  almost 
impossible  to  recognize,  and  consequently  to  prevent,  a  similar  alteration. 

The  case  is  rather  different  when  the  previous  abortions  have  been  attributed 
to  utero-placental,  or  intra-placental  effusions,  for  these  are  almost  always  the 
result  of  a  congestion  of  the  uterus,  of  sufficient  intensity  to  produce  a  rupture 
of  vessels.  In  another  pregnancy,  it  might  be  possible  to  avoid  such  accidents. 
We  would,  however,  call  attention  to  the  fact,  that  these  local  congestions  may 
occur  in  chlorotic,  as  well  as  in  plethoric  women,  and,  consequently,  that  although 
revulsives  applied  to  the  upper  part  of  the  body,  or  to  the  superior  extremities, 
are  useful  in  all,  bleedings  from  the  arm  at  the  menstrual  periods  are  very  ad- 
vantageous with  the  latter,  whilst  the  former  are  benefited  by  the  preventive  use 
of  ferruginous  preparations,  administered  from  the  commencement  of  gestation. 

Under  some  unfortunate  circumstances,  natui-e  seems  to  deride  all  the  attempts 
of  art,  and  abortion  re-occurs.  Still,  we  must  not  despair  when  the  woman  be- 
comes again  pregnant,  for  experience  fully  proves  that,  notwithstanding  numerous 
former  abortions,  a  fresh  pregnancy  has  sometimes  succeeded,  in  reaching  full 
term.  Dr.  Young  (Rujh}j,  91)  relates,  in  his  lectures,  the  history  of  an  unfortu- 
nate lady,  who,  after  having  had  thirteen  successive  abortions,  became  pregnant 
for  the  fourteenth  time,  and  was  happily  delivered  of  a  living  infant  at  term. 

But,  notwithstanding  all  these  precautions,  it  sometimes  happens  that  an  abor- 
tion is  threatened.  The  patients  are  affected  with  shiverings  from  the  most 
trifling  causes,  pains  in  the  hypogastrium,  loins,  &c. ;  uterine  contractions  appear, 
the  sexual  parts  become  moist,  and  occasionally  even  the  os  uteri  dilates;  but, 
even  here,  we  must  not  lose  all  hopes  of  arresting  the  accident,  notwithstanding 
these  symptoms. 

If  the  patient  is  robust,  the  pulse  full  and  frequent,  more  especially  if  the 
development  of  the  symptoms  had  been  preceded  by  indications  of  plethora, 
bleeding  in  the  arm  should  be  at  once  resorted  to,  the  woman  be  laid  as  horizon- 
tally as  possible,  and  opiates  immediately  administered.  The  laudanum  of  Syden- 
ham may  be  given  in  the  dose  of  twenty,  forty,  or  even  sixty  drops,  diffused  in  a 
small  quantity  of  some  mucilaginous  liquid  as  an  injection,  and  repeated  at  in- 
tervals of  an  hour,  until  the  contractions  disappear.  This  remedy,  of  which  we 
have  before  spoken,  is  one  of  the  most  efficacious  in  cases  of  this  kind,  and  some- 
times it  alone  has  enabled  us  to  arrest  a  labor,  whose  termination  seemed  to  be 
inevitable,  and  thus  has  permitted  the  gestation  to  pursue  its  regular  course. 

I  cannot  refrain  from  citing  the  following  instance  in  illustration.  A  woman, 
advanced  to  three  months  and  a  half,  was  taken  with  pains  in  the  abdomen  and 
loins,  after  a  violent  altercation  with  her  husband  ;  on  the  following  day  the  pains 
augmented,  and  a  little  bloody  fluid  escaped  from  the  genital  organs;  the  pains 
still  continuing,  and  the  discharge  having  somewhat  increased,  on  the  third  day 
the  patient  came  on  foot  to  the  Clinique.    I  found,  on  her  arrival,  that  the  uterine 


852  GENERATION. 

contraction  was  very  distinct,  the  pains  sharp,  and  renewed  every  eight  or  ten 
minutes ;  pure  blood  was  discharging  from  the  vulva,  and  the  orifice  was  sujB5- 
ciently  dilated  to  ]}C'>">nit  the  finger  to  pass  readily  as  far  up  as  the  nahed  mem- 
branes. I  administered  sixty  drops  of  laudanum,  divided  into  three  doses,  which 
were  given  at  intervals  of  three-quarters  of  an  hour,  and,  by  the  end  of  this 
time,  the  pains  disappeared,  everything  resumed  its  natural  order,  and  the  ges- 
tation went  on  till  full  term. 

I  might  multiply  such  citations  almost  ad  infinitum,  but  the  above  is  sufficient 
to  show  that,  however  inevitable  the  abortion  may  at  first  appear,  we  should  never 
abandon  all  hopes  of  preventing  it.  I  may  add,  that  the  administration  of  opium 
in  the  doses  just  indicated,  or  even  carried  to  a  hundred  drops  in  the  twenty-four 
hours,  has  never  been  followed  by  serious  consequences.  Sometimes,  perhaps,  a 
little  somnolency  or  heaviness  about  the  head,  or  a  general  torpor  may  result,  but 
which  a  few  glasses  of  lemonade  will  soon  dissipate.  For  after  all,  when  even 
death  of  the  foetus  must  have  been  either  the  cause  or  the  effect  of  the  primary 
symptoms,  what  do  we  risk  in  calming  or  arresting  the  uterine  contractions  ? 
because,  as  we  have  already  seen,  the  dead  child  may  remain  long  within  the 
intact  membranes  without  any  unfavorable  consequences  resulting  to  the  mother. 
And  besides,  as  it  is  almost  impossible  to  ascertain  its  death  with  any  degree  of 
certainty  prior  to  the  fifth  month  of  gestation,  we  must  act  in  such  doubtful  cases 
just  as  if  it  were  living;  although  there  can  be  no  question  that,  if  the  foetus 
were  really  dead,  it  would  be  better  to  permit  the  contractions  to  go  on,  and  its 
expulsion  to  be  effected.  But,  even  supposing  these  are  wholly  suspended,  the 
expulsion  is  somewhat  retarded,  and  that  is  all ;  for  after  the  lapse  of  a  certain 
time  the  foetus,  acting  like  a  foreign  body  in  the  uterine  cavity,  will  irritate  its 
walls,  and  a  new  labor  sooner  or  later  take  place  in  consequence. 

To  these  remedies  (the  venesection  and  opiate  treatment)  we  must  add  strict 
confinement  to  bed,  absolute  rest  of  mind  and  body,  the  use  of  demulcent  beve- 
rages, cold  lemonade,  veal  broth,  chicken  water,  and  the  application  of  cold 
compresses,  frequently  renewed,  over  the  abdomen ;  which  compresses  are  to  be 
saturated  with  some  fluid  whose  temperature  is  progressively  lowered.  "  Local 
bleedings,"  says  M.  Gendrin,  "are  too  much  neglected,  especially  in  the  treat- 
ment of  the  utero-placental  hemorrhages ;  indeed,  we  have  so  often  had  occasion 
to  congratulate  ourselves  for  having  advised  them  in  those  cases,  that  we  now 
prescribe  them  with  great  confidence  whenever  the  general  condition  does  not 
directly  indicate  a  depletory  venesection.  We  direct  them  :  1.  When  there  are 
any  sharp  pains  in  the  neighborhood  of  the  uterus  or  groins,  and  we  apply  them 
to  the  latter,  the  anus,  or  even  the  vulva;  2.  In  cases  of  a  considerable  turges- 
cence  of  the  hemorrhoidal  tumors  (if  any  such  exist);  and  3.  In  the  phlegmasia 
of  the  adjacent  organs,  such  as  the  large  intestine,  etc." 

In  these  two  latter  cases  we  fully  coincide  in  the  opinion  of  M.  Gendrin ;  but, 
in  the  first,  we  should  much  prefer  having  recourse  to  a  general  bleeding  in  the 
arm,  or,  as  he  himself  advises,  further  on,  to  the  application  of  leeches  at  a  dis- 
tance from  the  utenis ;  for  instance,  near  the  breasts,  armpits,  &c.  &c.  Finally, 
to  the  means  already  enumerated,  we  must  further  add  the  use  of  irritant  revul- 


OF    ABORTION.  353 

sives,  placed  upon  the  upper  part  of  the  trunk  and  the  thoracic  extremities,  and 
must  also  recommend  in  a  more  special  manner  the  application  of  dry  cups,  the 
decidedly  beneiicial  effects  of  which  we  have  often  witnessed  in  cases  where 
uterine  plethora  seemed  to  be  the  cause  of  the  symptoms,  but  where  the  general 
condition  required  some  precaution  in  the  use  of  bloodletting. 

2.  It  has  been  already  stated  that  a  copious  hemorrhage,  intensity  of  the  pain 
and  of  all  the  other  phenomena,  and  more  particularly  a  rupture  of  the  mem- 
branes, render  abortion  thenceforth  inevitable;  and  hence,  the  only  course  in 
such  cases  is  to  facilitate  the  expulsion  of  the  product  of  conception.  But  still, 
if  the  hemorrhage  is  not  of  such  a  character  during  the  first  three  months  of 
gestation  as  to  compromise  the  woman's  life,  the  physician  should  remain  a 
simple  spectator  of  the  efforts  of  nature,  and  confine  himself  to  superintending 
the  progress  ;  for  the  expulsion  of  the  ovum  ought  to  be  left  entirely  to  the  uterine 
forces.  Sometimes  it  comes  away  whole,  which  is  a  very  favorable  circumstance- 
Moreover,  according  to  the  recommendation  of  Baudelocque,  he  should  be  very 
careful  not  to  rupture  the  membranes,  for  that  would  only  retard  the  delivery  of 
the  placenta,  and  render  it  still  more  dangerous.  In  fiict,  when  the  foetus  escapes 
alone,  this  latter  might  be  attended  with  the  difficulties  just  pointed  out  in  the 
preceding  article. 

We  should  here  remember  how  slowly  the  expulsion  of  the  ovum  is  effected  in 
certain  cases,  even  when  the  orifice  is  sufficiently  dilated  to  oppose  no  obstruction 
to  its  exit.  This  great  slowness  is  sufficiently  explained  by  the  slight  contractile 
power  of  the  uterus.  When  no  accident  complicates  the  abortion,  the  physician 
has  nothing  to  do  but  watch  the  progress  of  the  labor,  and  expect  the  complete 
delivery  to  be  effected  by  the  uterine  efforts.  At  a  more  advanced  period,  that 
is,  towards  the  fifth  or  the  sixth  month,  the  course  of  the  physician  is  very  nearly 
the  same  as  it  would  be  at  term.  The  size  of  the  foetus,  which  has  now  become 
quite  large,  requires  a  greater  dilatation  of  the  os  uteri ;  and  this,  in  consequence 
of  the  greater  softening  of  the  cervix,  is  accomplished  with  somewhat  greater 
rapidity.  Generally,  it  is  necessary  that  the  child  should  present  one  or  the 
other  extremity  of  its  long  diameter  to  the  os  uteri ;  however,  it  sometimes  hap- 
pens that  some  portion  of  its  trunk  presents  there,  and  its  delivery  is  neither 
much  more  difficult  nor  much  slower  than  usual.  It  is  in  such  cases  especially 
that  the  mechanism  of  spontaneous  evolution  may  be  frequently  observed.  The 
delivery  of  the  after-birth  does  not,  as  a  general  rule,  exhibit  those  difficulties 
which  it  presented  in  the  earlier  months;  in  truth,  it  closely  resembles  the  same 
process  in  the  labor  at  term. 

3.  Hemorrhage  is  one  of  the  most  common  symptoms.  It  may  precede,  ac- 
company, or  follow  the  expulsion  of  the  foetus,  and  is  of  such  frequent  occurrence 
that  most  authors  make  it  the  principal  disorder.  In  some  cases,  it  is  certainly 
the  cause  of  the  abortion,  though  often  merely  a  consequence.  Sometimes, 
indeed,  the  miscarriage  is  accompanied  with  but  slight  hemorrhage.  The  latter 
circumstance  is,  however,  rare,  especially  in  the  false  labors  that  take  place  before 
the  end  of  the  fourth  month ;  because  a  more  or  less  abundant  discharge  of  blood 
nearly  always  shows  itself  during  the  first  expulsive  pains,  and  persists  until  the 

23 


354  GENERATION. 

uterus  is  completely  emptied;  but,  as  we  all  know,  nothing  of  this  kind  is  ob- 
served in  labor  at  term.  M.  Jacqueniicr  has  happily  explained  the  difference 
between  "the  two  in  the  following  manner  :  He  states  that,  towards  the  end  of 
gestation,  the  placenta  spreads  out  from  the  centre  towards  its  circumference,  in 
order  to  conform  itself  to  the  uterine  enlargement  at  its  greatest  extent;  and  this 
is  accomplished  in  such  a  way  that  its  different  lobes,  by  separating  from  one 
another,  have  a  considerable  space  left  between  them.'  From  this  it  follows, 
that  within  certain  limits,  the  uterine  contractions  have  no  tendency  to  detach  it; 
for  the  placenta  accommodates  itself  wonderfully  to  the  retraction  of  the  organ 
until  it  reaches  its  own  proper  limits ;  and  even  then  its  great  flexibility  permits 
a  further  reduction,  so  as  to  follow  the  uterus  as  it  becomes  less,  before  the  de- 
tachment commences,  and  this  latter  phenomenon  only  takes  place  when  the 
entire  foetus  is  nearly  expelled.  But,  prior  to  the  fourth  month,  the  after-birth 
is  far  from  offering  the  same  conditions,  since  the  thickness  of  the  utero-placental 
decidua  and  the  large  amount  of  plastic  matter  interposed  between  the  lobes  at 
that  time,  confer  upon  it  a  much  greater  density ;  and  therefore  it  can  only  yield 
within  very  narrow  limits,  either  in  the  way  of  extension  or  retraction  towards 
its  centre.  Hence,  the  facility  of  its  separation  during  the  early  contractions, 
the  rupture  of  a  certain  number  of  vessels,  and  the  incessant  hemorrhage  through- 
out the  whole  duration  of  the  labor. 

Whenever,  notwithstanding  the  use  of  general  measures,  such  as  the  hori- 
zontal position,  cold  drinks,  the  application  of  refrigerants  to  the  hypogastrium 
or  thighs,  and  the  administration  of  opiates,  the  discharge  of  blood  continues 
so  great  as  to  endanger  the  mother's  life,  an  abortion  thenceforth  becomes 
inevitable,  and  the  primary  object  of  the  accoucheur  should  be  to  bring  on  the 
contractions  and  the  evacuation  of  the  organ. 

He  should  also  administer  general  stimulants  to  sustain  the  woman's  strength, 
and,  at  the  same  time,  those  medicines  having  an  immediate  action  on  the 
womb  itself,  such  as  the  tincture  of  canclla,  &c.,  but  above  all  the  ergot.  How- 
ever, when  the  miscarriage  comes  on  at  an  early  stage  of  the  gestation,  these 
measures  are  often  ineffectual,  for  it  is  then  exceedingly  difficult  to  excite  the 
contractions  of  a  viscus  whose  muscular  organization  is  still  so  imperfect ;  or  at 
least,  if  they  are  aroused,  they  are  frequently  inadequate  to  dilate  th^  neck  suffi- 
ciently. The  tampon  is  then  the  only  resource;  this,  when  well  applied,  acts  in 
two  ways :  1st,  by  opposing  the  escape  of  the  blood  externally,  thus  forcing  it  to 
coagulate,  and  consequently  to  obliterate  the  bleeding  vessels;  2d,  by  irritating 
the  womb  by  mere  contact,  thereby  determining  its  retraction,  and  the  expulsion 
of  the  product  of  conception.  This  circumstance,  indeed,  is  one  of  the  best- 
founded  objections  to  the  use  of  the  tampon  in  the  early  months  of  gestation. 
But,  in  truth,  is  it  not  rather  an  advantage  than  otherwise?  because  the  cessation 
of  the  flooding  is  always  a  necessary  consequence  of  the  uterine  contractions ;  and 

'  To  convince  one's  self  of  tlie  truth  of  tliis  fact,  it  is  only  necessary  to  see  the  placenta 
still  adherent  to  a  uterus  which  has  been  developed  but  is  not  yet  retracted,  or  even  the 
uterine  surface  this  mass  occupied;  for  the  latter  is  nearly  one-third  larger  than  the  surface 
of  the  placenta  which  covered  it.     (Jacqucmier.) 


OF    ABORTION.  855 

is  the  mother's  life  bought  too  dear,  when  it  is  saved  by  the  expulsion  of  a  foetus, 
which,  in  most  cases,  is  dead  even  before  the  application  of  the  tampon  ?  Be- 
sides, this  measure  is  not  always  necessarily  followed  by  abortion.  Again,  there 
is  no  reason  to  fear  the  conversion  of  an  open  into  a  concealed  hemorrhage  by 
the  employment  of  the  tampon,  before  the  sixth  month ;  for,  notwithstanding 
the  observation  of  Chevallier,  the  accumulation  of  a  large  quantity  of  blood  in  the 
womb  would  seem  to  be  impossible  at  this  early  period,  without  supposing  an 
abnormal  relaxation  of  its  walls.  Where,  however,  the  pregnancy  is  advanced  to 
the  fifth  mouth,  the  accoucheur  should  carefully  watch  the  body  of  the  uterus 
after  the  tampon  is  applied,  and  assure  himself,  every  moment,  that  its  volume  is 
not  increasing. 

The  following  is  the  manner  in  which  this  operation  is  generally  performed  : 
some  dossils  or  pellets  of  charpie  are  prepared,  sometimes  dry,  at  others  smeared 
with  cerate,  and  the  vagina  is  then  stuffed  with  these  gradually,  care  being  taken 
to  have  the  first  portions  applied  directly  to  the  uterine  neck;  it  would  be  better, 
perhaps,  to  connect  these  by  means  of  a  thread,  so  that  they  can  afterwards  be 
withdrawn  the  more  easily.  When  the  vagina  is  filled,  some  thick  masses  of 
charpie  are  applied  directly  over  the  vulva  to  sustain  the  pellets,  and  the  whole 
is  held  in  position  by  a  T  bandage. 

This  operation  is  sometimes  tedious,  on  account  of  not  having  the  necessary 
materials  at  hand,  and  then  we  might  resort  to  the  plan  often  advantageously 
employed  by  Dewees;  namely,  to  use  a  soft  sponge  large  enough  to  fill  the 
whole  vaginal  cavity,  and  which  is  to  be  pushed  up  as  far  as  the  os  uteri, 
after  having  been  previously  soaked  in  vinegar.  The  blood  infiltrating  into  the 
pores  of  the  sponge  soon  coagulates  and  forms  a  voluminous  clot  which  seals  up 
the  vagina  hermetically,  without  giving  rise,  says  Dewees,  to  any  of  the  accidents 
produced  by  the  ordinary  tampon ;  besides,  it  is  borne  without  inconvenience, 
and  may  be  left  there  until  the  expulsion  of  the  ovum,  although  it  would  be 
better  to  withdraw  it  after  the  lapse  of  some  hours,  to  observe  the  progress  of 
the  dilatation,  and  then  replace  it,  if  the  neck  is  still  closed.  Nevertheless,  the 
accoucheur  ought  constantly  to  bear  in  mind  that,  whatever  plan  be  adopted,  the 
application  of  the  tampon  is  nearly  always  followed  by  abortion,  and  therefore 
must  never  be  resorted  to  until  the  latter  seems  to  be  inevitable. 

When  the  ovum  remains  intact,  and  the  labor  lasts  too  long,  the  continuation 
of  the  hemorrhage  being  at  the  same  time  such  as  to  cause  serious  anxiety,  some 
practitioners  prefer  rupturing  the  membranes  to  applying  the  tampon.  This 
measure,  to  which  I  shall  again  allude  in  speaking  of  hemorrhage  during  the 
last  three  months,  does  not  seem  to  me  applicable  before  the  sixth  month,  except 
in  a  ftw  occasional  instances,  and  I  should,  in  general,  decidedly  prefer  the 
tampon  to  it. 

In  fact,  a  rupture  of  the  membranes  is  necessarily  followed  by  miscarriage; 
but  the  tampon,  when,  early  applied,  leaves  some  hope  that  the  gestation  may 
continue  till  term:  again,  the  tampon  always  arrests  the  bleeding,  whereas,  after 
rupturing  the  membranes,  it  may  happen  that  the  uterus,  whose  muscular  fibres 
have  not  acquired  the  contractile  power  which  they  would  have  at  a  later  period; 


356  GENERATION. 

might  not  retract,  nor  the  hemorrhage  cease,  so  that  it  might  still  be  necessary 
to  have  recourse  to  the  tampon. 

Finally,  let  us  add  that,  in  the  first  three  months,  the  rupture  is  followed 
almost  immediately  by  a  discharge  of  the  waters,  and  the  escape  of  the  foetus ; 
but  the  expulsion  of  the  placenta  and  membranes  is  thereby  rendered  much  more 
difficult. 

After  the  complete  expulsion  of  the  ovum,  the  patient  must  observe  the  same 
precautions  as  are  required  after  ordinary  labor ;  and  we  shall  treat  hereafter  of 
the  attentions  which  her  state  demands. 


CHAPTER  IV. 

OF  THE  DISEASES  WHICH  MAY  EXIST  DURING  PREGNANCY,  AND  OF  THE 
RECIPROCAL  INFLUENCE  WHICH  THEY  MAY  HAVE  UPON  THEIR  PRO- 
GRESS   AND   TERMINATION. 

Though,  says  Antoine  Petit,  pregnancy  exposes  women  to  various  disorders, 
it  also  protects  them  from  many  very  dangerous  diseases,  arrests  the  progress  of 
others,  and  sometimes  even  cures  those  with  which  they  were  previously  affected. 
This  proposition,  though  asserted  almost  as  a  maxim  by  the  author  quoted,  is, 
unfortunately,  far  from  being  strictly  true.  Antoine  Petit  was  indeed  strangely 
deceived  in  his  appreciation  of  the  influence  of  pregnancy  upon  acute  diseases 
existing  before  it  or  occurring  during  its  progress ;  still,  as  many  physicians  par- 
take of  his  error,  we  have  thought  it  right  to  notice  it  at  the  outset. 

§  1.  Epidemic  Diseases. 

1.  Though  some  epidemics  have  appeared  to  spare  pregnant  women,  many 
have  affected  them  as  severely,  at  least,  as  other  individuals  exposed  to  the  same 
influences.  Thus  I  found,  as  did  also  M.  Jacquemier,  at  the  Maternity  Hospital, 
that  the  epidemic  of  influenza  attacked  a  great  many  pregnant  women ;  but,  con- 
trary to  his  observation,  I  witnessed  numerous  abortions  as  a  consequence  either 
of  the  disease  itself,  or  of  the  violent  spells  of  coughing  which  tormented  the 
patients. 

2.  The  severe  epidemics  of  cholera  which,  in  1832  and  1849,  were  so  fatal  in 
the  capital,  did  not  spare  pregnant  women  ;  and  we  had  the  pain  of  witnessing 
the  death  of  quite  a  number. 

Dr.  Bouchut  has  endeavored,  in  a  quite  recent  work,  to  appreciate  the  effect 
of  pregnancy  upon  cholera,  and  vice  versa.  Relying  upon  52  observations,  ho 
commences  by  showing  that  pregnancy  has  no  influence  upon  the  invasion  of 
cholera,  that  it  protects  from  it  no  more  than  it  predisposes  to  it,  and  that  when 
the  disease  appears,  it  does  so  without  any  modification,  in  all  its  forms  and 
severity. 


DISEASES    OCCURRING    DURING    PREGNANCY.  357 

Cholera  has,  however,  an  incontestable  influence  upon  the  course  of  gestation, 
often  shortening  its  duration.  Thus,  25  women  out  of  52  aborted  in  conse- 
quence of  the  disease,  and  the  same  would  probably  have  been  the  case  with 
others,  had  not  the  patients  been  removed  by  an  early  death.  Except  in  some 
rare  instances,  abortion  took  place  only  in  cases  in  which  the  disease  lasted  over 
twenty-four  hours. 

Of  the  25  women  who  aborted,  16  recovered;  12  had  the  disease  with  mode- 
rate severity,  though  lasting  for  a  considerable  time ;  the  attack  in  4  was  dan- 
gerous and  rapid,  and  9  died. 

The  observations  of  M.  Bouchut  have  elicited  the  remarkable  fact,  that  abor- 
tion is  very  common  in  cholera  patients  after  the  fifth  month  of  pregnancy,  but 
very  rare  at  its  commencement.  Thus,  of  the  16  women  who  aborted  and  reco- 
vered, only  1  was  three  months  pregnant,  1  four,  6  five,  and  1  sis ;  and  the  least 
advanced  of  the  9  who  died  after  abortion,  had  reached  four  months  and  a  half. 

Of  the  27  women  who  did  not  miscarry,  only  6  recovered  and  had  their  preg- 
nancies to  continue.  The  attacks  which  they  suffered  were  of  medium  severity, 
and  of  several  days'  duration.  21  died  with  the  disease  in  a  dangerous  and  rapid 
form. 

Altogether  there  were  30  deaths  out  of  52  cases.  We  see,  therefore,  that  tlie 
prognosis  of  cholera  is  not  rendered  more  favorable  by  the  state  of  pregnancy. 

We  have  said  that  G  of  the  patients  recovered,  and  had  their  pregnancies  to 
pursue  their  regular  course.  Others,  who  had  reached  a  more  advanced  stage, 
were  delivered  prematurely  of  living  children.  From  this,  it  plainly  results  that 
cholera  is  not  always  communicated  to  the  foetus,  and  that  though  the  latter 
usually  succumbs  either  before  its  expulsion,  or  before  the  mother,  in  those  cases 
where  her  early  decease  did  not  allow  the  abortion  to  take  place,  its  death  cannot 
be  attributed  to  a  transmission  of  the  disease.  Besides,  the  autopsy  of  the  chil- 
dren revealed  nothing  which  could  be  regarded  as  pertaining  to  cholera. 

What,  then,  is  the  cause  of  the  death  of  the  foetus,  preceding  as  it  almost 
always  does  its  own  expulsion,  or  the  death  of  the  mother  ? 

M.  Bouchut  thinks  that  it  is  a  consequence  either  of  a  mechanical  compression 
of  the  uterus  produced  by  the  cramps  and  convulsions  of  the  abdominal  muscles, 
or  to  the  severe  diet  to  which  the  patients  are  subjected ;  again,  he  supposes  that 
it  may  be  occasioned  by  the  profuse  discharges  from  the  bowels,  which,  by  de- 
priving the  blood  of  its  serum,  dry  up,  as  it  were,  the  sources  of  nutrition.  For 
my  own  part,  I  regard  asphyxia  as  the  only,  or  at  least  the  usual,  cause  of  the 
death  of  the  foetus.  The  coagulation  of  the  blood,  and  its  stagnation  in  the  ves- 
sels, are  evidently  calculated  to  suspend  the  utcro-placental  circulation ;  and  the 
interruption  of  the  latter,  depriving  the  foetus  as  it  does  of  the  means  of  respira- 
tion, must  necessarily  lead  to  its  rapid  death. 

M.  Devilliers,  Jun.,  read  before  the  Academy  of  Medicine  an  observation 
tending  to  prove  that  abortion  has  a  favorable  eifect  upon  the  termination  of 
cholera,  and  causing  him  to  feel  justified  in  recommending  the  provocation  of 
premature  labor,  as  a  means  of  diminishing  the  danger  of  the  disease.  In  exa- 
mining under  this  point  of  view  the  results  furnished  by  M.  Bouchut,  a  result 
favorable  to  the  opinion  of  M.  Devilliers  is  at  once  discoverable;  since  of  the  27 


358  GENERATION. 

patients  who  did  not  miscarry,  21  died,  whilst  9  deaths  only  occurred  after  25 
abortions.  Still,  it  should  be  observed,  that  of  the  women  who  recovered  after 
aborting,  4  only  had  the  disease  in  a  rapid  and  dangerous  form  ;  whilst  of  the  21 
who  died  undelivered,  the  disease  was  very  severe,  and  barely  lasted  a  few  days. 
This  early  flital  termination  was,  very  probably,  the  only  cause  which  prevented 
abortion. 

The  view  of  M.  Devilliers  cannot,  therefore,  be  received  without  new  confir- 
matory observations. 

In  short,  though  pregnancy  does  not  affect  sensibly  the  progress  and  danger  of 
cholera,  the  latter  leads,  in  the  great  majority  of  cases,  to  the  death  or  premature 
expulsion  of  the  foetus. 

§  2.  Sporadic  Diseases. 

1.  Tijplio id  fever  is  rarely  observed  during  pregnancy,  and  does  not  appear  to 
be  influenced  unfavorably  by  the  coincidence.  When  the  attack  is  severe,  we 
can  readily  conceive  that  it  may  occasion  abortion,  though  the  occurrence  of  the 
latter  is  certainly  exceptional. 

Though  I  have  rarely  had  occasion  to  observe  typhoid  fever  during  pregnancy, 
I  have  frequently  seen  it  occur  during  the  lying-in.  Its  commencement  is 
usually  insidious,  the  first  symptoms  having  always  been  those  of  a  puerperal 
inflammation,  and  presenting  all  the  characters  of  the  typhoid  disease  only  after 
the  lapse  of  the  first  few  days,  and  the  disappearance  of  the  abdominal  symptoms. 
What  is  very  singular,  if  I  may  judge  by  the  cases  which  I  have  observed,  the 
typhoid  fever,  so  far  from  being  influenced  unfavorably  by  the  puerperal  state,  is 
even  less  grave  than  in  the  ordinary  conditions  of  life.  Not  one  case  of  17,  of 
typhoid  fever  supervening  a  few  days  after  delivery,  proved  fatal.  The  same 
remark  is  made  by  M.  Fauvel,  who  did  not  witness  a  single  death  in  the  cases 
of  7  recently-delivered  women  in  whom  he  observed  the  disease.  These  facts 
are,  doubtless,  too  few  to  justify  a  definite  conclusion,  though  they  appear  to  me 
of  sufficient  interest  to  deserve  mention. 

2.  The  eriqitive  fevers  seem,  generally,  to  be  much  more  dangerous  to  preg- 
nant women  than  to  other  individuals.  Variola,  especially,  of  all  these  diseases, 
has  the  most  disastrous  influence  upon  the  pregnant  condition ;  some  authors, 
indeed,  state  that  it  is  almost  uniformly  fatal,  particularly  when  it  produces 
abortion. 

It  is  important,  as  regards  the  prognosis,  to  distinguish  between  the  confluent 
and  discrete  forms  of  small-pox.  (Chaigneau.)  The  former,  which  is  so  fatal, 
independent  of  pregnancy,  as  to  destroy  a  third  of  Avhora  it  attacks,  is  still  more 
to  be  dreaded  during  gestation,  sparing,  as  it  docs,  almost  none  of  its  victims; 
the  latter,  on  the  contrary,  is  far  from  always  occasioning  abortion  or  premature 
labor,  and  even  where  the  pregnancy  is  ended  before  term,  the  mother  often 
recovers. 

Dr.  Gariel  thinks  that  the  lumbar  pains  which  are  so  severe  in  the  first  stage 
of  variola,  have  a  great  tendency  to  produce  abortion.  I  have  seen  in  two  cases 
of  the  discrete  form,  slight  contractions  coinciding  with  these  lumbar  pains;  but 
I  was  able  to  arrest  them  by  the  use  of  opiate  injections.     In  several  other  in- 


DISEASES    OCCURRING    DURING     PREGNANCY.  359 

stances,  I  witnessed  nothing  of  the  kind,  and  I  think  with  M.  Chaigneau  (Thesis, 
1847),  that  abortion  is  especially  liable  to  occur  when  the  pustules  are  in  full 
suppuration,  and  the  secondary  fever  appears,  in  connection  with  the  grave  symp- 
toms which  usually  accompany  it. 

When  the  foetus  is  not  expelled,  it  may  continue  to  grow,  and  often  it  does 
not  appear  at  birth  to  have  suffered  much  from  the  disease  which  had  endan- 
gered its  mother's  life  so  greatly ;  in  other  cases,  however,  either  because  it 
receives  the  germ  of  the  disease  which  affects  the  mother,  or  because  the  deep- 
seated  disorders  which  the  variola  produces  in  the  maternal  system  also  exert  an 
unfavorable  influence  upon  the  foetal  life,  it  soon  perishes.  In  the  former  case, 
variolous  pustules,  in  every  respect  similar  to  those  on  the  mother,  may  be  detected 
on  the  body  of  the  child. 

To  recapitulate,  confluent  small-pox  nearly  always  occasions  abortion,  and  this 
is  almost  uniformly  followed  by  the  death  of  the  mother :  out  of  23  alwrtions 
observed  by  M.  Serres  under  these  circumstances,  there  were  22  deaths.  Dis- 
crete small-pox,  on  the  contrary,  generally  allows  the  pregnancy  to  continue  its 
course,  and  even  when  it  interrupts  its  progress,  the  mother  usually  recovers,  and 
in  the  latter  months  the  child  is  expelled  alive. ^ 

3.  Scarlatina,  when  of  some  severity,  acts  in  nearly  the  same  way  as  variola  ; 
the  danger,  however,  is  usually  far  less  both  to  mother  and  child.  It  sometimes 
gives  rise  to  abortion,  and  then  the  patients  very  often  succumb.  My  opinion 
coincides  with  that  of  M.  Serres,  who  thinks  that  women  are  much  more  likely 
to  contract  the  disease  when  recently  delivered  than  they  are  during  pregnancy, 
for  I  have  never  seen  scarlatina  during  gestation,  though  I  have  had  the  misfor- 
tune to  lose  two  newly-delivered  females  from  the  disease. 

4.  Measles,  according  to  Levret,  is  quite  as  grave  as  the  preceding.  In  four 
cases,  however,  observed  by  M.  Grisolle,  the  regular  course  of  gestation  was 
undisturbed,  and  two  similar  instances  have  come  under  my  own  notice. 

5.  Pneumonia  is,  without  doubt,  of  all  the  acute  inflammations  of  the  enve- 
lopes or  of  the  parenchyma  of  the  organs,  one  of  the  most  likely  to  produce  abor- 
tion or  premature  labor.  M.  Grisolle  has  himself  observed  4  cases  of  pneumonia 
in  pregnancy,  and  collected  the  details  of  11  others.  Of  these  15  women,  10 
had  not  reached  the  sixth  month,  and  4  aborted  the  fourth,  fifth,  sixth,  and  ninth 
days  from  the  commencement  of  the  attack.  In  3  cases,  the  abortion  was  fol- 
lowed by  disease  of  the  lungs  of  the  severest  character,  all  proving  fatal  three  or 
four  days  after;  one  only,  whose  pneumonia  was  limited,  recovered  without  serious 
symptoms.  The  6  who  did  not  miscarry,  died  without  exception  during  the  pro- 
gress of  the  disease. 

'  Mead  states,  that  if  the  woman  does  not  miscarry,  the  child  is  protected  from  variola  for 
the  remainder  of  life,  unless  it  should  be  born  before  the  maturity  of  the  pustules.  This 
would  be  a  curious  fact,  but  it  is  denied  by  Contugno.  The  opinion  of  the  latter  may  be 
supported  by  the  following  facts.  Two  pregnant  women  were  inoculated  witb  small-pox ; 
the  eruption  was  discrete,  and  the  pregnancy  went  on.  They  were  delivered,  at  the  usual 
period,  of  two  healthy  children,  who  were  inoculated  when  three  years  old,  and  had  a 
regular  attack  of  variola. 


360  GENERATION. 

Of  the  5  women  who  had  reached  an  advanced  stage,  2  were  seven  months 
pregnant  when  attacked  with  pneumonia :  one  was  delivered  prematurely  on  the 
twelfth,  and  the  other  on  the  fifteenth  day,  both  dying  two  days  after.  The  8 
others  were  in  their  ninth  month :  2  were  delivered  of  living  children  on  the 
seventh  and  eighth  day  of  the  disease ;  the  other  died  undelivered  on  the  fifth 
day. 

From  the  preceding  data  it  may  be  concluded,  that  abortion  usually  follows  an 
attack  of  pneumonia  during  pregnancy.  I  think,  says  M.  GrisoUe,  that  its  dis- 
astrous influence  is  explained  by  the  importance  of  the  organ  affected,  by  the 
gravity  of  the  disease,  the  intensity  of  the  general  reaction,  and  the  numerous 
sympathetic  disorders  which  it  produces  in  all  the  functions,  much  rather  than 
by  the  paroxysms  of  coughing. 

That  the  pregnant  condition  exerts  a  most  dangerous  influence  upon  the  dis- 
ease is  shown  by  the  fact,  that  of  15  women  11  died,  though  the  general  state 
of  health  was  apparently  very  favorable  in  most  of  them.  The  prognosis  seems 
to  be  more  discouraging  before  than  after  the  seventh  month.  Finally,  if  it  be 
allowable  to  conclude  from  so  limited  a  number  of  facts,  abortion,  contrary  to 
what  we  have  seen  in  regard  to  variola,  would  appear  to  be  rather  favorable  than 
otherwise,  since  of  the  4  cases  of  miscarriage  one  recovered,  whilst  the  6  who 
did  not  abort,  all  died.  This  would  seem  to  confirm  the  following  proposition  of 
Desormeaux,  namely :  Abortion,  which  occurs  but  too  often  in  acute  diseases, 
frequently  leads  to  a  favorable  termination  in  inflammatory  affections. 

6.  We  have  but  very  imperfect  data  by  which  to  judge  of  the  reciprocal  influ- 
ence of  pregnancy  and  of  other  acute  inflammations.  The  statements  of  authors 
in  regard  to  it  are  limited  to  a  few  isolated  and  often  contradictory  facts,  whose 
very  restricted  number  allows  no  useful  conclusion  to  be  drawn  from  them. 

Whatever  be  the  acute  affection  from  which  the  pregnant  female  suffers,  the 
treatment  does  not  differ  materially  from  that  which  is  proper  under  ordinary 
circumstances.  So  long  as  there  remains  a  reasonable  hope  of  saving  the  mother 
by  the  use  of  mild  and  innocent  remedies,  none  other  should  be  resorted  to;  but 
if  the  disease  be  dangerous,  and  demands  more  active  but  more  efficient  means, 
it  should  be  treated  as  though  the  woman  were  not  pregnant.  Bleeding  and 
purgation,  which  have  been  reproached  with  a  tendency  to  produce  abortion  may, 
doubtless,  have  that  effect ;  but  it  must  not  be  forgotten  that  they  are  used  here 
to  combat  an  affection  which  is,  of  itself,  a  much  more  active  cause  of  abortion, 
besides  endangering  the  mother's  life  so  seriously. 

§  3.  Chronic  Diseases. 

1.  Icterus. — Though  icterus  appears  to  affect  the  pregnant  condition  unfovor- 
ably,  it  is  not  exactly  true  to  say  that  it  always  arrests  its  progress  and  produces 
abortion,  either  as  regards  the  severest  or  the  lightest  cases  of  the  affection.  I 
have  seen  several  cases  of  simple  jaundice  which  constituted  but  a  slight  indis- 
position, and  in  no  degree  affected  the  gestation.  The  contrary  has,  however, 
been  the  case  in  some  instances,  and  the  two  following,  quoted  by  M.  Ozanam, 
seem  to  me  to  be  evidently  exceptional. 


DISEASES    OCCURRING    DURING    PREGNANCY.  3G1 

A  young  primiparous  woman,  five  months  gone,  had  been  sick  for  five  days 
with  a  very  simple  jaundice,  when  she  entered  the  hospital :  three  days  after,  she 
miscarried.  Another,  seven  months  and  a  half  pregnant,  also  aborted  five  days 
after  the  commencement  of  a  simple  icterus.  Neither  of  the  children  presented 
a  yellow  hue.     Both  mothers  recovered. 

It  is  rarely  that  what  is  described  as  the  grave  form  of  essential  icterus  does 
not  determine  abortion,  and  it  is  also  rare  for  the  latter  not  to  be  followed  by  the 
death  of  the  mother.  Thus,  out  of  the  five  cases  reported  by  Dr.  Kerksig,  in 
the  account  of  the  epidemic  which  occurred  in  the  Margraviat,  in  1794,  there 
were  four  deaths.  M.  Ozanam  relates  the  case  of  a  woman  six  months  pregnant 
who  died  before  miscarrying;  and  my  friend,  Dr.  Fournier,  has  quite  recently 
had  a  case  of  abortion  followed  by  death. 

The  life  of  the  child  is  greatly  endangered  by  its  premature  expulsion,  though 
it  is  rarely  afiected  with  the  mother's  disease.  In  none  of  the  cases  which  have 
come  under  my  notice  did  the  foetus  present  an  icteric  hue,  although  the  amni- 
otic fluid  was  more  or  less  colored.  J.  P.  Frank,  however,  relates  the  case  of  an 
icteric  female  who  was  delivered  of  a  jaundiced  child. 

2.  Intermittent  Fever. — There  can  be  no  doubt  that,  as  M.  Ebrard  has  endea- 
vored to  prove,  the  grave  disorders  and  deep  perturbations  produced  throughout 
the  economy  by  the  febrile  paroxysms,  the  obstinate  vomitings  which  attend 
many  of  them,  and  the  cough,  diarrhoea,  and  colics,  may  disturb  greatly  the 
functions  of  the  womb ;  also  that  the  fluxion  and  congestion  so  often  produced 
by  this  fever,  may  cause  the  premature  expulsion  of  the  product  of  conception. 

The  possibility  of  the  occurrence  being  incontestable,  the  indication  to  remove 
the  morbid  condition  follows  as  a  matter  of  course.  I  mention  this  influence  of 
intermittent  fever  upon  the  pregnant  condition  only  as  affording  an  opportunity 
of  discarding  completely  the  advice  of  some  persons  who  recommend  the  rejec- 
tion of  sulphate  of  quinine,  as  likely  to  produce  abortion  or  premature  labor. 
The  miscarriages  laid  to  the  charge  of  the  sulphate  of  quinine  should  certainly 
be  attributed  to  the  disease  itself,  and  not  to  the  remedy.  For  my  own  part,  I 
have  had  occasion  to  use  it  six  times  at  various  periods  of  pregnancy,  in  doses  of 
ten,  twelve,  and  even  fifteen  grains  in  the  twenty-four  hours,  without  having 
had  to  repent  of  it.  Many  pi-actitioncrs,  who,  like  MM.  Thezet,  Delmaz,  Alamo, 
and  Ebrard,  have  long  practised  in  localities  where  this  fever  is  endemic,  have 
never  been  obliged  to  complain  of  the  action  of  sulphate  of  quinine  when  admi- 
nistered during  pregnancy.  Not  only  is  it  an  innocent  remedy,  but  the  surest 
preventive  means  when  abortion  is  imminent  in  consequence  of  the  fever. 

3.  Sijphlliii. — We  have  already  stated  that  syphilis  may  have  the  most  disas- 
trous effect  upon  the  course  of  gestation,  being  a  very  frequent  cause  of  abortion, 
and  especially  of  premature  labor.  Its  mode  of  action  is  various ;  sometimes, 
for  example,  the  mother  is  in  such  a  cachectic  condition  as  to  be  unable  to  pro- 
vide the  foetus  with  the  material  required  for  its  development,  her  enfeebled  con- 
stitution leaving  the  work  incomplete;  most  genei'ally,  however,  the  health  of  the 
mother  is  not  sensibly  altered,  and  the  action  of  the  poison  seems  to  be  directed 
upon  the  foetus  only.     In  most  cases,  indeed,  the  disease  does  not  disturb  the 


362  GENERATION. 

natural  course  of  gestation,  but  attacks  gravely  the  health  of  the  fcctus.  Nothing 
is  more  connnon  than  for  the  latter  to  perish  at  more  or  less  advanced  periods, 
and  be  expelled  prematurely.  In  these  instances,  numerous  visceral  lesions  are 
discovered  at  the  autopsy;  sometimes  it  is  an  abscess  of  the  thymus  gland  (P. 
Dubois) ;  sometimes  purulent  collections  in  the  lungs  (Depaul) ;  sometimes, 
again,  is  found  that  singular  alteration  of  the  liver  so  well  described  of  late  by 
M.  Gubler,  or  those  traces  of  peritoneal  inflammation  and  scro-purulent  effusions 
pointed  out  by  Dr.  Simpson  as  due  to  the  same  cause.  Neither  is  it  rare  to  find 
numerous  bulla)  of  pemphigus  upon  various  parts  of  the  body  of  the  child,  espe- 
cially upon  the  soles  of  the  feet,  and  the  palms  of  the  hands. 

Should  these  lesions  not  be  developed  until  the  pregnancy  is  far  advanced,  the 
foetus  is  born  at  term,  and  then  is  often  dead,  or  almost  dying  at  the  moment  of 
delivery ;  in  other  instances  it  has  every  appearance  of  perfect  health,  but  the 
fatal  germ  derived  from  its  parents  is  soon  developed,  and  it  perishes  rapidly. 
At  the  autopsy,  the  alterations  mentioned  are  frequently  discovered.  These 
lesions  appear,  therefore,  to  be  oftenest  due  to  hereditary  syphilis;  and  had  MM. 
Dubois  and  Depaul  contented  themselves  with  stating  that,  in  the  majority  of 
cases,  this  was  the  cause,  they  would  have  met  with  no  opposition ;  they  went, 
however,  much  too  far  in  asserting  that  notliing  but  syphilis  is  capable  of  pro- 
ducing these  lesions,  and  that  their  presence  in  the  foetal  organs  was  sufficient 
evidence  of  a  venereal  infection  of  the  father  or  mother,  even  though  the  latter 
might  present  no  trace  of  it,  and  declare  that  they  had  never  been  affected  with 
the  disease. 

A  much  larger  number  of  facts  than  they  relied  on,  were  necessary  to  esta- 
blish so  absolute  a  proposition ;  for  a  coincidence  should  occur  a  gi-eat  number  of 
times  before  being  held  to  establish  an  absolute  relation  of  causality,  and  that, 
especially,  when  contrary  facts  are  never  met  with.  Now,  unless  we  regard  the 
observations  occurring  in  science  as  badly  made,  these  two  conditions  are  wanting 
in  the  present  instance. 

Finally,  there  are  cases,  which,  too,  according  to  all  specialists,  are  the  most 
numerous,  where  the  pregnancy  passes  regularly  through  all  its  periods,  where 
the  child  presents  no  appreciable  alteration  at  birth  nor  during  the  days  imme- 
diately succeeding,  and  in  which  the  symptoms  of  constitutional  syphilis  appear 
only  after  the  lapse  of  six  weeks  or  two  months. 

Cases  such  as  we  have  just  mentioned  are,  unfortunately,  but  too  common ;  it 
is  not,  however,  to  be  understood  that  every  child  born  of  infected  parents  must 
necessarily  suffer  all  the  consequences.  We  even  insist  that  such  is  not  the  most 
frequent  result,  for  considering  the  large  number  of  parents  who  are  diseased,  or 
who  have  been,  the  syphilitic  lesions  of  new-born  children  would  be  much  more 
frequent  than  is  really  the  case. 

M.  Legendre,  in  discussing  the  question  of  the  latent  condition  of  syphilis  in 
the  parents,  and  of  its  influence  upon  the  health  of  the  child,  arrives  at  a  denial 
of  this  influence  in  the  majority'  of  cases. 

Of  the  fi.'>  patients  who  came  under  my  observation,  he  says,  there  were  14, 
who  had  altogether  G8  children,  during  the  period  intervening  between  the  dis- 


DISEASES    OCCURRING    DURING     PREGNANCY.  363 

appearance  of  the  primary  symptoms  and  the  development  of  the  venereal  erup- 
tion. Of  this  number,  35  died  -without  ever  having  had  an  eruption  upon  the 
body.  The  mean  of  the  ages  of  these  children  at  death  was  7  years ;  the  ex- 
tremes being  6  months  and  22  years. 

All  the  33  surviving  children  enjoyed  good  health,  the  mean  of  their  ages 
being  17  years;  the  extremes  1  year  and  38  years. 

4.  Fhthisif — ^lost  authors,  in  writing  upon  this  disease,  have  given  cuiTcncy 
to  the-idea,  that  its  progress  is  arrested  by  the  occurrence  of  pregnancy,  but  that 
immediately  after  delivery,  the  pulmonary  affection  advanced  rapidly  to  a  fatal 
termination. 

In  a  work  read  lately  before  the  Academy  of  Medicine,  M.  Grisolle  has 
endeavored  to  determine  the  reciprocal  influence  of  these  two  conditions,  and 
in  so  doing  Jias  arrived  at  somewhat  different  conclusions  from  those  which  had 
been  received  as  a  general  expression  of  the  truth.  We  think  it  right  to  give  a 
brief  analysis  of  this  memoir. 

Of  seventeen  cases  collected  by  M.  Grisolle,  and  ten  others  furnished  him  by 
M.  Louis,  twenty-four  were  those  of  women  attacked  with  the  disease  during 
pregnancy,  at  periods  not  far  removed  from  its  commencement ;  the  three  others 
had  reference  to  individuals  who  presented  the  rational  signs  of  tuberculosis 
at  the  time  of  conception,  but  in  whom  the  disease  became  well-marked  only 
at  a  later  period. 

In  none  of  these  cases  was  the  pulmonary  affection  arrested,  nor  did  it  fiiil  to 
progress  quite  rapidly.  The  symptoms  peculiar  to  tuberculosis,  whether  local  or 
general,  were  developed  with  the  same  order,  the  same  regularity,  and  the  same 
constancy  as  in  the  ordinary  conditions  of  life.  But,  on  the  other  hand,  con- 
trary to  what  might  have  been  expected,  the  pregnant  condition  neither  aggra- 
vated, nor  rendered  more  frequent,  the  accidents  of  the  disease ;  bronchial 
hemorrhage  was  noticed  as  being  even  rather  less  frequent  than  usual. 

The  entire  duration  of  the  phthisis  in  13  women  who  were  followed  to  the  end, 
was  rather  shortened  than  otherwise.  Thus,  in  all  of  them  it  lasted  on  an  average 
nine  months  and  a  half,  which  is  a  figure  more  than  a  third  less  than  that  which 
expresses  its  duration  for  women  of  the  same  age,  but  not  pregnant. 

Pregnancy  has  not,  therefore,  the  power  of  suspending  phthisis  which  has 
been  supposed.  But  is  it  true,  as  is  generally  believed,  that  labor,  and  the  puer- 
peral condition,  give  to  the  process  of  tuberculization  such  an  unusual  impulse 
as  to  make  it  prove  fatal  in  a  very  short  time?  The  facts  appealed  to  by  M. 
Grisolle,  invalidate  this  opinion  also.  Thus,  12  women,  in  whom  the  disease  had 
reached  the  second,  and  in  most  of  them  the  third  degree,  at  the  time  of  delivery, 
resisted  its  inroads  for  four  months  on  an  average;  and  in  all,  the  symptoms  fol- 
lowed the  progression  that  is  usually  observed.  In  10  others,  in  whom  the  affec- 
tion was  in  the  first  degree,  or  at  the  beginning  of  the  second,  at  the  period  of 
delivery,  the  pulmonary  lesion  was  found  in  3  to  advance  slowly;  in  two  only  did 
it  exhibit  a  notable  aggravation ;  whilst  in  5,  or  one-half  the  number,  there  was 
a  considerable  amelioration  both  of  the  general  health  and  local  symptoms,  with- 


364  GENERATION. 

out,  however,  encouraging  the  hope  of  a  cure,  or  of  a  long  suspension  of  the 
disease. 

Does  phthisis  exert  an  unfavorable  influence  upon  the  progress  of  gestation  ? 
In  this  point  of  view,  it  may  at  least  be  regarded  as  much  less  serious  than  pneu- 
monia. Thus,  of  22  women,  only  3  aborted  in  the  fourth  and  sixth  months,  3 
were  delivered  prematurely  about  the  eighth  month,  whilst  all  the  others  reached 
their  full  time ;  however,  in  nearly  two-thirds  of  the  latter,  the  pulmonary  dis- 
ease commenced  in  the  early  months  of  gestation,  passed  through  all  its  phases, 
and  produced  a  deep-seated  cachexia. 

With  one  exception,  delivery  was  accomplished  after  four  or  five  hours  of  suf- 
fering, which  is  explained  rather  by  the  relaxation  and  want  of  resistance  of  the 
soft  parts,  than  by  the  small  size  of  the  children.  Although  the  latter  were 
generally  feeble  and  emaciated,  yet  in  more  than  a  quarter  of  the  _^nuraber  the 
tissues  were  firm,  the  form  rounded,  and  of  an  embonpoint,  contrasting  remark- 
ably with  the  reduced  condition  of  the  mother. 

In  all  the  patients,  except  those  who  were  in  the  last  stage  of  consumption, 
and  who  died  a  few  days  or  weeks  after  delivery,  milk  was  secreted,  and  in  the 
majority  of  cases  so  abundantly,  that  it  was  impossible  to  prevent  them  from 
nursing  the  children. 

The  flow  of  milk,  however,  lessened,  or  even  ceased,  within  a  period  varying 
from  one  to  four  weeks ;  and  even  this  short-lived  lactation  was  always  accompa- 
nied by  a  sensible  aggravation  of  the  disease,  and  had  the  most  disastrous  eff"ects 
upon  the  children ;  for  they  died  shortly  after  of  softening  of  the  intestinal 
mucous  membrane. 

From  a  very  interesting  memoir  upon  the  same  subject,  by  M.  Dubrueille,  of 
Bordeaux,  it  appears  that  the  result  of  his  observations  has  been  nearly  the  same. 

In  short,  neither  pregnancy  nor  delivery  afi'ect  the  progress  of  phthisis;  nor 
does  the  latter  disturb  sensibly  the  course  of  the  former. 

5.  Hysteria,  Epilepay,  Mental  Diseases,  Chlorosis. — Some  physicians  have 
imagined  that  the  occurrence  of  pregnancy  might  exert  a  favorable  influence 
upon  hysteria  or  epilepsy,  either  by  suspending  the  attacks  during  the  continu- 
ance of  gestation,  or  even  by  ridding  the  patients  of  these  affections  entirely. 
Unfortunately,  these  hopes  have  not  been  realized  by  experience ;  for  although 
the  convulsive  attacks  have  seemed  in  some  cases  to  be  less  frequent,  or  have 
even  ceased  entirely,  in  others,  they  have  occurred  much  oftener  than  before. 
M.  Malgaigne  mentions  a  remarkable  case  in  which  the  first  epileptic  attack 
came  on  during  pregnancy  in  an  unfortunate  female  who  had  never  before  been 
afi'ected  with  it,  and  who  retained  it  throughout  her  futura  life. 

As  regards  mania  and  dementia,  we  can  scarcely  hope,  says  Desormeaux,  for 
either  a  lasting  amelioration  or  an  entire  cure,  except  they  be  due  to  disordered 
menstruation  or  certain  uterine  diseases.  Under  other  circumstances,  I  think 
that  pregnancy  is  rather  hurtful  than  useful,  though  not  in  itself,  but  in  conse- 
quence of  the  debility  succeeding  to  delivery. 

Marriage,  and  the  consequent  pregnancy,  have  often  been  recommended  as 
the  best  means  of  curing  chlorosis.     When  this  disease  appears  to  have  been 


DISEASES     OCCURRING    DURING    PREGNANCY.  365 

produced  by  disappointed  love,  the  cause  may,  indeed,  be  thus  removed,  and  the 
remedies  directed  against  it  rendered  more  eflBcacious.  Pregnancy  may,  in  this 
way,  regulate  the  uterine  functions  for  the  future,  cure  the  dysmenorrhoea,  and 
consequently  have  a  favorable  effect  when  the  irregular  or  difficult  menstruation 
was  the  cause  of  the  chlorosis.  Under  all  other  circumstances,  however,  preg- 
nancy has  seemed  to  me  to  aggravate  the  chlorotic  symptoms.  I,  therefore,  think 
it  most  prudent  to  defer  marriage  until  after  the  general  health  of  the  patient  is 
improved. 

§  -i.  Surgical  Diseases. 

1.  The  pregnant  condition  often  has  a  favorable  effect  upon  scrofulous  ulcers. 
Under  the  influence  which  it  exerts  upon  the  entire  organism,  glandular  en- 
gorgements sometimes  disappear,  diseases  of  the  bones  are  modified  favorably, 
ulcers  become  clean  and  covered  with  bright,  firm  granulations,  and  cicatrization 
follows. 

In  many  cases,  it  has  appeared  to  arrest  the  consolidation  of  fractures.  A 
curious  instance  of  the  kind  is  mentioned  by  Alanson.  A  woman  broke  her  tibia 
when  in  the  second  month  of  her  pregnancy,  and  during  the  seven  succeeding 
months,  the  solidification  made  no  progress.  Nine  weeks  after  delivery,  the 
callus  was  strong  enough  to  admit  of  walking.  As  proving  that  no  constitutional 
depravation  could  be  adduced  in  explanation  of  the  retarded  cure,  he  adds,  that 
three  months  before  impregnation,  she  had  recovered  rapidly  from  a  fractured 
thigh.  My  friend.  Dr.  Fournier,  cites  three  analogous  cases  from  Dupuytren's 
Clinic.  In  all  three,  there  was  no  consolidation  before  delivery,  though  it  took 
place  rapidly  afterward.  Though  other  similar  instances  are  on  record,  it  must 
be  acknowledged  that  there  is  also  a  considerable  mimber  in  which  recovery  did 
not  seem  to  be  at  all  delayed  by  the  pregnant  condition. 

2.  Serious  operations  have  several  times  been  performed  during  gestation 
without  producing  abortion,  whilst  in  other  cases  they  have  had  this  result. 
From  these  opposite  facts,  I  think  it  fliir  to  conclude  that  none  but  urgent  opera- 
tions should  be  performed,  and  that  all  others,  such  as  fistula  in  ano,  for  example, 
which  do  not  endanger  the  life  of  either  mother  or  child,  should  be  deferred  to 
another  time. 

3.  Tumors  in  the  Abdomen  and  Pelvis. — Most  authors  think  that  tumors  in 
the  abdomen  and  pelvis  during  pregnancy,  have  no  other  effect  than  to  impede 
mechanically  the  development  of  the  uterus,  or  to  present  an  obstacle  to  the 
delivery.  Sometimes,  however,  they  assort,  they  may  give  rise  to  abortion  or 
premature  delivery,  though,  generally,  they  are  not  otherwise  dangerous. 

That  this  complication  is  of  no  danger,  independent  of  the  risk  of  abortion 
which  it  may  occasion,  cannot  be  admitted  in  an  absolute  sense.  Dr.  Ashwell 
has  remarked  in  his  excellent  work,  that  the  uterus,  when  developed  until  term, 
exerts  a  strong  compressing  force  upon  the  pathological  tumor;  that  this  com- 
pression may  give  rise  to  an  inflammation  ending  sometimes  in  suppuration  at  the 
centre  of  the  diseased  mass,  at  others,  in  a  rapid  increase  of  the  tumor  immedi- 
ately after  delivery.     I  have  several  times  had  the  opportunity  of  verifying  the 


366  GENERATION. 

accuracy  of  these  statements.  Death  may  occur  in  a  short  time,  as  the  conse- 
quence of  this  inflammation  or  rapid  enlargement,  and  the  autopsy  has  several 
times  exhibited  the  uterus  in  a  perfectly  healthy  state,  together  with  the  more  or 
less  extensive  alteration  of  the  pathological  tumor. 

Deeply  impressed  by  the  cases  of  this  kind  which  he  had  occasion  to  observe, 
Dr.  Ashwell  asks,  whether  the  development  of  the  uterus,  and  the  pressure 
which  it  exerts  upon  the  neighboring  tumor,  are  not  the  causes  of  the  patholo- 
gical changes  of  the  latter,  and  consequently  whether  the  induction  of  prema- 
ture labor  would  not  be  the  surest  means  of  guarding  against  the  dangers  to 
which  the  female  is  so  often  exposed  in  these  cases,  even  after  having  overcome 
all  the  difficulties  of  labor.  When  treating  hereafter  of  premature  labor,  we  shall 
have  occasion  to  criticise  the  affirmative  decision  which  he  has  come  to;  but  we 
have  thought  it  i-ight  to  direct  attention  to  a  peculiarity  but  little  known  in  the 
history  of  the  tumors  which  complicate  pregnancy. 

4.  latra-parietal  fibrous  tumors,  or  those  developed  in  the  substance  of  the 
walls  of  the  uterus,  may  exert  an  injurious  influence  upon  the  cour.>e  of  gestation, 
and  become  a  cause  of  abortion  when  they  are  of  large  size ;  though  generally, 
they  have  no  effect  whatever  when  small.  In  the  latter  case,  the  physiological 
evolution  of  pregnancy  may  accelerate  wonderfully  the  increase  of  the  patho- 
logical tumor.  The  usually  slow  growth  of  these  intra-parietal  tumors  is  well 
known  ;  now  I  have  known  them  in  several  instances  to  acquire  a  size,  in  the  first 
three  or  four  months,  which  they  would  not  have  done  in  several  years  in  the 
non-pregnant  condition.  Developed  as  they  are  in  the  midst  of  the  uterine 
fibres,  they  participate  in  the  increased  vitality  with  which  the  latter  are  endowed 
during  gestation,  and,  like  them,  they  undergo  a  considerable  hypertrophy. 

In  some  cases  I  have  seen  .this  hypertrophy  of  the  morbid  tumor  continue,  and 
even  increase  after  delivery ;  but  in  others,  the  latter  event  was  followed  by  a 
notable  diminution  of  the  size  of  the  tumor,  which  gradually  grew  less  as  the 
•womb  resumed  its  normal  condition,  finally  attaining  the  size  which  it  bad  before 
conception.  In  one  case,  observed  in  1852,  this  process  of  absorption  went  on, 
and  the  tumor  disappeared. 

§  5.  Ulcerations  of  the  Neck  op  the  Uterus, 

It  is  rarely  that  cancerous  aflfections  of  the  neck  of  the  womb  seem  to  disturb 
the  course  of  gestation,  and  the  impediments  which  they  but  too  often  present 
during  labor,  prove  sufficiently  that  they  are  rarely  a  cause  of  miscarriage.  On 
the  other  hand,  I  have  never  observed  that  the  increase  or  degeneration  of  these 
tumors  was  sensibly  hastened  during  gestation.  Therefore,  I  shall  treat  no 
further  here  of  this  subject,  reserving  its  discussion  for  the  article  on  tedious 
labor ;  but  propose  to  speak  briefly  of  ulcerations  of  the  neck  during  pregnancy. 

It  has  been  but  a  short  time  since  surgeons  have  used  the  speculum  in  the 
cases  of  pregnant  women.  A  just  fear  of  the  mischievous  effect  which  might 
follow  its  repeated  introduction  prevented  them  from  obtaining  a  correct  idea  of 
the  condition  of  the  neck  at  the  various  stages  of  pregnancy.  These  fears  were, 
however,  somewhat  exaggerated,  for,  if  introduced  carefully,  the  speculum  never 


DISEASES     OCCURRING    DURING    PREGNANCY.  3G7 

causes  serious  accidents.     In  all  cases,  the  instrument  with  two  or  four  valves,  is, 
in  my  opinion,  the  best. 

Whenever,  in  default  of  great  experience,  there  is  considerable  difficulty,  no 
matter  what  instrument  be  used,  in  engaging  the  cervix  in  the  extremity  of  the 
speculum,  unless  the  situation  of  the  neck  is  first  ascertained  by  the  touch.  This 
difficulty  is  known  to  result  from  the  fact  of  the  direction  of  the  cervix  toward 
the  anterior  surface  of  the  sacrum. 

The  engagement  once  effected,  it  is  only  necessary  to  separate  the  valves  of 
the  instrument  slightly  in  order  to  bring  the  os  tincaa  into  view. 

As  the  touch  should  have  led  to  anticipate,  the  changes  which  the  eye  detects 
in  the  intra-vaginal  portion  of  the  neck,  are  very  different  in  the  primiparous 
female  from  what  they  are  in  one  who  has  had  children  j  we  would  also  add, 
that  the  ajjpearance  is  far  from  identical  at  the  beginning  and  termination  of 
pregnancy. 

As  seen  in  the  latter  third  of  gestation,  the  neck  is  generally  of  a  deep  violet 
red  color;  and,  if  it  be  a  first  pregnancy,  is  usually  quite  smooth  throughout  its 
extent:  the  external  orifice  is  ordinarily  more  or  less  rounded,  and  though  larger 
than  in  the  unimpregnated  condition,  it  barely  permits  the  sight  to  penetrate  its 
cavity,  even  though  the  valves  of  the  instrument  be  sepai'ated  considerably.  The 
circumference  of  the  external  orifice  and  the  free  portion  of  the' neck,  rarely  exhi- 
bit signs  of  ulceration,  though  it  is  quite  common  to  observe  a  series  of  granula- 
tions of  a  cherry-red  color,  of  sizes  varying  from  that  of  a  large  pea  to  that  of  a 
pin's  head.  These  species  of  vegetations  bleed  upon  the  slightest  touch  with  the 
cotton  used  for  wiping  them. 

In  the  female  who  has  had  several  children,  the  neck  is  usually  much  less 
voluminous,  and  it  is  somewhat  difficult  to  include  it  entirely  in  the  speculum. 
The  lips  of  the  os  tincae  seem  divided  in  several  portions,  a  sort  of  segmentation 
caused  by  the  ruptures  which  occurred  in  the  preceding  labors,  and  which  give 
to  the  orifice  considerable  irregularity.  In  consequence  of  these  numerous  solu- 
tions of  continuity,  the  opening  is  much  larger,  and  is  dilated  with  great  facility, 
provided  the  valves  be  sepai'ated,  thus  allowing  the  eye  to  explore  the  cavity  with 
readiness. 

The  walls  of  this  cavity  are  very  unequal,  frequently  presenting  an  uninter- 
rupted series  of  fungous  projections,  separated  by  depressions  of  variable  depth. 
Some  of  these  projections  are  transparent,  being  formed  probably  by  hypertro- 
phied  follicles ;  others  resemble  soft  vegetations.  The  latter  are  generally  covered 
by  an  intact  epithelium,  so  that  they  may  be  touched  without  being  made  to 
bleed ;  again,  what  is  by  no  means  rare,  they  seem  destitute  of  this  external 
covering,  and  bleed  upon  the  slightest  touch. 

It  is  more  especially  in  the  furrows  which  separate  these  that  linear  ulcerations 
of  variable  depth  are  discoverable.  These  ulcerations  sometimes  extend  over  a 
considerable  surface,  and  are  then  readily  perceived,  though  they  are  usually  con- 
cealed in  the  depth  of  the  anfractuosities,  and,  in  order  to  see  them,  it  is  neces- 
sary, after  a  thorough  cleansing,  to  unfold  the  neck,  as  it  were,  by  expanding  the 
speculum  considerably. 


368  GENERATION. 

According  to  MM.  Gosselin,  Danyau,  and  Costilhes,  ttese  linear  ulcerations 
are  much  less  frequent  than  I  had  supposed,  and  are  met  with  in  barely  more 
than  half  the  cases,  whilst  I  had  observed  them  in  seven-eighths.  However,  as 
I  stated  very  plainly,  I  intended  to  be  understood  as  speaking  only  of  multiparae 
■who  had  reached  the  latter  months,  whilst  M.  Gosselin  includes  in  his  statement 
all  stages  of  pregnancy,  and  M.  Danyau  does  not  appear  to  have  distinguished 
primiparai  from  multiparoe. 

Must  we  admit  that,  as  M.  Huguier  supposes,  we  have  been  deceived  ?  Ac- 
cording to  this  gentleman,  a  muco-pus  of  variable  consistence  is  frequently  depo- 
sited in  and  adheres  closely  to  the  bottom  of  the  furrows  observed  on  the  internal 
surface  of  the  neck.  This  matter  bears  a  complete  resemblance  to  the  bottom  of 
an  ulcer;  but  eiface  the  folds  and  wipe  them  well,  and  the  supposed  ulcerations 
disaj^pear.  .  .  It  is  difficult  for  us  to  believe  that  we  have  been  so  deceived ; 
still,  the  assertion  of  M.  Huguier  merits  serious  attention,  and  shall  receive  it 
hereafter. 

Unless  my  observations  have  been  for  a  long  time  subject  to  a  series  of  singular 
coincidences,  it  is  probable  that  what  we  have  just  described  is  the  normal  con- 
dition, and  should  not  be  regarded  as  pathological,  but  simply  as  a  consequence 
of  the  progress  of  gestation.  As  the  violet-red  color,  the  swelling,  the  softening, 
and  the  almost  fungous  condition  of  the  walls  of  the  neck,  are  peculiar  to  preg- 
nancy, and  in  nowise  interfere  with  its  progress,  so  I  regard  the  ulcerations  as  a 
consequence  of  a  physiological  process,  extreme  in  degree,  and  of  no  greater  im- 
portance than  they. 

Especially  am  I  convinced  of  their  non-injurious  character,  and  therefore 
regard  all  treatment  employed  against  these  ulcerations,  even  when  fun  (/aid,  as 
much  more  hurtful  than  useful.  I  say,  even  fungoid  ;  for,  contrary  to  the  opinion 
of  M.  Coffin,  who  attributes  a  great  prognostic  value  to  this  character  of  the 
ulceration,  I  think  that  they  are  fungoid,  not  because  they  have  a  natural  ten- 
dency to  become  so,  but  because  the  tissue  which  they  affect  always  presents  at 
a  certain  period  the  color  and  consistence  of  fungous  tissue. 

If,  therefore,  I  am  not  deceived,  and  if  the  peculiarities  just  described  really 
form  a  part  of  the  pregnant  condition,  and  are  merely  an  exaggeration  of  the 
changes  which  the  structure  and  vascularity  of  the  walls  of  the  uterus  undergo 
at  this  period,  the  condition  should  disappear  with  the  cause  which  produced  it. 
Like  the  vomitings,  varices,  hemorrhoids,  and  other  sympathetic  disorders  of 
pregnancy,  it  should  disappear  with  it.  Now  this  is  exactly  what  happens,  and 
it  may  be  regarded  as  a  principle,  that  no  traces  of  it  remain  two  months  after 
delivery.  The  non-specific  ulcerations  sometimes  met  with  in  recently-delivered 
women  are  of  different  appearance,  and  have  their  origin,  in  my  opinion,  in  the 
non-cicatrization  of  the  ruptures  which  took  place  during  labor. 

In  short,  therefore,  the  fungous  condition  of  the  neck,  and  the  ulcerations  of 
greater  or  lesser  depth  which  complicate  this  state  of  the  parts  near  the  termina- 
tion of  pregnancy,  seem  to  me  to  be  the  consequence  of  the  active  or  passive 
congestion  with  which  the  organ  is  affected.  I  think  that,  except  in  a 
few  rare  instances  marked  by  specificity  of  character,  or  strong  tendency  to 


DISEASES    OCCURRING    DURING    PREGNANCY.  369 

spread, — a  tendency,  by  the  way,  wliich  I  have  never  observed, — all  local  treat- 
ment should  be  refrained  from. 

Is  the  case  the  same  at  a  less  advanced  period,  and  are  the  ulcerations  which 
may  afifect  the  neck  in  the  early  months  of  an  equally  innoxious  character  ? 

MM.  Boys  de  Loury,  Costilhes,  Coffin,  and  Bennett,  who  have  directed  their 
attention  more  particularly  to  the  ulcerations  occurring  in  the  first  half  of  gesta- 
tion, have  been  so  forcibly  struck  with  their  tendency  to  produce  abortion  and 
puerperal  diseases,  that  they  class  them  with  the  most  common  causes  of  mis- 
carriage. Mr.  Bennett  goes  so  far  as  to  call  them  the  keystone  of  all  the  diseases 
of  the  pregnant  female,  and  the  most  frequent  cause  of  difficult  labors,  obstinate 
vomiting,  moles,  abortion,  and  hemorrhage. 

Notwithstanding  the  smallness  of  their  number,  the  observations  which  I  have 
been  able  to  make,  differ  so  completely  from  the  results  obtained  by  these  gentle- 
men, that  I  was  tempted  to  accuse  them  of  some  exaggeration.  However,  after 
having  heard  MM.  Huguier,  Gosselin,  Danyau,  Cloquet,  &c.,  proclaim  the  inno- 
cence of  these  ulcerations,  I  have  no  hesitation  in  saying  that  they  have  miscon- 
strued the  facts  observed  by  them.  Finally,  we  would  add,  that  after  having 
read  their  observations,  there  seemed  reason  for  inquiring  whether,  in  many 
cases,  syphilis  may  not  have  been  the  principal  cause  of  the  accidents,  and  in 
others,  whether  the  frequent  introduction  of  the  speculum,  and  the  numerous 
cauterizations  which  had  been  practised,  may  not  have  played  the  most  impor- 
tant part  in  the  production  of  the  abortions. 

I  ought,  perhaps,  to  except  the  peculiar  species  of  ulceration  described  by  my 
friend,  M.  Richet.  All  the  varieties  of  ulceration,  says  this  learned  surgeon, 
which  are  observed  in  non-pi"egnant  women,  may  occur  during  pregnancy ;  but 
it  has  seemed  to  me  that  they  had  a  tendency  in  some  cases  to  assume  a  fungous 
character,  to  excavate  the  lips  of  the  cervix,  to  bleed  readily,  and  give  rise  to 
serious  accidents ;  abortion,  for  example.  In  all  my  patients,  these  ulcerations 
with  well-defined  edges,  and  red  and  bleeding  bottoms,  were  covered  with  red- 
dish fungosities,  which  projected  between  the  partly-opened  lips  of  the  cervix. 
Of  6  patients,  four  miscarried,  and  two  left  the  hospital  apparently  cured ;  of  the 
four  who  aborted,  one  only  had  been  cauterized,  the  three  others  not  having 
undergone  any  treatment. 

Whoever,  like  myself,  has  examined  women  at  the  end  of  gestation,  will  find 
the  ulcerations  observed  by  M.  Bicliet  in  the  early  months,  and  which  he  has 
had  the  kindness  to  show  me,  to  bear  a  close  resemblance  to  those  sometimes  met 
with  in  the  latter  stages.  I  see  no  diSerence,  except  in  the  rather  greater  extent 
of  the  ulceration.  Their  size  leads  me  to  suppose  that  their  origin  dates  back 
long  before  impregnation,  and  their  sharp,  well-defined  edges,  excite  a  suspicion 
of  their  being  specific  in  character  (five  of  these  six  women  had  syphilis  at  the 
time,  or  had  previously  been  affected  with  it).  Now  we  may  readily  conceive 
that  under  such  circumstances,  the  softening,  congestion,  and  fungous  condition 
which  pregnancy  usually  produces  at  an  advanced  period,  may  here  take  place 
prematurely,  and  give  to  the  ulcerated  tissues  the  livid  hue  and  fungous  aspect 
described  by  M.  Eichet.     Thus,  we  may  understand  how  such  an  affection  of  the 

2-4 


370  GENERATION. 

cervix,  connected  most  frequently  witli  a  general  disorder,  under  whose  influence 
it  has  a  constant  tendency  to  increase,  may  ultimately  give  rise  to  abortion.  It 
also  seems  to  me  important  to  distinguish  the  ulcerations  which  existed  before 
pregnancy,  and  continued,  and  even  increased  after  conception,  from  those  which 
were  developed  after  the  formation  of  the  germ ;  the  former,  in  consequence  of 
the  irritation  which  they  may  suffer  as  a  consequence  of  fotigue,  and  especially 
of  too  frequent  coition,  might  readily  excite  the  contractility  of  the  uterus  and 
occasion  miscarriage ;  the  latter,  on  the  contrary,  should,  it  seems  to  me,  rarely 
exert  such  an  influence. 

I  agree,  therefore,  with  the  opinion  of  M,  Richet,  that  when  an  ulceration 
presents  in  the  first  half  of  gestation,  possessing  the  characters  which  he  de- 
scribes, and  which,  in  ray  opinion,  are  an  evidence  of  its  chronicity,  miscarriage 
should  be  anticipated,  and  means  be  taken  to  prevent  it.  Now,  aside  from  a 
specific  treatment  in  those  cases  which  indicate  it,  I  may  be  allowed  to  ask  of 
those  who  would  have  these  ulcerations  treated  as  a  matter  of  necessity,  what  are 
the  best  local  means  to  be  used  ?  "Which  caustic  is  preferable  ?  Is  not  the  solid 
nitrate  of  silver  accused  of  producing  abortion  by  the  partisans  of  the  caustic  of 
Pilhos,  of  the  acid  nitrate  of  mercury,  or  of  the  actual  cautery,  and  has  not  each 
of  these  latter  means  also  been  reproached  with  giving  rise  to  miscarriage  ?  The 
thesis  of  M.  Coflin  affords  some  curious  details  on  this  subject,  and  evidently 
proves,  that  though  cauterization  by  any  agent  whatever  may  claim  some  doubtful 
successes,  the  latter  are  greatly  compromised  by  the  abortions  which  have  fol- 
lowed it.  From  the  statements  of  Bennett  and  Boys  de  Loury,  the  same  infer- 
ence follows.  M.  Coflin  himself,  though  attributing  such  great  importance  to 
these  ulcerations,  arrives  at  this  discouraging  therapeutic  cojidusioii,  viz.,  thus 
far,  no  treatment  has  succeeded,  and  the  question  remains  open.  This,  which 
was  true  in  1851,  is  so  still;  for  quite  recently  we  heard  M.  Chassaignac  speak 
emphatically  of  the  inefficiency  of  all  methods,  and  M.  Richet  declares  himself 
undecided  as  to  the  best  course  to  pursue. 

The  insufficiency  of  local  treatment,  and  the  mischievous  effect  which  it  may 
have  upon  the  progress  of  gestation,  should,  it  seems  to  me,  in  the  present  con- 
dition of  science,  lead  us  to  dispense  with  it,  whenever  the  ulceration  has  no 
marked  tendency  to  invade  a  large  extent  of  the  cervix. 


PART    III. 

OF  LABOR  IN  GENERAL. 


Labor  is  that  function  whicli  consists  in  the  spontaneous  or  artificial  expulsion 
of  a  viable  foetus  through  the  natural  parts  of  generation. 

This  definition  of  labor,  differing  as  it  does  some\Yhat  from  those  given  by 
most  modern  writers,  has  the  advantage  of  furnishing  me  a  basis  whereon  to 
found  a  practical  division ;  for  when  the  expulsion  of  the  foetus  takes  place  from 
the  efforts  of  nature  alone,  it  is  called  a  spontaneous,  or  a  natural  labor;  but 
when  nature  is  inadequate  to  the  accomplishment  of  this  effect,  and  art  is  obliged 
to  intervene,  the  delivery  is  said  to  be  arfijjict'al,  laborious,  and  also  (though 
improperly)  unnatural. 

This  function  has  also  received  different  denominations,  according  to  the  period 
of  pregnancy  at  which  it  is  manifested ;  thus,  it  has  been  named  hyitimate, 
timely,  or  at  term,  when  occurring  within  a  week  before  or  after  the  expiration 
of  the  ninth  month.  On  the  contrary,  it  is  called  ^re»ia^»rc,  or  j^recocious,  if  it 
takes  place  during  the  seventh,  the  eighth,  or  the  beginning  of  the  ninth  month. 
Again,  the  latter  may  be  spontaneous  or  artificial,  according  to  whether  it  is 
simply  the  work  of  nature  or  has  been  brought  on  by  the  intervention  of  art. 
This  last  case  should  be  carefully  distinguished  from  what  the  ancients  called 
forced  labor,  in  which  they  not  only  provoked  the  manifestation  of  the  uterine 
contractions,  by  a  more  or  less  direct  irritation,  but  effected  the  delivery  at  once. 

Lastly,  it  is  called  tardy,  or  retarded,  when  the  delivery  is  not  accomplished 
before  nine  months  and  a  half  or  ten  months. 


BOOK  I. 

OF  PREMATURE  AND  RETARDED  LABORS. 
ARTICLE   I. 

OF   PREMATURE   LABOR. 

When  a  woman  is  delivered  in  the  seventh  or  eighth  month  of  her  gestation, 
the  labor  is  said  to  be  premature.    Now  a  great  number  of  causes  may  determine 


372  LABOR. 

the  expulsion  of  tlie  child,  before  the  ordinary  term  of  its  intra-uterine  life ; 
such,  for  instance,  as  an  excessive  distension  of  the  womb,  whether  this  be  occa- 
sioned by  too  great  a  quantity  of  the  amniotic  liquid,  by  hydrorrhoea,  or  by  the 
presence  of  two  or  more  infants  in  the  uterine  cavity;  the  accidental  death  of  the 
foetus ;  the  artificial  evacuation  of  the  liquor  amnii ;  any  violent  muscular  effort ; 
the  abuse  of  strong  purgatives ;  various  acute  diseases,  more  especially  those  of 
the  skin ;  and  certain  conditions  of  the  animal  economy,  as  plethora,  great  debi- 
lity, or  an  excessive  irritability  and  sensibility.  Finally,  in  a  singular  case  already 
mentioned,  premature  labor  occurred  eight  times  consecutively,  in  consequence  of 
extreme  itching  of  the  surface. 

Delivery  before  term  is  said  to  be  often  preceded  by  a  severe  chill :  Bui-ns 
supposes  that  this  chill  occurs  immediately  before  or  after  the  death  of  the  foetus. 
I  have  no  recollection  of  ever  having  observed  anything  of  the  kind. 

In  some  cases,  the  uterus  is  fully  developed  prior  to  the  ordinary  term  of  ges- 
tation, and  then  the  contraction  commences  and  goes  on  as  regularly  as  usual ; 
but,  in  most  instances,  the  organ  has  not  as  yet  undergone  all  the  necessary 
modifications  for  the  proper  accomplishment  of  labor,  and  the  latter,  conse- 
quently, exhibits  numerous  irregularities  in  its  course.  The  uterine  neck  and 
orifice  are  not  yet  properly  eifaced  and  softened.  For  example,  it  is  not  at  all 
uncommon  to  find  the  neck  sufficiently  dilated,  during  the  primary  pains,  to 
permit  the  introduction  of  the  finger,  and  this  notwithstanding  the  lips  are  still 
thick  and  of  a  considerable  length.  This  length  of  neck  must  greatly  retard  the 
dilatation,  for  the  latter  cannot  really  commence  until  after  the  efiacement  is 
completed,  which  often  proves  a  tedious  process. 

This  first,  or  preparatory  stage,  is  marked  by  pains  that  are  very  irregular  both 
in  their  duration  and  intensity,  accompanied  by  a  feverish  state ;  the  patient  ex- 
periences a  very  distressing  sensation  of  weight  about  the  belly,  and  she  is  usually 
restless  and  agitated.  When  the  cervix  is  once  effaced,  the  os  uteri  begins  to 
dilate ;  but  this  dilatation  is  much  slower  than  at  term,  because  the  neck  has  not 
yet  attained  the  same  degree  of  softening,  and  therefore  ofi"ers  more  resistance  to 
the  contractions  of  the  body. 

But,  although  the  first  stage  is  somewhat  longer,  the  second,  or  that  wherein 
the  expulsion  occurs,  is  generally  shorter  than  in  labor  at  term,  owing  to  the 
small  size  of  the  child ;  nevertheless,  this  advantage  is  often  counterbalanced  by 
the  irregularity  and  the  spasmodic  nature  of  the  contractions,  which  are  then 
more  apt  to  assume  this  form  than  under  ordinary  conditions.  For,  as  the  mus- 
cular organization  of  the  uterus  is  not  yet  complete,  we  can  understand  why  its 
contractile  powers  are  less  perfect;  and  also,  on  the  other  hand,  how  the  morbid 
cause  which  has  developed  a  premature  action  in  it  must  necessarily  influence  the 
regularity  of  the  contractions. 

The  vertex  presentations  are  far  from  being  so  frequent  here  as  in  the  natural 
labor  at  term,  and  those  of  the  breech,  according  to  M.  P.  Dubois,  are  propor- 
tionably  more  common  as  the  labor  is  more  premature.  For  instance,  in  ninety- 
six  stillborn  children,  delivered  during  the  last  two  months'  of  gestation  at  the 
hospital  of  La  Maternity,  seventy-two  presented  by  the  head,  twenty-two  by  the 


OF    PREMATURE    AND    RETARDED    LABORS.  373 

pelvic  extremity,  and  two  by  the  shoulder ;  whilst  in  seventy-three  living  chil- 
dren, who  had  only  reached  the  seventh  month  of  intra-uterine  life,  sixty-one 
presented  the  head,  ten  only  the  breech,  and  two  the  shoulder.  Hence,  it  is 
evident  that  the  number  of  pelvic  presentations  in  premature  parturitions  is  com- 
paratively greater  where  the  children  are  born  dead,  and  also  that,  when  the 
foetuses  are  living,  the  podalic  extremity  presents  first  much  oftener  than  in  ordi- 
nary labors. 

Finally,  according  to  Burns,  women  who  are  taken  in  labor  before  term  are 
more  exposed  than  others  to  hemorrhages  during  its  progress,  and  their  delivery 
is  both  more  difficult  and  more  complicated  than  usual.  What  was  said  on  page 
354,  in  explanation  of  the  frequent  occurrence  of  hemorrhage  during  abortion,  is 
also  applicable  under  these  circumstances ;  only  with  the  exception  that  as  the 
condition  of  the  placenta  approaches  more  nearly  to  that  which  it  has  at  the  ter- 
mination of  pregnancy,  the  discharge  will  generally  be  small  in  proportion  as  the 
woman  shall  be  delivered  nearer  to  term. 

"When  a  woman  is  threatened  with  premature  labor,"  continues  the  author 
just  named,  "  we  ought,  unless  we  arc  sure  of  the  death  of  the  child,  to  endeavor 
to  check  the  process,  which  is  done  by  keeping  the  patient  cool  and  tranqu.il  in 
the  horizontal  position,  bleeding  her  in  the  arm  if  she  be  plethoric,  or  the  pulse 
be  throbbing;  but  above  all,  by  administering  opiate  injections  immediately 
(forty  to  sixty  drops  of  Sydenham's  laudanum,  in  two  or  three  doses,  in  the 
course  of  a  couple  of  hours)." 

When  the  labor  is  once  established,  it  is  to  be  conducted  much  in  the  same 
way  with  parturition  at  the  full  time ;  nevertheless,  says  Burns,  the  following 
observations  should  be  carefully  attended  to :  1.  The  patient  must  avoid  much 
motion,  lest  a  hemorrhage  be  excited;  2.  Frequent  examinations  are  hurtful  by 
retarding  the  process,  and  tending  to  produce  spasmodic  contraction ;  and,  if  this 
takes  place,  a  full  dose  of  the  tincture  of  opium  should  be  given  at  once;  3.  A 
rigid  state  of  the  os  uteri  requires  venesection  to  a  moderate  extent;  4.  The  de- 
livery of  the  child  is  to  be  retarded  rather  than  accelerated  in  the  last  stage,  in 
order  that  the  uterus  may  have  time  to  contract  on  the  placenta ;  5.  This  is  to 
be  further  assisted  by  rubbing  and  gently  pressing  on  the  uterine  region  after  the 
child  is  born;  6.  The  delivery  of  the  after-birth  requires  more  than  ordinary 
care :  thus,  we  are  not  to  pull  on  the  cord,  for  it  is  easily  broken ;  besides,  it  is 
often  necessary  to  introduce  the  hand  in  the  uteras  to  aid  the  detachment  of  the 
placenta  artificially,  and  to  prevent  its  being  retained  by  the  irregular  contrac- 
tions; and  lastly,  great  attention  is  to  be  paid  to  the  patient  herself  for  some  days 
after  the  delivery,  for  it  has  justly  been  observed  that  she  is,  from  the  mere  fact 
of  having  had  a  premature  labor,  more  exposed  than  others  to  those  inflammatory 
aiFections  which  so  often  complicate  the  parturient  state.  With  regard  to  the 
premature  labors  brought  on  by  the  accoucheur  we  shall  say  nothing  at  present, 
as  we  shall  have  to  treat  of  them  more  particularly  in  the  fourth  part  of  this 
work. 


374  LABOR. 

ARTICLE   II. 

or    llETARDED   LABOR. 

As  an  ordinary  rule,  the  pregnancy  terminates  about  the  two  hundred  and 
seventieth  day  after  conception.  However,  kbor  often  occurs  at  an  earlier 
period  than  this,  and,  on  the  other  hand,  it  may  not  appear  until  some  time  in 
the  course  of  the  tenth  month,  or  even  at  the  termination  of  this  period,  although 
the  latter  is  a  much  more  unusual  circumstance.  In  making  this  statement,  we 
decide  a  question  in  advance  that  gave  rise  to  some  very  sharp  and  animated 
discussions  during  the  last  century;  and,  still  more  recently,  the  tribunals  of 
England  have  summoned  to  their  bar  the  most  celebrated  physicians  of  Great 
Britain,  and  have  listened  to  numerous  and  protracted  pleadings  for  and  against 
the  legitimacy  of  retarded  labors. 

But  this  question  no  longer  presents  to  the  medical  jurist  the  same  difficulty 
that  it  did  in  the  past  century,  for  the  French  law  has  now  declared  every  child 
to  be  legitimate  that  is  born  after  the  one  hundred  and  eightieth  or  before  the 
three  hundredth  day  of  marriage ;  and,  as  if  it  were  possible,  in  the  eye  of  the 
law,  for  a  pregnancy  to  continue  more  than  ten  months,  it  further  adds  that  the 
legitimacy  of  a  child  born  three  hundred  days  after  the  dissolution  of  the  mar- 
riage contract  may  he  contested. 

Although  a  legal  decision  has  thus  deprived  the  question  of  retarded  labors  of 
its  greatest  interest,  yet  we,  as  practitioners,  may  be  permitted  to  recall  briefly 
the  principal  reasons  that  militate  in  their  fiivor. 

At  first,  it  was  very  natural  to  study  the  process  in  those  animals  which  ap- 
proach the  nearest  to  man  in  this  respect,  in  order  to  judge  of  the  possibility  of 
a  retarded  birth  in  the  human  species. 

Among  the  numerous  observations  made  on  this  subject,  those  submitted  by 
M.  Tessier,  in  1819,  to  the  Academy  of  Sciences  at  Paris,  of  which  the  follow- 
ing is  a  summary,  are  probably  the  most  exact,  namely :  out  of  one  hundred  and 
seventy-one  cows,  fourteen  calved  from  the  two  hundred  and  forty-first  to  the  two 
hundred  and  sixty -sixth  day;  three,  on  the  two  hundred  and  seventieth;  fifty, 
from  the  two  hundred  and  seventieth  to  the  two  hundred  and  eightieth ;  sixty- 
eight,  from  the  two  hundred  and  eightieth  to  the  two  hundred  and  ninetieth ; 
and  five,  on  the  three  hundred  and  eighth  day,  which  gives  a  difference  of  sixty- 
seven  days  between  the  births,  if  we  compare  the  shortest  with  the  longest  period. 
Of  one  hundred  and  two  mares  : 


3  foaled  on  the 

311th  day. 

1       " 

" 

314th     " 

1       « 

(( 

325th     «     . 

1       " 

(1 

326th     " 

2      " 

11 

330th     " 

47       " 

from  the 

340th  to  the  350ih  day. 

25      " 

II 

350th    «       360th    « 

21      " 

11 

360th     «       377th    « 

1      « 

on  the 

394  th  day. 

102 


OF  PREMATURE  AND  RETARDED  LABORS.       375 

Making  a  difference  of  eiphty-three  days  between  the  two  extremes.  Nine 
months  and  ten  days  being  the  average  term  for  cows,  and  eleven  months  and 
ten  days  for  raares. 

Those  well-ascertained  variations  in  the  terms  of  gestation  in  animals,  certainly 
afforded  a  strong  presumption  of  their  existence  in  the  human  species  also  ;  for 
if  cows  and  mares,  whose  gestations  are  not  disturbed  by  the  various  causes  that 
may  load  to  changes  in  a  woman,  may  thus  defer  for  some  time  the  ordinary 
period,  how  much  more  would  human  females,  who  are  subject  to  so  many  dis- 
eases, and  upon  whom  the  moral  and  social  relations  exert  so  powerful  an  influ- 
ence,— how  much  more  likely  would  they  be  to  exhibit  numerous  varieties  in  the 
duration  of  their  pregnancies  ? 

But  all  this  was  a  mere  probability ;  and  the  question  would  still  remain  unde- 
termined, if  careful  observations  directly  made,  and  well  made  on  the  human 
species,  had  not  removed  all  doubts  on  that  point;  for  several  cases  bearing  on 
this  subject  now  enrich  our  science,  where  a  single  well-established  instance 
would  suffice  to  produce  conviction.  Take,  for  example,  the  following  case, 
reported  by  Desormeaux :  A  lady,  the  mother  of  three  children,  became  affected 
with  insanity,  for  which  all  the  resources  of  therapeutics  were  tried  in  vain.  As 
her  physician  thought  that  another  pregnancy  might  possibly  re-establish  her 
intellectual  faculties,  the  husband  consented  to  note  on  a  register  the  time  of 
each  sexual  union,  which  only  took  place  every  three  months,  lest  a  previous 
conception  (then  uncertain)  should  be  disturbed.  Now,  this  lady,  who  was 
closely  watched  by  her  domestics,  and  was  besides  endowed  with  the  most  rigid 
principles  of  religion  and  morality,  was  not  delivered  before  the  expiration  of 
nine  months  and  a  half. 

Merriman  furnishes  a  summary  of  one  hundred  and  fifty  gestations,  in  each  of 
which  he  has  noted  the  precise  day  of  the  last  appearance  of  the  menses.  From 
this  table  it  appears  that — 

5  women  were  delivered  in  the  37tli  week — i.  e.,  from  252  to  259  days. 

IG  "  " 

21  «  « 

46  «  " 

28  "  " 

18  «  " 

11  "  " 

5  "  " 

150 

The  foregoing  statement  exhibits  the  great  variety  in  the  length  of  gestation. 
There  is,  in  fact,  a  difference  of  fifty-six  days  between  the  two  extremes ;  and, 
supposing  that  each  woman  became  pregnant  five  days  before  the  return  of  her 
courses,  five  of  them,  at  least,  would  overrun  the  average  term  of  nine  months  by 
ten  or  twelve  days. 


3  Stir 

It 

262  to  266 

39th 

t( 

'         267  to  273 

40th 

(( 

'         274  to  280 

41st 

" 

'         281  to  287 

42d 

It 

288  to  294 

43d 

" 

295  to  301 

44th 

tt 

'         303  to  306 

376  ^  LABOR. 


BOOK  II. 

OF  NATURAL  LABOR,  AT  TERM. 

At  whatever  period  delivery  may  occur,  it  is  always  accomplished  under  the 
influence  of  the  same  forces ;  though  there  is  an  important  distinction  to  be  esta- 
blished in  the  phenomena,  constituting  what  practitioners  are  agreed  to  call  the 
lahor.  Whenever  we  examine  carefully  the  whole  of  those  phenomena,  we  can 
readily  make  out  two  very  distinct  orders  of  facts.  The  one  is  nothing  more 
than  an  expression  of  the  vital  action  brought  into  play  for  the  expulsion  of  the 
foetus,  while  the  other  is  constituted  of  the  successive  movements  which  the  child 
itself  executes  during  such  expulsion ;  the  first  is  purely  physiological,  the  second 
embraces  the  mechanical  phenomena  of  the  labor.  Though  often  confounded  in 
practice,  these  two  orders  should  be  carefully  distinguished  in  theory. 

We  shall  therefore  have  to  examine,  in  as  many  separate  chapters,  the  causes 
and  physiological  phenomena,  as  also  the  mechanical  phenomena  of  a  natural 
labor.  Again,  although  in  the  vast  majority  of  cases  the  woman  is  really  able  to 
deliver  herself,  yet  there  are  many  precautions  which  the  accoucheur  should 
bear  in  mind,  and  a  series  of  little  attentions  he  must  give  to  the  patient  in  the 
•  course  of  the  parturition ;  besides,  the  child  will  likewise  require  his  intelligent 
aid,  either  during  the  travail  or  immediately  after  its  birth,  and  therefore  we 
shall  devote  a  fourth  chapter  to  the  exposition  of  those  attentions  and  precautions. 


CHAPTER  I. 

OF   THE   CAUSES   OF   LABOR. 
These  have  been  divided  into  the  efficient  and  the  determining  causes. 

§  1.  Efficient  Causes. 

For  a  long  time  the  foetus  was  regarded  as  the  principal  agent  of  its  own  de- 
livery, and  as  the  chick  breaks  the  shell  of  the  egg,  so  it  was  supposed  to  effect 
the  rapture  of  the  membranes  which  contained  it.  The  advocates  of  this  opinion, 
which  is  no  longer  admitted,  except  by  some  persons  out  of  the  profession,  relied 
chiefly  on  the  fact  of  dead  children  being  expelled  more  slowly  from  the  womb, 
and  with  more  difficulty  than  others ;  and  further  also  because,  in  certain  in- 
stances, the  child  has  been  known  to  escape  from  the  uteras  some  time  after  the 
mother's  death.  But,  in  reality,  these  two  facts  have  no  value  whatever  in  the 
question  before  us ;  for  the  death  of  the  foetus,  when  recent,  does  not  materially 
retard  the  parturition,  and  writers  were  altogether  in  error  as  to  the  influence 
attributable  thereto. 


CAUSES    OF    LABOR.  377 

The  living  infant  is  expelled  more  rapidly,  not  in  consequence  of  being  the 
agent  of  its  own  discharge,  but  because  its  movements  irritate  the  uterus  and 
solicit  its  more  frequent  contractions ;  after  its  death  the  organ  is,  on  the  con- 
trary, deprived  of  that  natural  irritant.  Besides,  whenever  the  foetus  has  been 
defunct  for  a  long  time,  another  cause  of  retardation  is  added  to  the  former;  for 
where  the  product  of  conception  has  undergone  a  partial  decomposition,  the  con- 
tractility of  the  uterine  walls  is  unflivorably  influenced  thereby.  In  fact,  the 
vitality  of  the  organ  seems  to  be  in  relation,  to  a  certain  extent,  with  that  of  the  en- 
closed body;  the  blood  being  no  longer  attracted  thither  by  the  ordinary  stimulus, 
does  not  reach  there  in  such  large  quantities  as  before,  and  consequently  the 
greater  vital  activity  usually  manifested  in  gestation  is  lost ;  hence  arises  atony 
of  its  walls,  an  excessive  feebleness  of  its  contraction,  and  slowness  of  the  labor. 
Again,  the  foetal  trunk,  being  softened  by  the  changes  before  described,  collapses, 
as  it  were,  and  ceases  to  offer  that  resistance  to  the  uterine  wall  which  is  neces- 
sary to  the  energy  and  the  maintenance  of  its  contraction.  Therefore,  if  it  be 
true  that  the  death  of  the  infant  renders  its  delivery  more  difficult,  it  is  solely 
from  the  unfavorable  influence  that  this  occurrence  may  have  over  the  exercise 
of  the  organic  contractility. 

Instances  of  children  having  been  delivered  spontaneously  after  the  mother's 
death  are  quite  numerous,  and  this  is  the  strongest  argument  adduced  by  those 
who  believe  that  the  foetus  is  the  principal  agent  in  the  expulsion.  But  nume- 
rous observations,  among  others  those  related  by  Dr.  Planque  (in  La  Bibliotlilque 
de  Medecine  Choisie),  prove  that  those  infants  were  dead  even  before  the  mother. 
Now,  these  facts,  extraordinary  as  they  appear,  can  be  very  naturally  explained 
as  follows :  Supposing  the  delivery  took  place  shortly  after  the  parent's  death, 
the  motor  faevilty  of  the  uterus  is  not  so  dependent  on  the  nervous  system  as  to 
be  entirely  lost  immediately  upon  the  cessation  of  vitality  in  the  latter,  and  is 
evidently  retained  for  some  time  after  the  mother  has  succumbed.  Thus,  Leroux 
has  observed  the  uterus  contract  a  quarter  of  an  hour  after  the  last  breath ;  and 
Osiander,  after  having  performed  the  Caesarean  section  on  a  corpse,  found  the 
uteinis  as  much  contracted  the  next  day  as  it  usually  is  in  a  woman  just  after  her 
confinement.  It  is,  therefore,  very  natural  to  suppose  that  such  deliveries  are 
owing  to  the  contractile  action  of  the  womb,  which,  says  Desormeaux,  it,  like 
other  hollow  muscles,  still  preserves  for  some  time  after  death  ;^  and  finally,  let 

'  Dr.  Tyler  Smith  states  that  the  reflex  action  may  continue  for  some  time  after  the  com- 
plete cessation  of  the  respiratory  movements,  and  in  some  cases  be  powerful  enough  to  effect 
the  delivery  when  the  patient  has  died  during  labor ;  but  that,  in  most  instances,  the  post- 
mortem  expulsion  of  the  foetus  is  due  to  a  peristaltic  contraction  of  the  uterine  fibres.  We 
find  it  difficult  to  admit  the  existence  of  a  vermicular  contraction  powerful  enough  to  produce 
such  a  result. 

M.  Brown  Sequard  has  recently  advanced  what  he  regards  as  an  explanation  of  this  post- 
humous contractility.  According  to  this  learned  physiologist,  the  contact  of  venous  blood 
with  the  muscular  fibre  is  sufficient  to  stimulate  it  to  contraction.  I  have  observed,  he  says, 
movements  in  the  uteri  of  recently-killed  animals,  whose  spinal  marrow  had  been  destroyed 
throughout  its  length.  I  have  seen  these  same  movements  in  the  uterus  extracted  from  a 
living  animal.     These,  which  could  not  be  attributed  to  reflex  action,  since  there  was  no 


378  LABOR. 

US  add,  that  the  real  death  in  many  cases  may  have  been  preceded  by  an  appa- 
rent one,  and  possibly  that  the  former  may  not  have  occurred  until  just  at  the 
instant  of,  or  immediately  after  the  delivery  took  place.  But  when  the  expulsion 
of  the  foetus  did  not  occur  before  the  lapse  of  two  or  three  days,  we  must  sup- 
pose, with  M.  Velpeau,  that  the  labor  was  well  advanced  at  the  time  of  the 
mother's  death,  and  gas  being  rapidly  produced  in  large  quantities  in  the  intes- 
tinal canal,  the  uterus  was  thereby  mechanically  compressed  on  its  exterior,  and 
the  ovum  consequently  forced  out  entire.  Perhaps  the  subjoined  case,  reported 
by  Hermann,  might  be  explained  in  that  way.  (Edin.  Med.  and  Sarg.  Journal, 
New  Series,  No.  vi,  p.  431.) 

A  young  woman  died  in  her  tenth  month,  and  the  third  day  after,  the  atten- 
dants noticed  a  strange  noise  about  the  corpse.  A  physician  was  hastily  sum- 
moned, who  found  that  twins,  still  enclosed  by  the  intact  membranes,  had  been 
just  delivered.  The  children  presented  no  traces  of  putrefaction,  the  placenta 
alone  showing  a  commencing  alteration. 

But,  besides  these,  numerous  other  objections  still  remain  against  this  theory: 

1.  The  delivery  exhibits  nearly  the  same  phenomena,  at  whatever  period  of  ges- 
tation it  takes  place;  now,  can  any  one  suppose  that  the  foetus,  which  scarcely 
moves  at  all  in  the  early  months,  can  at  once  acquire  a  sufficient  degree  of 
streno-th  to  overcome  the  great  resistance  made  at  that  time  by  the  uterine  neck? 

2.  It  is  well  known  that,  if  the  child  present  by  any  other  part  than  the  head  in 
labor  at  terra,  the  presenting  part  is  so  high  up,  before  the  rupture  of  the  am- 
niotic pouch,  that  it  can  .in  nowise  contribute  to  the  dilatation  of  the  os  uteri. 

3.  Again,  the  foetal  efforts  certainly  ought  to  affect  the  bag  of  waters  first,  and 
therefore  a  rupture  of  the  enveloping  sac  should  always  be  among  the  earliest 
phenomena  of  the  labor ;  however,  such  a  rupture  often  does  not  occur  until  the 
very  last  moments ;  sometimes  even  the  ovum  escapes  entire.  4.  Would  it  be 
possible  for  the  most  healthy  and  vigorous  infant  to  make  any  exertions  strong 
enough  to  surmount  the  resistance  opposed  to  its  delivery  in  some  of  the  instances 
of  tedious  labor  ?  &c.  &c.  From  all  which  we  may  conclude  that  the  foetus  has 
no  influence  over  its  own  expulsion,  and  that  the  eflScient  cause  of  the  delivery 
evidently  belongs  to  the  contraction  of  the  uterine  walls,  aided  by  that  of  the 
diaphragm  and  the  abdominal  muscles. 

Furthermore,  to  be  convinced  that  the  womb  acts  the  principal  part  in  this 
process,  it  is  only  necessary  to  examine  a  woman  during  labor,  and,  more  espe- 
cially, to  introduce  the  hand  into  the  uterus  in  a  case  of  difiicult  version.  It  is 
its  contractions  alone  which  generally  produce  the  dilatation  of  the  os  uteri,  thus 
preparing  a  way  for  the  child's  passage ;  and  they  also  perform  the  most  impor- 
tant part  in  the  later  periods  of  the  labor.  They  are  even  capable  of  effecting 
the  delivery  themselves.     Thus,  for  instance,  the  parturition  does  not  the  less 

opportunity  for  the  exercise  of  nervous  influence,  were  due  simply  to  the  contact  of  non- 
oxygenated  blood,  to  prove  which  he  relates  the  following  experiment.  The  spinal  marrow 
in  two  Guinea-pigs,  which  had  reached  the  end  of  gestation,  was  destroyed  from  the  sixth 
rib  to  the  sacrum,  yet  labor  began  and  ended  shortly  after  a  ligature  was  drawn  tightly 
around  the  trachea. 


CAUSES    OF    LABOR.  379 

take  place  in  animals,  where  the  belly  is  laid  open,  and  the  abdominal  walls 
thereby  rendered  incapable  of  any  further  action.  It  also  takes  place  in  women 
affected  with  procidentia  uteri,^  as  also  in  those  who  suffer  from  a  paralysis  of  the 
abdominal  muscles,  in  consequence  of  an  affection  of  the  spinal  marrow,  or  some 
one  of  the  nervous  centres.  Finally,  the  use  of  anaesthetics  within  certain  limits, 
destroys  the  contractility  of  the  voluntary  muscles,  together  with  the  sensibility; 
yet  the  uterine  contractility  remains,  and  the  delivery  is  accomplished.  Ordi- 
narily, however,  in  the  second  or  expulsive  stage  of  the  labor,  the  uterine  con- 
traction is  assisted  by  the  simultaneous  action  of  the  diaphragm  and  abdominal 
muscles. 

At  the  moment  when  the  head  clears  the  neck  of  the  uterus,  especially  when 
by  pressing  strongly  upon  the  floor  of  the  pelvis  it  distends  the  perineum,  com- 
presses greatly  the  lower  part  of  the  rectum  and  neck  of  the  bladder,  and  opens 
and  dilates  the  vulva,  the  pressure  upon  these  parts  is  so  violent  that  instinc- 
tively, not  to  say  involuntarily,  the  woman  exerts  herself  powerfully,  in  order  to 
relieve  herself  as  soon  as  possible  from  the  insupportable  sensation.  Thus,  fixing 
her  feet  firmly  against  the  foot-board  of  her  bed,  and  clinging  to  anything  around 
that  may  offer  a  solid  resistance,  the  patient  takes  a  full  inspiration,  dilates  her 
chest,  and  then,  retaining  the  inhaled  air  in  her  lungs,  she  strongly  contracts  all 
the  muscles  forming  the  abdominal  enclosure.  This  auxiliary  contraction  is  so 
evident  that  nobody  can  doubt  it,  and  authors  only  differ  as  to  the  kind  of  aid  it 
brings  to  the  uterine  forces.  Ilaller  and  others  considered  the  uterine  contrac- 
tion as  being  merely  secondary,  and  attributed  to  the  abdominal  muscles  the 
principal  part  in  the  expulsion  of  the  child;  thus  they  suppose  that  the  contrac- 
tion of  the  organ  simply  serves  to  support  the  foetal  trunk,  to  embrace  it  properly 
like  a  cylinder,  and  to  prevent  the  great  pressure  of  the  diaphragm  from  crush- 
ing it  in,  while  at  the  same  time  the  act  of  inspiration  and  the  contraction  of  the 
abdominal  walls  force  it  outwards.  But,  from  the  facts  before  stated,  we  may 
judge  of  the  value  of  this  hypothesis.  True,  in  certain  cases  of  excessive  feeble- 
ness of  the  uterus,  and  of  a  complete  inertia  of  its  walls,  the  abdominal  muscles 
have  proved  sufiicient  to  terminate  the  delivery;  yet  how  much  oftener  has  it 
happened  that  the  woman,  exhausted  by  antecedent  disease,  and  left  without 
energy  or  strength,  has  been  unable  to  assist  the  womb  by  any  voluntary  contrac- 
tion whatever. 

Again,  some  women  have  been  delivered  during  hysterical  or  epileptic  fits,  in 
a  state  of  total  loss  both  of  feeling  and  movement,  where  evidently  the  uterine 
contraction  alone  could  accomplish  it.  This  harmony  of  action  is  therefore  use- 
ful but  not  indispensable,  since  the  labor  will  often  terminate  under  the  sole 
influence  of  the  uterine  forces;  but  it  will  be  nearly  always  impossible  in  cases  of 
total  inertia  of  the  organ,  however  powerful  the  contractions  of  the  abdominal 
muscles  may  be. 

The  researches  of  Cloquet  and  Bourdon  on  the  physiology  of  the  process,  do 

'  According  to  the  report  of  Biirdach,  Wimmer  has  actually  known  the  labor  to  take  place 
regularly  in  a  woman  whose  womb  formed  a  tumor  between  her  thighs,  eleven  inches  long 
and  seven  and  a  half  inches  broad  j  the  opening  in  which  was  directed  downwards. 


380  LABOR. 

not  warrant  the  supposition  of  any  active  pressure  by  the  diaphragm  on  the 
upper  part  of  the  uterus.  They  have  proved,  in  fact,  that  the  principal  pheno- 
mena consist  in  a  change  of  the  acts  of  respiration,  and  that  the  object  of  such 
change,  is  to  furnish  a  solid  point  of  insertion  to  the  muscles  passing  from  the 
chest  both  to  the  trunk  and  upper  extremities.  When  the  air  has  penetrated 
into  this  cavity,  the  glottis  closes  spasmodically ;  the  abdominal  muscles  begin  to 
contract;  they  press  back  the  viscera  in  the  cavity  of  the  peritoneum  against  the 
diaphi'agm ;  the  latter  contracts  in  turn;  and,  being  sustained  above  by  the  resis- 
tance from  the  air  contained  in  the  lungs,  gives  to  the  base  of  the  chest  a  degree 
of  immobility  and  solidity,  which  affords  a  fixed  point  for  the  muscles  inserted 
there;  so  that,  in  the  effort  of  expulsion,  the  diaphragm,  by  its  contraction,  only 
exhibits  a  power  of  resistance  sufficient  to  sustain  the  thoracic  parietes,  but  not 
an  active  force,  which  is  to  operate,  like  the  abdominal  muscles,  directly  on  the 
uterus. 

On  the  whole,  then,  the  efficient  cause  of  labor  is  inherent  in  the  womb  itself. 
Its  contraction  alone  is  brought  into  play  during  all  the  first  half  of  the  labor; 
but  it  is  aided  in  the  second  period  by  the  abdominal  muscles,  which  become 
more  and  more  active  as  the  labor  draws  towards  its  termination.  Most  generally 
the  uterine  contractions  would  be  sufficient,  but  the  abdominal  contraction  alone 
could  scarcely  ever  complete  the  delivery. 

§  2.  Determining  Causes. 

This  name  is  applied  to  everything  that  can  determine  the  action  of  the  effi- 
cient causes;  and,  as  before  stated,  this  class  consists  both  of  unnatural  and 
natural  causes.  The  former  have  been  already  studied  under  the  heads  of  abor- 
tion and  premature  labor,  and  hence  the  second  only  claims  our  attention  here. 
The  regular  and  almost  fixed  period  at  which  the  gestation  terminates  in  the 
majority  of  women,  has,  in  all  ages,  claimed  the  attention  of  physiologists.  By 
some,  the  determining  cause  of  labor  has  been  attributed  to  the  child,  and  by 
others  to  the  womb. 

1.  According  to  the  partisans  of  the  first  opinion,  the  foetus,  having  arrived  at  a 
certain  stage  of  development,  will  have  acquired  such  a  degree  of  muscular 
power  that  the  resulting  movements  of  its  limbs  will  produce  such  blows  and 
shocks  upon  the  uterine  walls,  as  will  irritate  the  organ  and  determine  its  con- 
traction. 2.  The  weight  of  the  infant  might  also  lead  to  the  same  effect.  3. 
Being  confined  in  the  uterine  cavity,  whose  dimensions  have  not  augmented  in 
proportion  to  those  of  the  foetus,  the  latter  will  be  incommoded.  4.  Suffering 
from  the  prolonged  accumulation  of  meconium  in  the  intestinal  canal,  of  urine  in 
the  bladder,  and  from  its  contact  with  the  amniotic  fluids,  which  ultimately 
acquire  acrid  and  irritating  properties,  and  no  longer  finding  in  the  materials 
furnished  by  the  mother  the  elements  necessary  to  its  nutrition  and  respiration, 
the  infiint  will  experience  a  necessity  of  changing  its  residence,  of  seeking  a 
medium  more  suited  to  its  ulterior  development ;  which  necessity  will  prove  an 
instinctive  desire  of  escaping  from  the  surrounding  inconveniences,  that  will 
cause  it  to  give  itself,  so  to  speak,  the  signal  of  departure.     Surely,  it  is  only 


CAUSES    OF    LABOR.  381 

necessary  to  present  sucli  reasons  as  these  in  a  summary  manner,-  to  obviate  the 
necessity  of  refuting  them.  In  short,  the  foetus  is  as  foreign  to  the  determining 
as  to  the  efficient  cause  of  labor.  The  opinion  favorable  to  the  cause  residing  in 
the  uterus  rallies  around  it  a  greater  number  of  partisans,  but  all  of  these  do  not 
explain  the  mode  of  action  in  the  same  way.  Thus,  according  to  some,  the  womb 
only  possesses  the  fliculty  of  distension  to  a  certain  degree^  and,  when  carried 
beyond  that  limit,  the  walls  react  and  contract;  others  believe  that  the  term  of 
nine  months  is  assigned  by  nature  for  the  fulfilment  of  the  new  organization  of 
the  womb ;  and  having  acquired  at  that  period  all  the  qualities  necessary  to  the 
accomplishment  of  the  great  function  to  which  it  is  destined,  it  immediately 
enters  into  action.  But  most  of  the  modern  accoucheurs  consider  the  following 
explanation  as  the  more  reasonable  : 

Observation  proves,  say  they,  that  the  fundus  and  body  of  the  uterus  are  the 
parts  first  distended,  for  the  purpose  of  forming  the  cavity  which  encloses  the 
product  of  conception ;  and  the  cavity  of  the  neck  subsequently  participates  in 
the  dilatation,  which  begins  at  its  upper  part,  then  gradually  descends,  so  that 
the  ring  formed  of  the  external  orifice  has  alone  undergone  but  little  alteration  at 
the  approach  of  labor.  Again,  the  walls  of  the  neck,  whose  tissue  is  denser  and 
more  resistant  than  that  of  the  body,  undergo  certain  changes,  which  follow  the 
same  progression  in  dilating  as  the  cavity  does ;  their  tissue  is  saturated  with 
juices;  they  soften  and  become  supple;  their  fibres  unfold,  as  it  were,  are  elon- 
gated and  developed ;  and,  consequently,  the  resistance  of  the  neck  to  the  escape 
of  the  ovum  progressively  diminishes  as  the  term  of  gestation  draws  near. 

According  to  this  view,  the  fibres  of  the  neck  are  considered  antagonistic  to 
those  in  the  body,  the  contraction  of  which  latter  is  therefore  reduced  to  a  simple 
tonic  action,  so  long  as  the  resistance  of  the  neck  is  superior  to  their  power;  but 
when  this  opposition  is  diminished  by  the  progressive  dilatation  of  the  cervix, 
the  orifice  alone  remaining,  the  fibres  of  the  body  then  begin  to  act  more  evi- 
dently, and  their  contractions  become  more  and  more  energetic.  (^Dlct.  de  3Ied., 
en  25  v.) 

According  to  Ant.  Petit,  the  body  only  will  dilate  prior  to  the  sixth  month ; 
but  at  that  period  it  commences  borrowing  from  the  cervical  fibres  the  elements 
of  its  ulterior  distension,  to  which  it  can  no  longer  contribute  itself;  and  such 
contributions  will  continue  to  be  drawn  during  the  last  three  months,  and  then, 
when  all  the  fibres  held  in  reserve  by  the  neck  shall  have  yielded,  the  distension 
being  carried  to  the  utmost,  the  accouchement  will  take  place.  M.  Velpeau 
adopts  nearly  the  same  opinion.  On  the  other  hand,  M.  P.  Dubois,  who  origi- 
nally advocated  the  opinions  avowed  by  Desormeaux  in  the  first  edition  of  the 
Dictionnaire,  has  since  taught,  in  his  course  of  1837-8,  the  following  theory 
proposed  by  Jones  Power,  in  1819. 

The  uterine  tissue  at  term  may  be  justly  compared  to  that  of  the  other  hollow 
muscular  organs,  the  bladder  or  rectum,  for  example;  and,  like  these  organs,  it 
is  formed  of  two  muscular  layers,  the  external  of  which  has  longitudinal  fibres, 
and  the  internal  has  circular  ones ;  it  also  presents  a  superior  cavity,  a  dilatable 
and  contractile  reservoir,  to  which  the  structure  just  indicated  principally  belongs; 


382  LABOR. 

as  also  a  closed  orifice  below,  formed  solely  by  the  circular  fibres  arranged  as  a 
sphincter  muscle.  It  likewise  resembles  the  bladder  and  rectum  in  having  two 
orders  of  nerves — the  sympathetic  and  the  spinal ;  those  coming  from  the  gan- 
glionic system  are  distributed  to  the  body,  while  the  others,  derived  from  the 
nervous  centres  of  animal  life,  go  to  the  neck,  which  is  a  true  sphincter  for  the 
uterus;  the  similitude  is  further  maintained  by  the  presence  of  a  membrane 
lining  its  interior,  and  by  being  covered  externally,  though  at  the  superior  part 
only,  by  the  peritoneum. 

The  agreements  in  structure  are  not  the  only  ones  claiming  our  attention ;  for 
the  well-marked  sympathies  existing  in  the  rectum  or  bladder,  between  the  reser- 
voir and  its  sphincter,  are  found  quite  as  distinctly  marked  between  the  body  of 
the  uterus  and  its  neck ;  for  as  an  irritation  of  the  neck  of  the  bladder  or  the 
sphincter  ani  is  capable  of  producing  an  urgent  desire  to  urinate,  or  to  go  to 
stool,  so  irritations  affecting  the  cervix  uteri  also  solicit  the  contractions  of  that 
orscan ;  moreover,  it  is  well  known  that  an  extreme  fulness  or  distension  of  the 
first-named  organs  acts  mechanically  in  two  ways :  1.  By  irritating  their  walls 
by  the  direct  contact  of  the  contained  substances;  2.  By  dragging  or  pressing 
on  the  fibres  forming  the  sphincter,  and  these  latter  reacting  on  those  of  the 
body.  Now,  who  does  not  recognize  in  this  resemblance,  says  Dubois,  an  easy 
explanation  of  the  determining  causes  of  labor  ?  For,  so  long  as  the  cervix  uteri 
retains  a  certain  length,  its  most  inferior  fibres,  those  especially  supplied  by  the 
nerves  of  animal  life,  and  therefore  enjoying  a  high  degree  of  sensibility,  are 
not  exposed  to  any  kind  of  excitation ;  but,  towards  the  end  of  the  gestation, 
and  in  consequence  of  the  successive  expansion  at  the  superior  part  of  the 
neck,  its  whole  length  has  disappeared  by  contributing  to  the  gradual  develop- 
ment of  the  organ ;  a  circular  collar  alone  remaining,  formed  of  the  horizontal 
and  the  circular  fibres,  which  appertain  to  the  external  orifice.  The  growth  of 
the  uterus  cannot  continue  without  producing  a  severe  tension  on  the  fibres  of 
this  collar;  and  further,  being  brought  immediately  into  contact  with  the  amni- 
otic sac,  and  consequently  with  the  presenting  part  of  the  foetus,  they  must 
necessarily  suifer,  must  be  irritated  and  excited  by  this  constant  and  unusual 
contact.  As  this  double  cause  of  irritation  is  constantly  acting,  it  must  inevi- 
tably happen  with  the  fibred  belonging  to  the  body  of  the  uterus,  as  it  docs  with 
the  rectal  and  vesical  walls  when  their  sphincter  is  irritated,  i.  e.,  they  must 
immediately  enter  into  contraction.* 

'  jNIr.  Power  cites  the  following  case,  cominiinicated  by  his  brother,  in  support  of  his 
opinion,  and  which  we  bring  forward  as  being  interesting  in  many  respects. 

A  lady,  the  mother  of  several  children,  supposed  herself  near  the  term  of  a  fresh  preg- 
nancy, and  she  felt  two  or  three  slight  pains ;  but  they  soon  passed  off  again,  and  three 
months  more  elapsed  without  her  experiencing  any  other  pain.  Becoming  uneasy  about  her 
condition,  she  consulted  several  physicians,  who,  after  having  made  the  usual  examination, 
declared  she  was  not  pregnant.  The  author's  brother  having  been  called  in,  participated  at 
first  in  the  same  opinion  ;  nevertheless,  he  found  the  abdomen  greatly  enlarged,  and  much 
inclined  forwards,  so  that  it  descended  in  front  of  the  thighs,  almost  down  to  the  knees, 
when  the  patient  was  standing.  A  distinguished  physician,  a  friend  of  the  lady,  who  was 
present,  then  mounted  on  a  chair  above  her.  and  by  passing  a  towel  underneath  the  belly 


CAUSES     OF    LABOR.  383 

Dr.  Tyler  Smith,  of  London,  has  lately  endeavored  to  prove,  in  accordance 
with  the  observations  of  Carus,  Mende,  and  Merriman,  that  the  determining 
cause  of  labor  must  be  sought  for  in  the  ovary;  that  natural  labor  always  corre- 
sponds with  the  tenth  menstrual  period,  and  that  the  congestion  of  the  ovaries, 
produced  by  reflex  action,  first  a  simple  irritation,  and  ultimately  true  contrac- 
tions of  the  uterine  parietes. 

Admitting  as  proved  that  the  menstrual  ovulation  goes  on  during  pregnancy, 
it  would  still  remain  to  be  shown  why  it  should  be  rather  at  the  tenth  than  at 
the  eighth  or  eleventh  period  that  this  influence  of  the  reflex  action  of  the 
ovary  should  be  strong  enough  to  excite  the  contractions  of  natural  labor  in  the 
uterus. 

I  have  contented  myself  with  simply  presenting  the  principal  views  that  have 
been  entertained  as  to  the  determining  cause  of  labor,  although  it  would  be  an 
easy  matter  to  start  numerous  objections  against  all  of  them,  which  perhaps  could 
not  be  set  aside.  Thus,  the  uterus  is  as  much  distended,  in  some  cases,  at  eight 
months  as  it  is  in  many  others  at  nine,  without  the  term  of  pregnancy  being 
anticipated.  The  muscular  organization  of  the  uterus  is  as  perfect  several  weeks 
before  the  two  hundred  and  seventieth  day  as  it  is  at  a  later  period.  The  sort  of 
antagonism  fancied  by  some  authors  to  exist  between  the  fundus  and  the  neck  of 
the  uterus,  is  a  pure  hypothesis  unsupported  by  evidence;  besides,  this  opinion, 
like  that  of  Antoine  Petit,  rests  upgn  a  false  observation,  namely,  that  of  the 
progressive  shortening  of  the  neck  after  the  sixth  month. 

I  admit  that  the  theory  of  Jones  Power  has  the  greatest  appearance  of  proba- 
bility. Contrary  to  the  views  of  the  author,  it  has  no  need  of  the  supposed  gra- 
dual dilatation  of  the  upper  part  of  the  cervix  after  the  sixth  month  to  support 
it,  and  the  changes  which  we  have  spoken  of  as  occurring  in  the  last  month,  are 
themselves  sufficient  to  allow  the  inferior  segment  of  the  ovum  or  the  head  of  the 
foetus,  to  press  upon,  and  finally  irritate  the  sensible  fibres  of  the  neck. 

At  one  of  the  late  sittings  of  the  Biological  Society  (September,  1855),  M. 
Brown-Sequard  suggested  a  theory  which  doubtless  is  subject  to  objections,  but 
which  certainly 'is  one  of  the  most  ingenious  of  all  that  have  yet  been  projjosed 
in  reference  to  the  determining  cause  of  labor. 

Like  all  the  muscles,  those  especially  of  organic  life,  the  muscles  of  the  uterus 
are  very  sensitive  to  the  contact  of  venous  blood,  and  the  carbonic  acid  gas  which 
the  latter  contains  in  large  amount,  is  capable  of  producing  their  contraction. 
Of  the  experiments  tending  to  prove  this,  one  certainly  seems  very  conclusive. 
M.  Sequard  applied  a  ligature  to  the  trachea  of  a  pregnant  rabbit.  Six  or  eight 
minutes  after  the  commencement  of  asphyxia,  uterine  contractions  became  mani- 
fest ;  the  ligature  was  removed,  the  contractions  ceased ;  it  was  again  applied, 
and  they  reappeared. 

Now,  according  to  M.  Brown-Sequard,  at  the  end  of  gestation,  the  irritability 

raised  it  up;  the  vaginal  touch  being  once  more  resorted  to,  the  child's  head  was  distinctly 
felt.  A  suitable  bandage  retained  the  tumor  in  that  position,  and  four  or  five  days  after- 
wards the  pains  came  on,  and  the  woman  was  hapi)ily  delivered  of  a  very  large  living 
infant. 


381  LABOR. 

of  the  uterine  fibre  is  very  great,  and  tlie  development  of  tlic  venous  apparatus 
of  the  organ  such,  that  a  considerable  amount  of  venous  blood  is  contained 
within  its  Trails.  These  two  conditions  together,  constitute,  he  thinks,  the  deter- 
mining cause  of  the  first  contraction,  since  the  excitability  must  necessarily  be 
awakened  by  the  prolonged  contact  of  carbonic  acid.  The  effect  of  the  first  con- 
traction would  be  to  expel  the  blood  from  the  veins,  and  the  contraction  would 
cease  promptly  with  the  exciting  cause,  did  not  the  pain  which  it  occasions  stimu- 
late the  reflex  action  of  the  spinal  marrow ;  the  latter,  therefore,  sustains  it  for 
some  moments.  But,  as  we  shall  state  hereafter,  the  contractile  power  of  a 
muscle  of  organic  life  is  rapidly  exhausted,  its  fibre  relaxes,  and  repose  soon  suc- 
ceeds to  activity.  This  relaxation  of  the  uterine  fibre  allows  the  venous  blood  to 
flow  back  into  the  uterine  sinuses,  so  that  after  a  time  the  series  of  phenomena 
just  mentioned  recommences. 


CHAPTER  II. 

/ 

OF   THE   PHYSIOLOGICAL    PHENOMENA    OF    LABOR. 

For  the  purpose  of  facilitating  the  study  of  the  phenomena  of  labor,  most 
writers  have  divided  them  into  several  distinct  groups,  which  they  have  denomi- 
nated the  star/es  of  labor;  and  each  one  has  built  up  his  own  classification,  so  that 
we  may  now  enumerate  some  twenty  or  thirty.  Of  all  these,  the  division  of 
Desormeaux  appears  to  us  the  most  simple,  and  we  shall  therefore  adopt  it.  His 
first  stage  extends  from  the  beginning  of  the  labor  to  the  complete  dilatation  of 
the  cervix  uteri ;  the  second  includes  all  the  interval  from  this  time  until  the 
child  is  expelled;  and  the  third  embraces  the  delivery  of  the  placenta. 

Precursor!/  Signs. — The  term  of  gestation  is  most  usually  announced  by  a 
collection  of  symptoms,  to  which  the  majority  of  authors  have  applied  the  name 
of  the  ''precursory  signs  of  labor."  Thus,  during  the  last  fortnight  of  preg- 
nancy, sometimes  a  little  sooner,  at  others,  only  five  or  six  days  before  the  deli- 
very takes  place,  the  uterus,  which  previously  extended  up  to  the  epigastric 
region,  sensibly  sinks  lower,  and  seems  to  spread  out  laterally ;  and  the  mecha- 
nical obstruction  to  the  respiration  being  thus  removed,  the  latter  becomes  more 
free ;  the  stomach  is  no  longer  compressed,  and  digestion,  if  hitherto  impaired, 
becomes  more  easy ;  the  patient,  no  longer  troubled  with  nausea  and  vomiting, 
and  respiring  more  freely,  becomes,  it  is  said,  gayer,  more  cheerful,  and  disposed 
to  movement.  However  true  this  last  proposition  may  be  with  regard  to  some 
women,  it  certainly  does  not  apply  to  all ;  but,  on  the  contrary,  it  has  seemed  to 
me  that  in  proportion  as  the  term  approaches  their  position  becomes  more  and 
more  distressing ;  and  this,  I  think,  may  be  esjsily  explained ;  because  if  the  re- 
spiration becomes  more  free,  and  the  fundus  uteri  descends,  the  inferior  part  of 
the  organ  must  also  sink  down  in  the  same  ratio.     The  head,  when  presenting, 


PHENOMENA    OF    LABOR.  385 

engages  in  the  excavation,  carrying  the  lower  portion  of  the  uterus  before  it;  it 
sometimes  even  reaches  the  pelvic  floor,  and  consequently  gives  rise  to  an  annoy- 
ing sensation  of  weight  about  the  fundament,  to  great  pressure  on  the  neck  of 
the  bladder  and  rectum,  strainings  at  stool,  ineffectual  desires  to  urinate,  vesical 
tenesmus,  dysury,  and  sometimes  even  to  strangury;  the  oedema  and  varices  of 
the  inferior  extremities  and  genital  parts  then  augment  considerably;  the  hemor- 
rhoidal vessels  swell  up,  and  the  tumors  of  the  same  name,  if  they  existed  before, 
become  more  voluminous  and  very  painful ;  at  the  same  time  copious  glairy  dis- 
charges escape  from  the  vulva. 

i\.bout  the  same  period  the  pelvic  ligaments  become  softened,  and  the  gliding 
of  the  articular  surfaces  being  rendered  easier,  the  joints  are  more  movable, 
and  consequently  walking  is  uncertain,  painful,  and  sometimes  even  impossible. 
Lastly,  to  all  these  inconveniences  and  pains,  another  is  often  added,  which  sin- 
gularly aids  in  making  the  woman's  condition  still  more  distressing ;  it  is  this  : 
the  uterus,  in  the  last  periods  of  gestation,  seems,  by  contractions,  which  are 
short  and  distant  at  first,  but  soon  increasing  both  in  length  and  frequency,  to 
prepare,  as  it  were,  for  the  more  violent  contractions  of  parturition.  Indeed,  she 
often  experiences  the  true  pains  from  time  to  time,  and  should  the  accoucheur 
then  examine  the  abdomen,  he,  like  her,  will  feel  it  hardening,  and  the  uterus 
manifestly  contracting.  At  times,  these  contractions  are  scarcely  painful,  are 
not  attended  with  bearing  down,  and  can  only  be  detected  by  placing  the  hand 
upon  the  abdomen. 

We  know  that  the  uterine  globe  is  contracting,  from  its  greater  hardness ; 
then,  after  a  short  time,  relaxation  occurs,  and  the  walls  regain  their  habitual 
suppleness.' 

In  women  who  have  previously  had  children,  we  may  ascertain  by  the  vaginal 
touch,  that  the  membranes  bulge  out  during  contraction,  and  engage  slightly  in 
the  upper  part  of  the  cervix  uteri.  These  precursory  phenomena  are  manifested 
much  sooner  in  primiparoe  than  in  others. 

According  to  certain  writers,  the  pains  are  felt  first,  and  with  more  severity 
than  at  any  other  time,  about  four  weeks  before  term ;  so  that  some  women,  who 
have  been  pregnant  before,  do  not  hesitate  then  to  aflirm  that  their  labor  will 
take  place  in  the  course  of  a  month.    (Burdach.) 

Further,  these  pains  are  not  wholly  useless,  for  they  tend  to  diminish  the 
thickness  of  the  neck,  and  generally  bring  on  its  dilatation ;  thus,  I  have  re- 
marked that,  when  no  cause  of  dystocia  existed,  the  labor  was  usually  much  more 

'  These  contractions,  which  are  the  precursory  symptoms  of  labor,  I  regard  as  due  to  the 
changes  which  the  upper  part  of  the  neck  undergoes  in  the  latter  M-eeks  of  gestation.  We 
have  already  stated  that,  in  the  last  fortnight,  the  internal  orifice  softens  and  yields  to  disten- 
sion, then  expands  from  above,  so  that  the  upper  half  of  the  neck  gradually  becomes  con- 
founded with  the  cavity  of  the  body;  the  lower  part  of  the  ovum  will  evidently  engage  in 
the  dilated  portion,  and  soon  come  in  contact  with  the  parts  in  the  neighborhood  of  the  ex- 
ternal orifice.  This  contact  occasions  a  progressive  irritation  of  the  irritable  fibres  of  the 
lower  half  of  the  cervix,  which,  by  reacting  upon  the  body,  excites  its  contractions,  until 
finally,  the  entire  neck  being  effaced,  the  irritation  reaches  its  maximuni;  and  labor  com- 
mences. 

25 


386  '  LABOR. 

rapid  in  those  females  who  had  been  thus  tormented  by  frequent  pains  during 
the  last  fortnight  of  their  pregnancy. 

On  the  whole,  therefore,  contrary  to  the  proposition  reiterated  in  all  the  clas- 
sical works,  that  women  are  more  gay,  cheerful,  and  disposed  to  action,  I  have 
observed  that  they  are  in  general  more  sad,  and  are  greater  sufferers,  than  at 
other  times ;  an^  although  they  appear  to  endure  their  pains  better,  it  is  simply 
because  they  are 'encouraged  by  the  hope  of  a  speedy  delivery,  the  announcement 
of  which  is  recognized  in  the  very  sufferings  they  endure. 

First  Stage. — The  term  of  gestation  finally  arrives,  and  the  labor  begins.  In 
primiparae,  this  is  made  known  by  the  opening  of  the  neck,  which  until  that 
time  had  remained  closed ;  and  in  other  women,  by  the  total  effacement  of  the 
rounded  collar  presented  by  the  os  tiucai.  The  pains  just  mentioned  as  occur- 
ring in  the  last  fortnight  of  pregnancy,  suddenly  become  more  acute  and  frequent, 
and  while  they  last  the  abdomen  retracts,  and  the  uterus  hardens,  as  may  easily 
be  verified  by  examination.  If  the  fundus  was  heretofore  inclined  towards  the 
right  ox  the  left,  it  will  now  return  to  the  median  line ;  the  inequalities  of  the 
foetus  can  no  longer  be  perceived  through  the  abdominal  wall ;  the  cervix  uteri, 
which  is  already  somewhat  dilated,  closes  partially  during  the  pain,  and  its  mar- 
gins are  tense  and  resistant,  though  growing  thinner ;  the  membranes  are  dis- 
tended, press  at  first  on  the  neck,  then  engage  in  it  as  soon  as  the  dilatation  is 
sufficiently  advanced,  under  the  form  of  a  segment  of  a  sphere,  whose  dimensions 
progT«essively  increase  with  the  dilatation. 

The  organs  of  generation  are  more  humid;  the  glairy  discharges  are  streaked 
with  blood ;  the  pains  continue  to  increase  in  force  and  frequency,  each  one  being 
ushered  in  by  a  slight  shivering,  or  horripilation  ;  while  it  lasts,  the  pulse  is  hard, 
frequent,  and  full ;  the  countenance  is  flushed,  the  surface  and  tongue  dry,  and 
the  patient  very  thirsty ;  nausea  and  vomiting  often  come  on ;  she  weeps,  de- 
sponds, and  becomes  quite  irritable,  and,  being  unconscious  of  the  progress  of 
her  labor,  because  no  advance  is  perceived,  she  cries  out  repeatedly,  that  she  will 
never  get  over  it.  After  the  contraction,  she  is  less  agitated ;  still,  however,  the 
cessation  of  the  pain  docs  not  seem  to  be  perfect,  the  calm  is  not  yet  complete, 
and  the  poor  sufferer,  still  under  the  influence  of  the  last  pain,  dreads  inces- 
."^antly  the  arrival  of  its  successor.  During  the  interval,  the  margins  of  the  os 
uteri  again  become  supple,  thick,  and  rounded  ;  the  membranes  that  were  smooth 
and  tense,  while  the  pain  lasted,  are  now  flaccid,  and  hang  in  folds,  and  the  foetal 
head,  which  was  temporarily  removed  from  the  orifice,  seems  to  return,  and  is 
much  more  accessible  to  the  finger.  In  proportion  as  the  contractions  are  re- 
peated, the  os  uteri  gradually  dilates  more  and  more,  until  at  last  it  is  completely 
opened  ;  the  cavity  of  the  uterus  and  the  vagina  thenceforth  forming  but  a  single 
uninterrupted  canal. 

Some  females  are  able  to  conceal  these  early  pains,  but  most  of  them  find  it 
impossible  to  do  so  for  any  length  of  time ;  for,  if  conversing,  they  will  at  once 
leave  the  phrase  incomplete,  and  remain  silent  until  the  pain  has  diminished,  or 
.>topped  altogether;  or,  if  they  happen  to  be  walking  up  and  down  the  chamber. 


PHENOMENA    OF    LABOR.  387 

they  stop  short  and  lean  on  a  chair,  or  the  first  article  that  comes  to  hand,  until 
it  passes  over. 

The  occurrence  of  violent  shivering,  and  sometimes  of  general  tremors,  at  the 
termination  of  this  stage  is  by  no  means  unusual,  and  that,  too,  without  any  sen- 
sation of  cold  being  perceived.  The  patient  herself  frequently  expresses  surprise 
at  her  trembling.  It  is  doubtless  caused  by  one  of  the  singular  impressions  pro- 
duced upon  the  nervous  system  by  the  act  of  parturition. 

Second  Stage. — At  length,  under  the  influence  of  these  first  pains,  the  dura- 
tion of  which  is  very  variable,  the  orifice  is  enlarged  until  it  forms  a  sufl&cient 
opening ;  and  from  that  moment  all  the  uterine  forces  are  directed  to  the  expul- 
sion of  the  foreign  body  contained  within  the  organ.  Up  to  this  time,  the  uterus 
alone  was  concerned  in  dilating  the  neck,  but  it  now  seems  to  call  in  aid  the 
contraction  of  the  abdominal  muscles,  and  consequently  both  the  pain  and  the 
bearing  down  are  carried  to  a  much  higher  degree.  The  heat  of  the  surface  is 
much  more  considerable,  the  agitation  extreme,  and  in  some  instances  there  is 
even  a  marked  disorder  in  the  intellectual  functions.  The  pains  are  stronger, 
and  the  intervals  shorter^  nevertheless,  the  woman  bears  them  with  more  patience, 
nay,  she  even  assists  them  by  voluntarily  contracting  all  the  muscles  of  the  trunk; 
and  each  pain  is  followed  by  a  calm  more  perfect  than  that  in  the  first  stage. 
Indeed,  when  the  interval  is  rather  long,  some  females,  exhausted  by  the  pre- 
vious fatigue,  sleep  profoundly,  and  thus  get  a  refreshing  repose  that  should  be 
respected,  but  which  is  soon  interrupted  by  a  new  pain.  The  inferior  segment 
of  the  membranes  gradually  engages  in  the  orifice ;  the  successive  and  repeated 
contractions  cause  the  liquor  amnii  to  flow  towards  this  point ;  the  amniotic  pouch 
becomes  tense  and  bulging  at  its  lower  part,  and,  being  entirely  unsupported  by 
the  parietes  of  the  neck,  it  gives  way,  and  the  contained  waters  escape  with  more 
or  less  rapidity  and  abundance,  according  to  circumstances. 

Immediately,  the  foetus,  urged  on  by  the  same  contraction,  applies  itself  to  the 
OS  uteri,  and  the  head,  if  ihat  is  the  presenting  part,  engages  like  a  stopple  in 
the  orifice,  thereby  preventing  a  further  discharge  of  the  waters.  The  head  is 
then  said  to  be  at  the  crowning.  The  rapid  discharge  of  a  considerable  quantity 
of  the  waters,  which  then  takes  place,  suspends  the  uterine  contractions  for 
several  moments,  and,  as  the  head  no  longer  presses  on  the  circumference  of  the 
neck,  a  small  amount  of  fluid  is  again  discharged.  But  a  more  energetic  pain 
shortly  comes  on,  by  which  the  child's  head  advances  and  clears  the  circle  of  the 
uterine  orifice,  and  just  at  this  moment  the  patient  very  frequently  gives  a  loud 
cry,  an  expression  of  the  great  pain  caused  by  its  passage.  Next,  the  head  de- 
scends into  the  vagina,  the  transverse  folds  of  which  become  effaced,  the  canal 
enlarging  and  elongating  for  its  reception.  When  a  rupture  of  the  membranes 
takes  place  before  the  os  uteri  is  completely  dilated,  the  head  often  descends  to 
the  pelvic  floor,  though  still  retained  in  the  womb,  and  does  not  clear  the  uterine 
orifice  until  it  engages  in  the  inferior  strait ;  though,  whichever  happens,  the 
pains  go  on  increasing  in  violence.  Each  one  is  announced  by  a  general  shiver- 
ing; the  patient  clings  to  anything  around  her,  supports  her  feet  against  the 
mattress,  throws  the  head  backwards,  takes  a  deep  inspiration,  and  violently  con- 


388  LABOR. 

tracts  all  the  muscles  of  her  body.  The  foetal  head,  being  thus  forcibly  urged 
on,  presses  against  the  floor  of  the  pelvis,  and  causes  it  to  protrude  at  every  pain  j 
and  the  consequent  pressure  on  the  rectum  gives  rise  to  illusory  desires  of -going 
to  stool. 

After  a  greater  or  less  resistance,  the  perineum  at  last  yields,  becomes  dis- 
tended and  bulging  in  front;  the  vulva  partially  opens,  and  the  nymphse  are 
effaced,  the  skin  in  the  neighborhood  contributing  to  the  enlargement;  the  head 
then  appears  in  the  dilated  vulva,  and  the  feces  as  well  as  the  urine  are  passed  in- 
voluntarily;  then  the  pain  again  ceases;  the  head,  just  apparent,  now  seems  to  re- 
enter the  excavation;  the  over-distended  perineum  retracts  from  its  own  inherent 
elasticity;  the  labia  externa  approach  each  other,  and  the  vulva  again  closes  up; 
at  each  pain,  the  latter  opens  more  and  more,  then  retracts,  until,  at  last,  all 
these  parts,  from  the  force  of  the  repeated  contractions,  become  incapable  of  any 
further  resistance ;'  finally,  a  horrible  pain  comes  on,  forcing  loud  cries  from  the 
woman,  which  is  made  up  of  two  others  of  unequal  violence,  for  which  nature 
seems  to  have  reserved  all  her  powers  ;  this  first  brings  the  parietal  protuberances 
to  a  level  with  the  tuberosities  of  the  ischium,  and  then  expels  the  head  alto- 
gether from  the  parts. 

In  some  instances,  the  delivery  of  the  body  immediately  follows  that  of  the 
head ;  but  in  the  larger  number,  some  seconds  elapse ;  then  the  pain  is  renewed, 
the  uterus  again  contracts,  and  drives  out  the  foetal  trunk,  together  with  the  rest 
of  the  amniotic  liquid. 

The  rapid  sketch  of  these  phenomena,  just  given,  has  not  afforded  us  an  oppor- 
tunity of  dilating  upon  any  of  them ;  nevertheless,  some  ought  to  be  studied 
more  carefully.  For  instance,  the  pain,  the  dilatation  of  the  uterine  orifice,  the 
glairy  discharges,  and  the  rupture  of  the  membranes,  demand  a  more  particular 
attention.  We  shall,  however,  be  brief  in  the  physiological  considerations  apper- 
taining to  each. 

§  1.  The  Pain,  or  Contraction. 

In  most  females,  the  pain  is  so  inseparable  from  the  contraction,  that,  in  com- 
mon language,  the  cause  is  readily  confounded  with  the  effect;  and  the  two 
expressions  are  used,  indifferently,  to  express  the  uterine  contraction,  its  returns, 
duration,  weakness,  and  intensity.  We  must  remark,  however,  that  although, 
the  intensity  of  pain  is  generally  in  relation  to  the  contraction,  yet  it  is  not 
always  so,  for  the  perception  of  pain  thereby  produced  necessarily  varies  with  the 
susceptibilities  of  the  patient  herself.  Some  experience  trifling  pains  very  acutely, 
and  express  themselves  freely;  others,  on  the  contrary,  whose  sensibility  seems 
more  obtuse,  scarcely  complain  at  all  of  the  strongest  contractions  (see  page  122). 
Again,  there  are  certain  females  who  have  the  happy  privilege  of  being  delivered 

'  Certain  authors  attribute  the  retreat  of  the  head  after  each  pain  to  a  winding  of  the  cord 
around  the  child's  neck,  and  therefore  propose  various  measures  for  facilitating  its  delivery. 
But  this  simply  results,  says  Bandelocque,  from  the  elasticity  of  the  perineum  and  the  re- 
action of  the  muscles  contained  in  its  substance,  as  also  from  the  elasticity  of  the  cranial 
bones.     Consequently,  we  have  nothing  to  do  but  to  await  the  spontaneous  expulsion. 


PHENOMENA    OF    LABOR.  389 

almost  witliout  any  or  at  least  with  but  very  inconsiderable  paing.  For  instance, 
I  had  an  opportunity  of  observing  a  young  priraipara  at  the  Clinique,  who  was 
aroused  by  the  pains  at  four  o'clock  in  the  morning,  and  was  delivered  at  six ; 
she  suffered  so  little  during  these  two  hours,  that  she  did  not  consider  it  neces- 
sasy  to  alarm  any  one,  and  the  midwife  was  only  summoned  when  the  pain 
became  a  little  more  severe ;  she  soon  arrived,  and  found  the  head  delivered. 
This  case  was  still  more  remarkable,  from  the  fact  of  a  partition  existing  in  the 
vagina,  which  divided  its  cavity  into  two  parts;  indeed,  it  had  been  proposed  to 
incise  this  septum  when  the  hour  of  labor  should  arrive. 

It  is  highly  probable  that  the  dilatation  of  the  neck  goes  on  quietly  in  such 
cases,  under  the  influence  of  contractions  which  are  not  perceptible  to  the  patient 
from  being  unattended  with  pain.  The  pains  have  received  different  names 
according  to  the  period  of  their  occurrence ;  thus,  the  trifling  ones  appertaining 
to  the  precursory  phenomena  of  labor  are  named  mouches,  from  a  comparison 
with  the  sensation  caused  by  the  pricking  of  a  fly ;  those  of  the  first  stage,  in 
which  the  neck  is  dilated,  are  termed  preparative  ;  those  of  the  second  are  desig- 
nated as  the  expulsive;  and  finally,  in  the  last  moments  of  labor,  when  the  head 
forcibly  distends  the  perineum  and  partially  opens  the  vulva,  the  pains  are  so 
violent  in  character  as  to  have. been  denominated  the  conquassantes} 

The  pains  are  felt  in  the  lower  part  of  the  abdomen ;  and,  iii  the  early  stages, 
generally  follow  a  line  drawn  from  the  umbilicus  to  the  second  bone  of  the 
sacrum,  but  when  the  head  presses  against  the  pelvic  floor  they  run  more  towards 
the  coccyx.  Sometimes  they  are  felt  in  the  lumbar  and  sacral  regions  only ;  the 
women  then  call  them  the  pains  in  the  back ;  and  the  patient  has  good  cause  for 
dreading  them,  for  they  do  not  much  advance  the  delivery,  and  always  leave 
behind  them  a  feeling  of  discomfort  and  prostration.  These  lumbar  pains  often 
come  on  early  in  the  labor,  at  other  times  a  little  later,  but  they  rarely  continue 
till  its  close ;  sometimes  they  coincide  with  a  great  obliquity  of  the  uterus.  Ac- 
cording to  JMadame  Lachapelle,  they  may  generally  be  referred  to  too  great  a 
rigidity  of  the  external  orifice,  either  because  this  experiences  a  kind  of  cramp, 
or  that  owing  to  its  unyielding  condition  it  receives  the  full  force  of  the  uterine 
efforts,  and  consequently  suffers  more  than  when  softened. 

These  lumbar  pains  doubtless  depend  on  the  sensibility  of  the  orifice,  and  this 
can  readily  be  explained  by  the  origin  of  the  nerves  distributed  to  the  neck,  for 
the  hypogastric  and  lumbar  plexuses  furnish  them ;  whilst  the  ovarian  plexus  of 
the  splanchnic  nerve  alone  sends  its  branches  to  the  fundus  uteri.  Various 
plans  have  been  tried  to  assuage  these  pains ;  thus,  venesection,  emollient  injec- 
tions, and  the  opiates,  have  often  succeeded ;  but  there  is  one  which,  of  itself, 
may  suffice  in  many  cases  to  relieve  the  patient,  that  is,  to  raise  her  up  by 
passing  a  towel  under  the  loins.  The  pains  have  been  divided  by  writers  into 
true  and  false,  according  to  whether  they  are  produced  by  a  regular  labor,  or 
by  some  disorder  in  the  uterine  functions ;  but  as  we  shall  endeavor  to  establish 

'  I  give  these  terms  (mmickes  and  conquassantes)  as  found  in  the  original,  because,  in  our 
American  practice,  they  have  no  synonymes;  perhaps  the  words /jric^uig:  and  tearing  would 
express  their  sense. —  Translator. 


390  LABOR. 

the  diagnosis  carefully  further  on,  we  will  only  remark  now,  that  a  true  contrac- 
tion always  commences  in  the  fibres  of  the  neck,  and  only  reaches  the  fundus 
some  seconds  afterwards;  and,  therefore,  every  contraction  beginning  at  this 
latter  part  is  irregular  and  abnormal. 

The  question  now  arises,  what  is  the  cause  of  the  labor  pain  ?  Some  suppose 
that  it  is  produced  by  the  tension  of  the  fibres  of  the  neck ;  others  by  the  pres- 
sure on  the  nerves  distributed  to  the  internal  surface  of  the  organ,  which  are 
necessarily  compressed  by  the  foetal  walls  during  the  contraction ;  and  lastly,  cer- 
tain accoucheurs  have  thought  that  it  was  owing  to  the  compression  of  the  parts 
contained  within  the  pelvis;  the  nervous  plexuses,  for  example.  But  these 
opinions  err  in  being  too  exclusive,  since  all  of  these  causes  evidently  contribute 
to  the  production  of  pain;  indeed,  there  can  be  no  doubt  that  the  dilatation  of 
the  neck  is  painful  during  the  first  stage  of  labor,  more  especially  when  the  head 
is  clearing  it,  this  being,  according  to  Madame  Boivin,  almost  the  only  source  of 
suffering;  though,  on  the  other  hand,  when  the  child  is  so  placed  that  it  neither 
rests  against  the  uterine  orifice,  nor  yet  on  the  superior  strait,  the  contraction  is 
still  painful ;  and  the  pain  must  then  be  owing  to  the  pressure  on  the  nerves  of 
the  body  of  the  womb.  Again,  in  the  last  moments  of  parturition,  when  the 
head  is  passing  the  inferior  strait,  the  perineum,,  and  vulva,  the  enormous  dis- 
tension of  those  parts,  and  the  pressure  on  each  of  them,  must  singularly  add  to 
the  pain  produced  by  the  contraction,  as  well  as  contribute  towards  giving  it 
that  particular  character  known  under  the  name  of  the  conquassante,  or  tearing 
pain. 

Without  denying  that  these  various  conditions  may  be  the  first  cause  of  the 
pain,  M.  Beau  observes,  that  the  suffering  which  they  produce  is  not  seated  in 
the  uterus,  but  in  the  lumbo-abdominal  nerves.  He  regards  the  pains  of  child- 
birth as  being,  for  the  most  part,  a  lumbo-abdominal  neuralgia,  precisely  as 
though  the  case  were  one  of  pathological  disease  of  the  uterus.  If,  says  he,  a 
woman  in  labor  be  examined  with  the  object  of  determining  the  existence  of  the 
five  painful  points  which  characterize  the  lumbo-abdominal  neuralgia,  there  will 
then  be  found,  as  in  disease  of  the  womb,  points  which  are  painful  on  pressure 
in  the  lumbar,  iliac,  hypogastric,  inguinal,  and  vulvar  regions.  In  some  cases, 
it  is  the  lumbar  point;  in  others,  the  inguinal  or  iliac,  &c.  Pressure  on  the 
same  points  is  much  less  painful  during  the  interval  of  the  pains;  in  some  cases, 
indeed,  all  tenderness  then  seems  to  disappear. 

Though  the  localization  of  the  pain  in  the  lumbo-abdominal  nerves  may  not 
explain  its  intimate  nature  and  first  point  of  departure,  it  at  least  enables  us  to 
understand  the  numerous  varieties  which  it  assumes;  just  as  certain  grave  lesions, 
and  some  extensive  displacements  of  the  organ,  are  in  some  women  attended  with 
no  pain,  whilst  with  others  a  trifling  disorder,  or  a  slight  displacement,  gives  rise 
to  extreme  suffering.  Thus,  some  women  suffer  very  little  from  powerful  con- 
tractions, whilst  others  complain  bitterly  of  the  slightest  expulsive  effort.  Here, 
as  in  the  pathological  case,  it  is  impossible  to  fix  a  constant  relation  between  the 
intensity  of  the  abdominal  neuralgia  and  the  contractile  action  of  the  uterus. 

The  degree  of  pain,  as  M.  Beau  remarks,  is  owing  here,  as  in  all  other  neural- 


PHENOMENA     OF     LABOR.  391 

gias,  to  the  nervous  susceptibility  of  the  female.  We  were,  therefore,  right  in 
saying  (page  122)  that  the  pain  is  not  intimately  connected  with  the  contraction. 

Still  another  question  has  been  agitated  by  physiologists,  that  is,  why  is  the 
contraction  intermittent?  and  here  far-fetched  reasons  have  been  adduced  to 
explain  a  very  simple  phenomenon ;  ju.st  as  if  any  single  muscle  of  the  economy 
could  contract  permanently ;  as  if  it  were  not  the  nature  of  all  muscular  contrac- 
tion to  be  interrupted  by  the  fatigue  of  a  too-prolonged  exercise,  and  as  if  it 
must  not  have  an  interval  of  repose,  in  order  to  preserve  its  activity.  Besides, 
if  the  uterine  contractions  are  dependent  upon  the  nerves  of  organic  life,  why 
should  they  not  be  subject  to  the  periodicity  which  marks  the  muscular  apparatus 
supplied  by  branches  from  the  great  sympathetic  ?  We  are  doubtless  ignorant 
of  the  cause  of  the  rhythmic  intermissions  in  the  contraction  of  the  heart,  as 
well  as  of  the  stomach  and  intestines ;  what  cause  is  there,  therefore,  for  greater 
astonishment  at  the  intermittence  of  the  uterine  action,  subject  as  it  is  to  the 
same  nervous  influence. 

It  is  certainly  very  curious  to  study  the  influence  of  the  contraction  over  the 
mother's  circulation,  which  exhibits,  according  to  Holl,  the  following  peculiarities 
during  a  pain.  In  general,  the  pulse  is  accelerated  as  soon  as  the  contraction 
begins,  increasing  in  frequency  as  it  goes  on,  then  diminishing,  and  gradually 
resuming  the  normal  type.  Now  there  exists  so  intimate  a  relation  between 
these  two  phenomena,  that,  where  the  pulse  is  gradual  in  its  acceleration,  where 
it  arrives  little  by  little  to  the  maximum  of  its  rapidity,  is  there  sustained  for  a 
certain  length  of  time,  and  finally  recedes  by  degrees,  the  pain  also  follows  an 
equally  regular  course;  it  gradually  attains  its  maximum  intensity,  remains  a 
while  stationary,  and  then  decreases  with  the  same  regularity;  but,  on  the  con- 
trary, if  the  pulse  accelerates  by  jerks,  the  contraction  will  be  short  and  precipi- 
tate, and  therefore  without  effect.  Holl  ascertained  this  regularity  in  the  pheno- 
mena, by  counting  the  pulsations  by  quarters  of  a  minute  during  the  whole  time 
a  pain  lasted.  For  instance,  he  noted  the  following  variations  in  a  contraction 
which  lasted  two  minutes  : — 


f  First  and  second  quarters,  each, 

.     18 

pulsations 

First  minute, 

i  Third  quarter,    .          .          .          .          . 

.     20 

(.  Last  quarter,       .          .         .         .         . 

.     22 

(1 

{  First  and  second  quarters,  . 

.     24 

K 

Second  minute, 

<  Third  quarter,     .         .         .         .         . 
(  Last  quarter,        .         .         .         .         . 

.     22 
,     18 

In  proportion  as  the  labor  advances,  the  pulse  accelerates  the  more ;  so  that,  a 
little  while  before  delivery,  it  has  the  same  frequency  in  the  intervals  as  it  had 
at  first  during  the  strongest  contractions.  We  have  already  pointed  out  the  modi- 
fications in  the  bellows  murmur,  noticed  by  the  same  observer  during  the  pain, 
and  shall  not  repeat  them  now,  merely  remarking,  however,  that  they  are  suffi- 
ciently well  marked  to  indicate  the  uterine  contraction,  even  when  the  woman 
herself  may  be  desirous  of  concealing  it. 


392  LABOR. 

§  2.  Dilatation  of  the  Os  Uteri. 

The  foetus  evidently  has  no  part  in  the  dilatation  of  the  os  uteri  until  the  bag 
of  waters  is  ruptured.  It  is  not  until  after  this  event  takes  place  that  the 
vertex,  by  engaging  like  a  wedge  in  the  uterine  neck,  can  hasten  the  dilatation 
mechanically;  and  it  is  equally  evident  that,  in  any  other  than  a  vertex  position, 
the  presenting  part  being  more  voluminous  and  irregular  than  the  head,  cannot 
perform  the  same  ofi&ce,  and  therefore,  cceteris  ■paribus,  the  orifice  will  open  more 
slowly.  Hence,  it  is  not  the  foetus,  at  least  during  the  greatest  part  of  the  labor, 
which  is  the  efficient  cause,  but  here  also  the  phenomenon  is  referable  to  the  con- 
traction of  the  uterine  fibres. 

Now,  in  order  to  understand  how  this  occurs,  we  must  remember,  says  Desor- 
meaux,  that  the  walls  of  the  womb  are  applied  to  an  ovoid  body;  that  the  longi- 
tudinal fibres  are  the  most  numerous,  and  that  the  circular  fibres  of  the  cervix, 
although  capable  of  stoutly  resisting  their  power,  yet  are  gradually  constrained 
to  yield  to  the  action  of  the  longitudinal  ones.  If  we  now  imagine  these  latter 
fibres  to  enter  into  contraction,  we  shall  readily  comprehend  that,  being  unable 
to  diminish  the  distended  uterine  cavity,  all  their  power  must  be  exerted  in 
drawing  upon  those  points  of  the  circle  which  form  the  orifice,  where  each  one 
is  inserted,  and  thus  remove  them  from  the  centre  of  the  opening.  Wherefore, 
every  portion  of  the  orifice  being  equally  operated  upon,  it  will  present  a  circular 
form;  but  if  the  foetus  is  placed  transversely,  and  the  womb  dilated  in  that  direc- 
tion, the  fibres  being  retracted  more  in  the  same  diameter,  the  orifice  will  be 
elliptical. 

The  rapidity  of  the  dilatation  bears  a  direct  ratio  to  the  force  and  frequency  of 
the  contractions.  In  general,  it  is  very  slow  in  the  commencement  of  labor,  but 
much  more  rapid  towards  its  close ;  for  instance,  if  the  opening  dilated  to  the 
extent  of  one  inch  in  four  hours,  it  would  only  require  two,  or  at  most  three 
hours  for  its  complete  enlargement;  this  progresses  more  slowly,  however,  in 
primiparge  than  in  other  women.  Again,  the  softness,  or  the  rigidity  and  ten- 
sion, of  the  neck  during  the  intervals  of  pain,  have  a  great  influence  over  the 
rapidity  of  its  dilatation  ;  and  the  same  may  be  said  of  the  obliquity  of  the  orifice; 
for  when  this  latter  is  carried  in  front  towards  the  pubis,  or  what  is  s  -il  more 
frequent,  is  strongly  directed  backwards  towards  the  sacrum — in  either  case,  the 
neck  is  no  longer  placed  in  the  axis  of  the  contractions,  and  the  head  is  forcibly 
pressed  towards  some  part  of  the  uterine  wall,  against  which  all  the  expulsive 
force  is  lost. 

It  is  likewise  important  to  bear  in  mind,  that  the  posterior  obliquity  of  the 
neck  may  be  owing  to  an  anterior  inclination  of  the  womb,  and  may  also  exist 
without  the  latter  being  at  all  changed  from  its  normal  position ;  this  results  from 
the  head  having  been  engaged  a  long  time  in  the  excavation,  and  having  pushed 
the  anterior  inferior  uterine  wall  before  it;  the  os  uteri  being  at  the  same  time 
carried  upwards  and  backwards.  The  orifice,  which  is  generally  very  thin  in 
primiparae  at  the  beginning  of  labor,  becomes  thicker  towards  the  last  half  of  the 
first  stage ;  then  it  gets  thinner,  and,  finally,  forms  a  thick,  rounded  collar,  which 
the  head  pushes  before  it  as  far  as  the  inferior  strait. 


PHENOMENA     OF     LABOR.  393 

The  reason  of  these  various  changes,  says  M.  Guillemot,  is  very  simple ;  for 
the  pressure  upon  the  neck  acts  more  forcibly  on  the  periphery  of  the  orifice  than 
on  any  other  part,  and  the  consequent  thinning  will  disappear  as  soon  as  the 
uterine  circle  yields,  and  is  carried  back  towards  the  parts  that  have  not  suffered 
an  equal  pressure,  but  have  maintained  their  original  thickness ;  though  soon 
after,  in  consequence  of  fresh  pains,  the  tension  on  this  new  circle  will  destroy 
its  bulk  and  reduce  it  to  the  condition  stated.  Finally,  a  period  arrives  when 
the  neck  maintains  its  thickness,  notwithstanding  the  dilatation  it  undergoes, 
because  the  uterine  fibres,  being  excessively  shortened,  give  more  density  to  this 
part.  I  will  add  that  the  thickness  of  the  anterior  lip  is  often  greatly  augmented 
when  the  engagement  is  far  advanced,  by  oedema  of  the  part,  due  to  its  compres- 
sion between  the  head  and  the  symphysis  pubis;  and  further,  that  it  is  not  at  all 
uncommon  to  find  the  posterior  lip  quite  thin,  whilst  the  anterior  one  still  re- 
mains considerably  thickened. 

§  3.  Or  THE  Glairy  Discharges, 

We  have  already  learned  that  an  abundant  secretion  takes  place  in  the  vagina 
during  the  latter  periods  of  gestation ;  but  when  the  labor  sets  in,  this  secretion 
augments  very  considerably,  and  discharges  of  viscid  mucus,  resembling  the 
white  of  an  egg,  designated  as  the  glairy  discharges,  flow  from  the  womb  and 
vagina.  In  some  women  they  become  sanguinolent  at  the  approach  of  the  tra- 
vail ;  but  in  others  they  are  only  so  during  labor.  When  blood  is  thus  mixed 
with  the  other  fluids,  it  is  said  to  be  an  evidence  that  the  dilatation  of  the  orifice 
is  advanced ;  this,  however,  is  not  always  true,  since,  in  some  instances,  several 
days  elapse  before  the  commencement  of  parturition.  In  some  cases,  indeed, 
they  are  wholly  absent,  and  the  labor  is  then  said  to  be  a  dri/  one ;  the  genital 
parts  experiencing  a  degree  of  heat  and  dryness  almost  akin  to  inflammation. 

With  regard  to  their  origin,  these  discharges  are  not,  as  Ant.  Petit  and  Bau- 
delocque  supposed,  the  product  of  a  transudation  of  the  amniotic  waters  through 
the  pores  in  the  membranes;  but  they  simply  result  from  the  more  abundant 
secretion  of  the  mucous  criptas  in  the  neck  and  vagina ;  a  secretion  which  is 
augmented  by  the  greater  irritation  in  those  parts,  caused  by  the  labor.  As  to 
the  blood  that  colors  them,  whether  before  or  during  the  labor,  it  may  come 
either  from  some  slight  laceration  in  the  borders  of  the  orifice,  from  a  rupture  of 
some  of  the  minute  vessels  which  run  from  the  internal  uterine  surface  to  be  dis- 
tributed upon  the  membranes,  or  from  the  detachment  of  a  small  portion  of  the 
placenta;  or,  according  to  Desormeaux,  it  may  escape  from  the  extremities  of  the 
capillaries  without  any  discoverable  rupture. 

These  mucosities,  commencing  as  we  have  before  seen  in  the  latter  weeks  of 
gestation,  serve  to  lubricate  the  genital  passages,  and  while  relieving  the  vaginal 
walls  and  the  parietes  of  the  neck  from  their  engorgement,  they  have  the  further 
advantage  of  moistening  those  parts,  of  softening  the  perineum  and  the  vulvar 
orifice,  and  thus  rendering  the  extreme  distension  which  all  of  them  must  shortly 
undergo,  more  easy.  Their  abundance  is  always  to  be  considered  a  good  sign, 
presaging  a  prompt  dilatation  and  an  easy  expulsion. 


094 


LABOR. 


FiK.  65. 


§  4.  Of  the  Bag  of  Waters. 

As  the  neck  pi-ogressively  dilates,  the  foetal  membranes  present  and  become 
engaged  therein,  forming  a  tumor  of  variable  size  in  the  vagina,  which  is  tense 
at  the  moment  of  contraction ;  and  this  is  what  is  understood  by  the  formation  of 
the  bag  of  waters.  The  sac  varies  in  its  shape  with  the  figure  represented  by 
the  uterine  orifice ;  it  is  generally  rounded  and  hemispherical,  though  ovoid  when 
the  cervix  uteri  dilates  more  in  one  diameter  than  another ;  when  the  membranes 
are  formed  of  a  loose,  uneontracted  tissue,  and  especially  when  they  contain  but 
a  small  quantity  of  liquid,  they  may  form  an  elongated  tumor  in  the  vagina,  with- 
out being  a  necessary  sign  of  a  presentation  of  either  the  hand  or  the  foot,  as 
some  have  incorrectly  supposed. 

We  must  acknowledge,  howevei*,  that  the  bag  of  waters  is  usually  less  volumi- 
nous in  vertex  presentations  than  in  others ;  and  consequently,  that  a  very  great 
protrusion  of  it  nearly  always  announces  an  unfavorable  position.  This  occa- 
sioned the  remark  of  Madame  Lachapelle  :  '*  I  do  not  fear  the  fiat  sacs."  As  soon 
as  the  pain  ceases  the  tumor  disappears,  the  fiuid  that  formed  it  re-enters  the 
uterine  cavity,  and  the  flaccid,  relaxed  membranes  hang  in  folds. 

The  formation  of  the  sac  is  easily  understood. 
The  uterine  cavity  is  gradually  diminished,  and  the 
amniotic  liquid,  pressed  on  all  sides,  naturally  flows 
towards  the  point  that  ofi'ers  the  least  resistance, 
and  such  point  is  evidently  the  opening  in  the  neck 
where  no  walls  are  found.  The  reason  why  so  much 
difiiculty  existed  in  comprehending  how  the  mem- 
branes could  project  into  the  vagina  under  the' 
infiuence  of  this  pressure  of  the  liquid,  was  because 
the  amniotic  cavity  was  supposed  to  be  distended 
to  the  utmost  by  the  waters,  and  consequently  that 
there  must  either  exist  a  very  great  extensibility 
of  the  membranes,  or  else  a  transudation  of  the 
fiuid  through  the  walls  of  the  ovum ;  but  both  hy- 
potheses are  false.  For  it  is  only  necessary  to 
press  upon  the  abdomen  of  a  pregnant  woman  to  become  satisfied  that  in  most 
females  a  very  slight  pressure  will  be  sufficient  to  flatten  the  ovum,  whether  in 
its  vertical,  transverse,  or  antero-posterior  diameters.  This  is  what  takes  place 
in  labor,  excepting  that  the  ovum  can  only  elongate  below,  on  account  of  the 
uterine  pressure  upon  all  other  parts,  and  thus  produces  the  amniotic  tumor. 

When  the  dilatation  is  completed  and  the  contraction  energetic,  the  inferior 
part  of  the  membranes  being  no  longer  supported,  soon  yields  to  the  impulse,  and 
becomes  raptured,  thereby  permitting  a  variable  quantity  of  liquid  to  escape. 
Where  the  pouch  is  voluminous,  and  gives  way  just  at  the  moment  of  a  strong 
pain,  the  rupture  takes  place  with  such  a  loud  noise,  that  women  in  their  first 
labor  are  often  much  alarmed,  and  then  also  the  waters  gush  out  in  large  quan- 
tity.    But  where  the  pouch  is  flat,  and  only  a  small  quantity  of  fluid  is  inter- 


The  form  of  ihe  bag  of  waters 
when  the  os  uteri  is  fullv  dilated. 


PHENOMENA    OF    LABOR.  395 

posed  between  the  head  and  the  membranes,  the  latter  are  lacerated  without  any 
noise,  and  but  little  liquid  oozes  out  after  their  rupture ;  because,  the  head  by 
engaging  at  once  in  the  os  uteri  obliterates  it  completely  and  blocks  up  the 
waters. 

In  the  vast  majority  of  cases,  the  membranes  are  lacerated  on  that  portion  of 
the  bag  corresponding  to  the  uterine  orifice.  But  sometimes  the  rupture  occurs 
much  higher  up;  and  this  fact,  which  is  almost  inexplicable  in  the  present  state 
of  our  knowledge,  should  nevertheless  be  known,  because  it  accounts  for  the  cir- 
cumstance of  the  inferior  segment  of  the  ovum  being  then  found  intact  after  the 
discharge  of  a  certain  quantity  of  water,  and  of  our  having  to  puncture  the 
membranes  subsequently  in  this  part.  Sometimes  they  are  ruptured  in  the 
beginning  of  the  labor,  which  is  thereby  usually  rendered  longer  and  more  diffi- 
cult for  the  mother,  as  also  more  dangerous  for  the  child,  especially  when  a  con- 
siderable quantity  of  water  escapes  at  the  same  time.  Besides  these  varieties,  I 
have  several  times  noticed  a  remarkable  peculiarity  that  seems  to  have  escaped 
the  attention  of  practitioners  generally,  I  allude  to  the  occurrence  of  a  rupture 
before  any  contraction  of  the  uterus  whatever.  This  constitutes  in  a  few  females 
the  first  phenomenon  of  the  labor;  but  the  pains  do  not  come  on  for  some  time 
afterwards,  occasionally  not  for  several  days.  Now,  this  premature  laceration  has 
seemed  to  me  to  be  coincident  with  a  presentation  of  the  vertex  that  is  deeply 
engaged  in  the  excavation ;  for  although  the  patient  felt  no  previous  pain,  and 
even  in  certain  cases  was  sleeping  profoundly  when  the  waters  escaped,  it  is 
highly  probable  that  the  uterus  had  already  been  contracting  for  some  time,  and 
the  occurrence  may  be  referred  to  those  non-painful  contractions  hitherto  de- 
scribed; unless,  perhaps,  it  may  possibly  depend  on  an  excessive  distension  of 
the  amniotic  pouch. 

Sometimes  the  membranes  are  very  hard,  thick,  and  resistant,  the  rupture  only 
taking  place  at  an  advanced  stage  of  the  labor,  when  the  head  clears  the  vulva, 
for  instance ;  or  it  may  occur  in  a  circular  manner,  and  the  head  escape  covered 
by  a  kind  of  hood.  The  child  is  then  said  to  be  born  with  a  caul,  and  the  vul- 
gar, from  that  circumstance,  prophesy  a  happy  fuhire. 

The  infant  may  also  be  born  hooded,  when  a  rupture  of  the  membranes  first 
occurs  at  an  elevated  point,  one  not  corresponding  at  all  with  the  uterine  neck ; 
and  should  the  head  then  push  before  it  a  portion  of  the  amniotic  pouch,  serious 
accidents  might  result  in  consequence;  for  instance,  this  late  rupture  might 
delay  the  labor,  or  the  tension  experienced  by  the  membranes,  extending  to  the 
placenta,  may  cause  its  premature  detachment,  especially  when  it  is  inserted  on 
the  sides  of  the  organ,  and  thus  produce  a  uterine  hemorrhage. 

In  ordinary  cases,  the  rupture  takes  place  at  the  commencement  of  the  second 
stage. 

The  subjoined  is  a  statistical  summary  made  by  Churchill,  at  the  Western 
Lying-in  Hospital,  during  the  years  1841  and  1842,  which  will  enable  the  reader 
to  judge  of  the  varieties  that  may  be  met  with. 

The  period  elapsing  between  the  commencement  of  the  labor  and  the  rupture 
of  the  membranes  has  been  noted  in  984  cases.     Thus, 


396 


LABOR. 

[n   167 

females, 

this 

time 

was 

2  hours 

"    335 

a 

u 

from   2 

0    6      " 

"    165 

u 

IC 

" 

6 

'   10      " 

"    113 

(I 

(I 

" 

10 

'    14       " 

"      71 

" 

(( 

cc 

14 

'    18       « 

"      33 

c 

(( 

" 

18 

'   22       " 

"      46 

" 

(( 

" 

22 

c   26      « 

"      23 

" 

a 

• 

cc 

26 

'   30      " 

8 

CI 

u 

(C 

30 

'    38       " 

9 

u 

u 

" 

38 

<   40      « 

4 

(( 

(I 

about 

50      " 

2 

" 

IC 

" 

60      " 

"        4 

" 

cc 

cc 

70      " 

3 

u 

cc 

cc 

80      " 

1 

li 

cc 

<c 

105      " 

984 


The  satue  observer  noted  tlie  time  from  tbe  rupture  of  the  membranes  until 
the  child's  birth  in  812  cases. 


[n 

396 

women, 

this  time  was 

1  hour. 

" 

142 

" 

" 

2  hours 

" 

120 

" 

cc 

4 

cc 

cc 

50 

cc 

cc 

6 

" 

cc 

34 

cc 

" 

8 

cc 

cc 

17 

(C 

cc 

10 

cc 

" 

26 

cc 

cc 

15 

cc 

cc 

11 

cc 

cc 

20 

cc 

" 

9 

cc 

cc 

28 

cc 

cc 

4 

cc 

cc 

35 

cc 

cc 

1 

woman 

cc 

40 

cc 

cc 

1 

cc 

cc 

50 

« 

cc 

1 

cc 

cc 

120 

(C 

812 


§  5.  Of  the  Duration  of  Labor. 

The  duration  of  labor  is  exceedingly  variable,  even  when  no  obstacle  opposes 
its  natural  course.  Some  women  are  delivered  in  an  hour  or  two,  whilst  others 
are  not  for  several  days ;  and  between  these  two  extremes,  there  is  every  inter- 
mediate grade. 

The  published  statistics  are  hardly  reliable,  for  most  of  them  have  been  collected 
in  hospitals ;  and  it  is  a  fact,  that  the  majority  of  women,  dreading  to  be  taken 
into  the  apartment  devoted  to  the  patients  in  labor,  conceal  their  first  pains,  and 
give  up  only  when  they  can  restrain  themselves  no  longer.  Therefore,  when  in- 
terrogated after  delivery,  their  statements  are  not  found  to  coincide  with  their 
record,  and  make  their  labor  appear  much  longer  than  the  latter  would  indicate. 
This  correction  seems  to  me  of  importance,  for  most  physicians  of  limited  expe- 
rience having  learned  that  the  duration  of  labor  is  from  five  to  six  hours,  are  apt 


PHENOMENA    OF    LABOR.  397 

to  become  alarmed  unnecessarily  wlien  they  find  it  coutinuiug  even  longer  than 
from  ten  or  twelve  hours. 

In  general,  it  is  longer  in  primiparge  than  in  others ;  and  this  difference  is 
chiefly  owing  to  the  resistal!ce  of  the  perineal  muscles,  which  is  much  greater 
in  the  formel',  though  it  is  also  influenced  by  the  dilatation  of  the  neck,  which  is 
effected  in* them  very  slowly. 

The  whole  length  of  their  labor  is  usually  from  ten  to  twelve  hours,  but  it 
should  be  known  that,  in  at  least  one  case  in  five,  it  may  not  terminate  under 
fifteen,  eighteen,  or  even  twenty  hours,  and  this  without  any  injury  whatever 
resulting  either  to  the  mother  or  the  child.  Women  who  have  had  children  are 
delivered  much  sooner,  only  suffering,  in  ordinary  cases,  about  six  or  eight  hours. 
According  to  Alph.  Leroy  and  Velpeau,  the  pains  are  apt  to  observe  periods  of 
sis  hours,  that  is,  the  labor  lasts  either  six,  twelve,  eighteen,  twenty-four,  or 
thirty  hours.  I  think,  if  their  observation  be  correct,  it  will  be  found  subject  to 
very  numerous  exceptions. 

But,  supposing  the  labor  has  really  commenced,  can  we  predict  the  hour  of  its 
ermination  with  any  degree  of  certainty  ?  This  question,  which  is  nearly 
always  addressed  to  the  accoucheur,  is  oftentimes  a  very  difiicult  one  to  answer, 
for  habit  alone  can  enable  us  to  judge  by  the  dilatation,  or  the  suppleness  of  the 
neck ;  by  its  tension,  its  hardness,  and  resistance ;  by  the  frequency  and  intensity 
of  the  pains ;  by  the  time  it  has  already  existed,  and  by  the  greater  or  less  re- 
sistance of  the  vulva  and  perineum,  of  the  probable  length  of  the  labor. 

It  must  also  be  remembered,  in  regard  to  the  duration,  that  the  first  stage  of 
labor  is  to  the  second,  as  two,  or  even  three,  to  one ;  and,  further,  this  difference 
is  still  more  marked  in  women  who  have  had  children,  than  in  primiparse ;  and 
that  the  first  half  of  the  dilatation  of  the  neck  is  much  slovver  than  the  second. 
But  how  many  exceptions  are  there  to  this  law  !  For  instance,  the  dilatation  is 
sometimes  regular,  and  sufficiently  rapid,  everything  seeming  to  promise  an  easy 
and  a  prompt  termination ;  yet  all  at  once  the  pains  become  feeble  and  languish- 
ing, and  our  art  is  often  obliged  to  interpose  in  aid  of  the  uterine  contractions ; 
while,  on  the  contrary,  it  not  unfrequently  happens  that  the  neck  is  expanded 
with  an  excessive  degree  of  slowness,  after  which,  a  few  moments  will  suffice  to 
effect  the  delivery. 

The  form  of  the  vagina,  according  to  Wigand,  should  also  be  taken  into  consi- 
deration, in  making  a  prognosis  as  to  theprobable  duration  of  the  labor;  thus,  if 
this  canal  is  large  throughout,  the  whole  time  will  be  short;  and,  on  the  other 
hand,  the  dilatation  of  the  cervix,  and  the  expulsion  of  the  child  will  be  very 
slow,  should  the  vaginal  cavity  be  regularly  contracted  throughout  its  extent ; 
again,  if  the  vulvo-uterine  canal  is  large  and  spacious  superiorly,  but  contracted 
and  unyielding  near  the  external  orifice,  the  first  part  of  the  labor- will  be  prompt, 
but  the  last  slow,  and  difficult ;  and,  finally  (though  more  rarely),  if  its  upper 
extremity  is  very  narrow,  the  inferior  being  at  the  same  time  largely  dilated,  we 
may  conclude  that  the  parturition  will  progress  slowly  at  first,  but  will  then  ter- 
minate speedily. 

It  is  a  very  singular  fact,  that  an  hereditary  influence  is  sometimes  manifested 


398  LABOR. 

in  the  process,  it  being  not  at  all  uncommon  to  find  the  same  peculiarities  trans- 
mitted through  three  or  four  successive  generations ;  the  mother,  the  daughter, 
and  the  granddaughters  being  remarkable  either  for  the  slowness  or  the  rapidity 
of  their  labors.  ** 

In  general,  it  is  impossible  to  predict  with  any  degree  of  certainty  the  hour  of 
its  termination ;  yet  most  people  seem  to  imagine  that  the  physician  is  bound  to 
give  the  most  particular  information  on  this  point.  He  must,  however,  always 
be  very  guarded  in  his  replies,  for  should  the  labor  overrun  the  fixed  time  by 
some  hours,  it  would  give*  rise  to  the  most  anxious  solicitude,  and  it  is  therefore 
prudent  not  to  be  too  precise.  When  such  questions  are  addressed  to  me,  I  am 
in  the  habit  of  saying,  that,  if  the  contractions  are  regular,  and  no  accident 
occurs,  if,  in  a  word,  all  things  go  on  right,  the  delivery  will  take  place  at  the 
hour  I  name.' 

In  fact,  it  is  absolutely  impossible  to  foresee  all  that  may  happen ;  because,  in 
certain  cases,  the  dilatation  of  the  03  uteri,  which,  perhaps,  only  amounted  to 
one  inch  after  five  or  six  hours  of  labor,  is  suddenly  completed ;  and,  at  other 
times,  this  process  being  very  little  advanced,  the  margin  of  the  orifice  is  lace- 
rated under  the  influence  of  a  strong  pain,  and  the  delivery  eS"ected,  perhaps, 
just  as  the  physician  has  announced  that  the  labor  will  still  last  for  several  hours. 

In  examining  a  young  woman,  pregnant  for  the  first  time,  I  found  the  orifice 
dilated  to  the  size  of  a  quarter  of  a  dollar,  and,  supposing  that  the  labor  would 
last  for  some  time,  I  withdrew,  but  scarcely  had  I  reached  the  foot  of  the  stair- 
case, when  a  messenger  came  running  after  me  in  great  haste ;  I  immediately 
returned,  and  found  the  head  on  the  point  of  clearing  the  vulva,  which  was 
already  considerably  opened.  After  the  labor  was  over,  I  ascertained  that  the 
whole  left  side  of  the  vaginal  portion  of  the  neck  had  been  lacerated. 

A  young  primiparous  female  experienced  the  first  pains  at  four  o'clock  in  the 
morning.  Throughout  the  day  the  contractions  were  very  feeble,  with  intervals 
varying  from  a  quarter  of  an  hour  to  an  hour.  The  dilatation  was  so  slow,  that 
at  four  o'clock  in  the  afternoon  the  orifice  had  barely  attained  the  size  of  a  dime. 
About  five  o'clock,  the  pains  were  rather  stronger  and  quicker;  at  nine,  p.m.,  the 
neck  was  very  thin,  and  presented  an  opening  of  three-quarters  of  an  inch  in 
diameter.  Being  obliged  to  leave  the  patient  for  an  hour,  I  thought  that  I  might 
do  so  with  safety,  but  immediately  after  my  departure  the  contractions  became 
powerful,  and  at  a  quarter  before  ten,  she  gave  birth  to  a  very  small  child,  which 
barely  weighed  five  pounds.  The  small  size  of  the  foetus  accounts  for  the  rapidity 
of  the  labor;  and  yet  this  lady  had  enjoyed  good  health  during  her  pregnancy, 
besides  having  reached  her  full  term. 

The  woman's  age  has  not  the  unfavorable  influence  upon  the  duration  of  labor, 
even  in  primiparge,  which  is  accorded  to  it  by  some  authors.  "There  has 
always,"  says  Madame  Lachapelle,  "been  an  opinion  prevalent  on  this  point 
which  I  can  by  no  means  adopt :  it  is,  that  the  dilatation  of  the  passages  is  more 
difficult  in  women  advanced  in  years  than  in  others,  and  there  is  not  an  accou- 
cheur who  does  not  dread  the  first  labor  in  a  female  of  thirty  or  thirty-five  years 
of  age ;  nor  is  there  a  woman  in  that  condition  who  does  not  anticipate  with 


PHENOMENA    OF    LABOR.  899 

terror  tlie  hour  of  her  delivery.     My  experience  has,  however,  so  often  proved 
the  fallacy  of  such  prejudices  that  I  cannot  adopt  them. 

"  No  doubt,  the  labor  is  often  slow  and  painful  in  middle-aged  women  who  have 
had  no  children,  yet  the  same  is  the  case  with  the  youngest.  I  dare  affirm,  in- 
deed, that  there  is  no  more  difficulty  in  the  one  case  than  in  the  other,  and  that 
if  four  young  primiparous  females  out  of  ten  have  easy  labors,  four  out  of  ten  of 
the  oldest  will  also  be  delivered  with  promptitude  and  facility." 

§  6.  Op  the  effect  of  Labor  upon  the  Mother  and  Child. 

A.  Effect  of  the  Labor  upon  the  Mother. — Independently  of  the  numerous 
accidents  which  are  liable  to  occur,  and  which  will  be  studied  hereafter  under 
the  head  of  Causes  of  Dystocia,  the  parturient  process  has  a  decided  effect  upon 
the  physical  and  moral  condition  of  the  female,  which,  unfortunately,  almost 
uniformly  escapes  attention.  This  effect  may  be  exhibited  in  both  the  first  and 
second  stages,  and  even  continue  for  a  few  hours  or  days  after  delivery. 

The  commencement  of  labor  is  preceded  in  many  females  by  a  state  of  anxiety 
and  prostration,  and  often  by  feelings  of  fear  and  disquietude.  This  usually 
ceases  after  the  first  pains  are  experienced,  all  the  powers  of  the  organism  seem- 
ing then  to  be  devoted  to  the  accomplishment  of  the  great  function  about  to  be 
performed.  All  others  are  modified  or  suspended,  the  appetite  is  lost,  and  if  the 
patients  have  eaten  shortly  before,  they  not  unfrequently  reject  all  that  has  been 
taken  by  vomiting.  If  much  time  be  occupied  by  the  process  of  dilatation,  they 
weep,  and  become  irritable  and  despairing. 

This  excitability  diminishes  as  soon  as  the  second  stage  commences,  and  the 
patient  begins  to  feel  that  her  lahor  has  really  begun.  From  that  time  her  atten- 
tion seems  concentrated  upon  a  single  object,  and  she  is  indifferent  to  everything 
else.  During  the  expulsive  pains,  her  condition  approaches  that  which  charac- 
terizes inflammation  or  fever;  thus,  the  circulation  is  quickened  in  a  degree 
which  seems  connected  with  the  force  of  the  contractions ;  the  heat  and  moisture 
are  sensibly  augmented,  and  the  red  and  even  livid  features  sometimes  covered 
with  profuse  perspiration ;  again,  in  some  cases  the  skin  may  be  dry  and  hot. 

The  intensity  of  the  pains  occasionally  throws  the  patient  into  a  state  of  extreme 
agitation,  and  so  disorders  her  faculties  that  she  commits  acts  of  violence  upon 
her  attendants. 

This  agitation,  which  is  very  moderate  when  the  labor  progresses  regularly, 
becomes  extreme  when  the  latter  is  retarded  or  prolonged  inordinately.  The 
beginning  of  each  pain  is  then  marked  by  an  almost  convulsive  txembling  of  the 
extremities.  The  face  is  burning,  and  the  entire  body  bathed  in  perspiration, 
the  eye  is  fixed  and  haggard,  and  the  features  changed ;  the  unfortunate  sufferer 
screams,  laments,  desires  to  die,  and  begs  to  be  either  killed  or  relieved  of  her 
agony.  The  well-marked  disorder  of  the  intellectual  faculties  is  sometimes  car- 
ried to  complete  delirium,  during  which  the  patients  utter  the  most  extravagant 
expressions.  Two  such  cases  have  come  under  my  own  observation.  The  deli- 
rium is  almost  always  preceded  and  accompanied  by  great  loquacity,  and  the 
pains  are  hardly  felt.    I  knew  a  young  lady,  after  a  rather  lengthy  labor  attended 


400  LABOR. 

with  extreme  suffering,  suddenly  to  cease  complaining,  assume  a  smiling  expres- 
sion, and  after  a  few  incoherent  phrases,  to  sing  in  full  voice  the  grand  air  of 
Lucia  di  Lammcrmoor.  I  cannot  express  the  terrifying  effect  produced  by  this 
song  upon  myself  and  the  attendants.  (A  bleeding,  followed  by  the  immediate 
application  of  the  forceps,  had  the  effect  of  calming  the  patient,  and  there  was 
no  recurrence  of  delirium.)  Montgomery  also  states,  that  he  has  known  women 
to  be  completely  delirious  for  a  few  moments,  just  as  the  head  was  escaping  from 
the  mouth  of  the  womb. 

These  great  disturbances  of  the  economy  are  not  confined  to  cases  of  very 
tedious  labor,  for  the  same  symptoms  have  been  witnessed  in  very  short  ones 
with  powerful  and  very  rapid  pains.  The  cerebral  excitement  which  their  vio- 
lence produces  may  be  carried  even  to  the  point  of  insanity ;  so  that  medico-legal 
jurists  have  accounted  for  infanticides  by  this  momentary  disorder  of  the  intel- 
lect, which  would  otherwise  have  been  inexplicable. 

The  disorder  is  sometimes  confined  to  the  affective  faculties.  I  have  seen  a 
mother,  says  Ed.  Rigby,  after  a  very  short  and  painful  labor,  exhibit  an  uncon- 
querable aversion  to  her  child,  and  express  herself  in  reference  to  it  in  terms 
which  contrasted  strangely  with  the  tender  and  affectionate  remarks  which  she 
had  uttered  but  a  few  moments  previously. 

These  disorders  of  the  intellectual  and  affective  faculties,  generally  last  but  a 
short  time,  and  are  not  significant  of  great  danger;  sometimes,  however,  the 
shock  to  the  system  is  so  great,  that  death  takes  place  suddenly,  either  during 
the  course  of  the  labor,  or  shortly  after  delivery.  A  poor  woman,  in  the  Charity 
Hospital,  says  Davis,  had  been  in  labor  for  five  hours ;  the  membranes  ruptured, 
and  a  large  amount  of  water  escaped;  the  discharge  was  immediately  followed  by 
a  feeling  of  great  weakness ;  having  a  desire  to  go  to  stool,  she  sat  down  upon  a 
chamber,  made  a  few  efforts,  and  fell  fainting.  She  was  placed  in  the  horizontal 
position  as  soon  as  possible,  but  had  hardly  been  replaced  in  bed  before  she  had 
ceased  to  live.  The  autopsy  revealed  nothing  which  would  account  for  the  death. 
Denman  also  mentions  several  cases  of  sudden  death  during  labor,  which  it  was 
impossible  to  explain. 

In  some  of  these  instances,  however,  the  sudden  discharge  of  a  large  amount 
of  water  might,  to  a  certain  extent,  lead  us  to  attribute  the  mortal  syncope  to  the 
same  cause  which  is  thought  to  produce  it  so  often  after  delivery,  namely,  the 
sudden  afflux  of  a  great  quantity  of  blood  to  the  abdominal  vessels,  which  had 
been  suddenly  relieved  from  the  pressure  to  which  they  were  subjected  during 
pregnancy. 

An  undue  importance  has,  I  think,  been  attributed  to  this  too  rapid  depletion 
of  the  organ  as  explanatory  of  sudden  death  after  labor.  In  some  instances,  it 
may  have  all  the  influence  accorded  to  it,  though  it  is  certainly  incapable  of 
accounting  for  all  known  facts. 

The  violent  efforts  made  by  the  woman  in  the  second  stage  of  labor,  may  also 
occasion  a  rupture  of  some  part  of  the  respiratory  organs.  This  explains  the 
cases  of  emphysema  of  the  face,  neck,  and  upper  part  of  the  breast,  mentioned 
by  several  authors  (Martin,  of  Lyons).     In  a  serious  case  related  by  M.  Depaul, 


PHENOMENA    OF    LABOR.  401 

death  resulted  apparently  from  double  puliuonary  emphysema  occurring  suddenly 
during  the  violent  expulsive  efforts  of  a  long  and  painful  labor. 

The  fatal  effect  of  the  process  of  parturition  upon  the  nervous  system  of  the 
mother,  after,  as  well  as  during  labor,  cannot  be  mistaken ;  and  I  believe  with 
Churchill  that  it  consists  in  a  shock  of  greater  or  less  intensity  to  the  cerebro- 
spinal system.  This  shock,  which  is  an  effect  of  the  extraordinary  agitation  pro- 
duced by  parturition,  is  altogether  similar  to  that  occasioned  by  extensive  wounds, 
and  which  sometimes  destroys  unfortunate  workmen  who  have  had  a  member 
crushed  by  a  machine,  or  to  that  produced  by  an  extensive  burn.  The  sudden 
death,  which  neither  the  circumstances  of  the  accident,  nor  the  lesions  dis- 
covered at  the  autopsy  are  capable  of  explaining,  is  attributed  by  surgeons  to 
nervous  shock. 

Not  only,  says  the  author  just  cited,  may  such  a  nervous  shock  take  place  in 
certain  labors,  especially  difficult  ones,  and  have  a  disastrous  result,  but  it  exists 
to  a  greater  or  less  extent  in  almost  every  case.  Moderate  attention  will  make 
this  manifest.  Thus,  after  an  ordinary  labor,  the  general  sensibility  is  almost  always 
extreme  :  although  the  senses  are  more  acute  than  usual,  the  eyes  have  lost  their 
lustre,  and  are  weak  and  languishing;  the  least  light  hurts  them,  as  the  slightest 
sound  offends  the  ear;  and  if  this  extreme  delicacy  be  not  respected,  serious 
accidents  may  ensue. 

Under  ordinary  circumstances,  patients  recover  from  this  slight  collapse  after 
a  few  hours'  rest;  but  when  the  labor  has  been  protracted,  or  an  operation,  such 
as  turning,  has  been  demanded,  the  symptoms  are  much  more  severe.  The 
patient  is  much  weaker,  and  the  expression  of  features  is  fixed  and  dull ;  she  lies 
motionless  in  bed,  with  closed  eyes,  or  opens  them  from  time  to  time,  without, 
however,  fixing  them  upon  any  object  in  particular;  she  pays  no  regard  either  to 
her  child  or  to  herself;  the  limbs  are  in  a  state  of  complete  relaxation;  the  pulse 
is  sometimes  slow,  at  others  frequent  and  irregular,  though  always  weaker  than 
usual,  and  the  breathing  slow  and  difficult,  or  quick  and  panting. 

The  patient  may  remain  in  this  condition  for  a  long  time,  and  I'ccovers  from  it 
slowly  and  gradually.  If  the  shock  has  been  too  great,  she  may  grow  weaker 
and  weaker,  until  the  prostration  ends  in  death.  The  autopsy,  under  these  cir- 
cumstances, fails  to  throw  any  light  upon  the  cause  of  death. 

This  singular  state  of  affairs  is  not  always  manifested  immediately  upon  deli- 
very; for  sometimes  considerable  time  elapses,  during  which  the  patient  expresses 
herself  as  feeling  very  well,  then  suddenly  complains  of  unusual  weakness,  ex- 
claims that  she  is  about  to  faint,  and  yet  is  unable  to  account  for  the  cause  of  her 
condition.  There  are  no  particular  abdominal  symptoms,  no  evidence  of  hemor- 
rhage, and  the  uterus  is  well  contracted ;  still  the  disorder  increases,  the  pulse 
grows  weakei',  the  face  becomes  pale  and  assumes  a  cadaverous  expression,  and 
the  patient  is  so  prostrated  as  to  be  able  to  express  her  feelings  only  by  a  groan. 
Suddenly,  she  experiences  a  sensation  of  violent  constriction  of  the  chest,  and 
expires  before  anything  can  be  done  for  her  relief. 

Opium,  says  Churchill,  has  seemed  to  me  the  most  effectual  remedy  in  these 
cases.     Five  drops  of  laudanum  may  be  given  every  half  hour,  then  every  hour, 

26 


402  LABOR. 

and  finally  at  longer  intervals.  It  appears  to  calm  the  general  disturbance,  dimi- 
nish the  cerebral  shock,  and  give  to  the  whole  system  sufficient  time  to  recover 
its  exhausted  forces.  Small  quantities  of  wine  and  brandy,  may,  at  the  same 
time,  be  given  at  intervals,  in  doses  sufficient  to  assist  in  re-establishing  the 
strength,  but  not  in  such  quantity  as  to  produce  a  general  reaction.  The  induc- 
tion of  sleep  will  be  assisted  by  entire  quietness  of  both  body  and  mind,  and  when 
so  fortunate  a  result  is  obtained,  the  strength  is  recruited,  and  the  pulse  and 
respiration  become  calm ;  if,  on  the  contrary,  the  prostration  continues,  the  case 
is  one  of  the  most  dangerous  character,  and  demands  the  increased  use  of  external 
and  internal  stimulants.  Ramsbotham  recommends  that  pressure  should  also  be 
made  upon  the  abdomen,  doubtless  with  the  object  of  preventing  the  afflux  of 
fluids  towards  the  abdominal  vessels. 

If  the  agitation,  spasm,  and  delirium,  of  which  we  have  spoken,  appear  during 
labor,  blood  should  be  taken  immediately  from  the  arm,  provided  the  general 
condition  of  the  patient  admit  of  it,  and  the  delivery  be  accomplished  as  soon  as 
possible. 

The  same  course  is  also  indicated  by  the  sudden  occurrence  of  a  marked  dis- 
order of  one  of  the  organs  of  the  special  senses, — amaurosis,  for  example. 

B.  The  eifect  which  labor  may  have  upon  the  foetus  depends  upon  a  multitude 
of  circumstances,  most  of  which  will  be  studied  hereafter.  Thus,  having  de- 
scribed the  mechanism  of  labor  in  each  presentation,  we  shall  treat  of  the  effect 
which  each  is  liable  to  have  upon  the  health  and  life  of  the  child.  The  various 
causes  of  dystocia  are  quite  as  unfavorable  to  the  latter  as  to  its  mother. 

We  have  but  these  observations  to  make  in  this  place,  namely,  that  all  things 
else  being  equal,  the  mortality  of  male  infants  is  much  greater  than  that  of 
females,  which  is  due,  as  we  have  said  before,  to  the  greater  size  of  the  former, 
and  the  proportionally  longer  duration  of  the  labor  in  consequence ;  the  extreme 
slowness  of  this  process,  which  so  often  proves  fatal  to  the  foetus,  has  this  unfor- 
tunate effect  only  when  it  affects  the  second  or  expulsive  stage.  Until  the  mem- 
branes are  ruptured,  and  even  until  the  dilatation  is  completed,  the  labor  may  be 
prolonged  indefinitely  without  injury  to  the  foetus,  provided  a  certain  amount  of 
fluid  remains  in  the  uterus. 


CHAPTER    III. 

OF    THE    MECHANICAL    PHENOMENA    OF    LABOR. 

ARTICLE   I. 

OF   THE   PRESENTATIONS   AND   POSITIONS. 

"When  speaking  of  the  child's  attitude  in  the  uterine  cavity,  we  stated  that  it 
was  generally  so  situated  that  the  cephalic  extremity  formed  the  most  dependent 


MECHANISM    OF    LABOR.  403 

part.  But  it  may  also  happen,  under  the  influence  of  causes,  hereafter  to  be 
studied,  that  some  other  point  of  the  great  axis  shall  correspond  to  the  uterine 
neck ;  that  is  to  say,  the  upper  or  the  cephalic  extremity,  the  inferior  or  the 
pelvic  extremity,  or  even  some  part  of  the  middle  portion  or  trunk,  may  first 
present  itself  at  the  superior  strait.  Now,  it  is  very  evident  that  such  different 
circumstances  of  presentation  must  necessarily  influence  the  mechanism  of  the 
labor,  as  also  the  facility  and  the  promptness  of  the  delivery,  and  it  is  therefore 
highly  important  to  understand  well  all  those  diverse  situations  before  com- 
mencing the  study  of  the  mechanism  proper.  This  study  comprises  the  presen- 
tations and  positions,  as  they  are  called ;  and  in  using  these  terms  we  wish  to 
designate  by  the  word  prese^itation  the  part  that  first  offers  at  the  superior  strait ', 
and  by  that  of  position,  the  relations  of  this  presenting  part  with  the  difierent 
points  of  the  same  strait. 

The  older  accoucheurs  only  endeavored  to  recognize  the  presenting  part,  without 
investigating  its  relations  with  the  various  points  of  the  circumference  of  the 
strait;  but  since  the  days  of  Solayres,  and  more  especially  since  those  of  his  pupil 
Baudelocque,  everybody  has  had  a  classification  of  his  own ;  and  the  number  of 
presentations  and  positions,  considered  as  so  many  separate  and  distinct  ones, 
varied  with  each  author  who  wrote  on  the  obstetrical  art. 

We  give,  in  the  following  tables,  the  classification  of  Baudelocque,  and  the 
principal  ones  of  those  who  have  succeeded  him. 


404 


LABOR. 


CO 

1^ 
O 
I— < 
H 

O 

hH 
fa 
I— I 
CO 

03 

-si 

O 

H 

fa 
o 

< 

t-:i 

o 


.2„  ^:H..^  S.2  £  2 

ex"    £.'5  £"  'I'  -5  o  - 

•^      o  S  8  2  E.  S  ^ 

-;    C    c  o 


_:  -5  '3 
S  og 


,-C     C     *- 


p      w     ~     '— '   M 


o  ::  c 


<IJ  ^        F^ 


rt    o    C3    3    o 


Ti        ^    -   es 


o  Pi  *-l  O  g  ^  ^  ^  J  p^  ^  O  J 


o  ,-  t;  6  J  ,„  ^ 


a 
u 
o 

>-] 
w 

Q 

P3 


MECHANISM     OF    LABOR. 


405 


•    •   a   a 

''C     <D    ^    h- 

at  the  lef 
at  the  rig 
at  the  rig 
at  the  left 
the  left  ac 
the  right 
the  right 
the  left  sa 

Right  si 
Left  sid 
Anterio 
Posterio 

Occiput 
Occiput 
Occiput 
Occiput 
Chin  at 
Chin  at 
Chin  at 
Chin  at 

J 

V.                                  J\ 

u 
a 

o 

w 
p 

< 


H 

tf  o  a  i;  ,^ 

w  <  M  z  :i 

>  fa  U.  Lii  CQ 


406 


LABOR. 


^2 


Br 


—  o 
^5 


•V   —     Oi     > 


S  ^  1  s  S  ^  ^  F  i: 


o 


&-  Qj   01    c-i'S   o    o    o    o    y    - 


p-'S-.-s 


o  ^ 


1 1 :-?  ;-s  6  .a  • 

"  5  "  -^  ;:  = 
~  5  S  S 

—  o 


uJlZolo^-Oo^^cJ:;-^, 


o   s   t;  ,2 


6     Oi     Cj     o    c 

^    o  „    c   _ 


bjj  St'— 


OJCO-5"     —IINCO'S'OCO 


1-1  h4 


-J 


0)  '     C  "J  >> 

o  >  p    5  o  '" 

^  -5  =  =  -^  rt 

r"  -c  -S  "5  c  -"r 

o  S  s  a;  o  2 

.  -  X  iJ   Ji  fi  o 

ii  —  C3     _  ^  </; 

«  g  ,„  ^  ^  ,„ 


<!••--;    ^ 


=  ~^     h-] »;  ci;  hJ  !  cs  ^  ^ 


2   <u   P   =   o   " 

„  <S  -g  ^  .^  .5 

tD.2    «    C    it    o 


o    „  ^  5    „ 


•     •  ^  is 

15    "^  t"  J:; 

m  :2  ,2  .2 

♦J    «  fc-  rt 

^  01  '^ 


^  _>i  C    O  t—    fcc 


_  'C  'C  —  ^_>,  c 

2  S  2  2  o  o  p^ 

w  t:  ■;:i  ~  <u  i*  -^^ 
*j  »^  4-.  «  •-  -i;  o 
ro   c3   ro   re  "^  ^    !< 


iihJ 


Qy    u    a>    oj 

ts  ti:  s  rc 


•z;  ^  ^     lu 


-^c  a  &.  Q-  E^ 
'  E  o   o   o  '5  • 

C    O     CJ     u    o  — 

o  c  c  c  — 


c   c    c     ^ 


U  hJ  1-1  h-5  hJ     PC 


^ 

a 

H 

Ul 

M 

M 

H 

rrj 

c^U! 

m 

o 

(Xi 

Pi 


X     Ph 


<D    O 


t-lM 


"3  K     ^2 


.     . 

R3 

iJ     ^ 

p. 

-t;  o 

iMi 

. 

'7i  rs 

O 

0 

*j    en 

0) 

TrC 

PC  J  Hh  -< 


<:  M  s^  cd 


MECHANISM     OF    LABOR. 


407 


CLASSIFICATION  OF  PROFESSOR  MOREAU. 


TWO  CLASSES 
FIRST 


1st  genus. 

Vertex  presentation. 


FIRST  ORDER 

Presentation    of  the- 
cephalic  extremity 


NATURAL  LABORS. 
ARTIFICIAL  LABORS. 
CLASS. — Natural  Labors. 

'  anterior, 
transverse, 
posterior, 
anterior, 
transverse, 
posterior. 
3d  position. — Occipito-pubic. 
4th  position. — Occipito-sacral. 


2d  genus. 
Face  presentation. 


3d  genus. 
Presentation    of    the 

sides  of  the  head. 
2  subdivisions. 
Right  side. 


1st  position. — Left  occi- 
pito  ilium. 

2d  position. — Right  oc- 
cipito-ilium. 


,  Left  side. 


1st  genus. 
Breech  presentation. 


1st  position. — Right 
mento-ilium. 

2d  position  — Left 
mento-iUum. 


r 

I    1st  position. — ^Lobulo-pubic. 
-{    2d  position. — Left  lobuln-iHum. 
3d  position. — Right  lobiilo-ilium. 

L 

(1st  position. — Lobulo-pubic. 
<  2d  position. — Left  lobulo-iliiim. 
'  3d  position. — Right  lobiilo-ilium. 


SECOND  ORDER 

Presentation   of  the - 

pelvic  extremity. 


2d  genus. 
Foot  presentation. 

3d  genus. 
Presentation    of  the 
knees. 


1st  position.- 
ilium. 


-Left  sacro- 


2d  position. — Ri 
sacro-ilium. 


Jht 


THIRD  ORDER. 


FIRST  ORDER. 
Accidental  artificial 
labor. 


SECOND  ORDER 
Essentially  artificial*; 
labor. 


Accidental    natural    la 

bor. 
SECOND  CL.ASS.— Artificial  Labors 

1st  genus. 
Accidents    on    the    mo- 
ther's part. 
2d  genus. 
Accidents  on  the  part  of 
the  foetus. 

single  genus. 
Presentation    of  the 

trunk. 
2  subdivisions. 

1st.  Right  side. 


3d  position. — Sacro-pubic. 

4th  position. — Sacro-sacral. 

1st  position. — Left  calcaneo-ilium. 

2d  position. — Right  calaneo-ilium. 
I    3d  position. — Calcaneo-pubic. 
t  4th  position. — Calcaneo-sacral. 
f  1st  position. — Left  tibio-ilium. 
J   2d  position. — Right  tibio-ilium. 
1    3d   position. — Tibio-pubic. 
L  4th  position. — Tibio-sacral. 
5  Single  genus. — Presentation  of  the 
(       trunk.     (See  below.) 


THIRD  ORDER. 
Labors    which     are  i 
the  result  of  mal- i 
formation. 


2d.  Left  side. 


1st  genus. 
On  the  part  of  the  child. 


C  1st  position. — Left  cephalo-ilium. 

(  2d  position. — Right  cephalo-ilium. 

<   1st  position. — Left  cephalo-ilium. 

(  2d  position. — Right  cephalo-ilium. 


2d  genus 
1   On  the  part  of  the  mo- 
l^       ther. 

APPENDIX,  OR  THIRD  CLASS.— Anom.\lies. 
Anomalies  either  in  the  seat,  course,  or  products  of  gestation,  or  lesions  of  the  womb. 


408  LABOR. 

The  reader  will  see,  by  the  foregoing  table,  that  Baudelocque  primarily  divides 
the  foetus  into  two  extremities;  the  one  represented  by  the  apes  of  the  head,  the 
other  by  the  feet,  knees,  or  breech  ;  and  further,  that  the  remainder  of  the  child's 
surface  is  divided  oif  into  four  regions,  which  are  again  subdivided  into  several 
others.  After  having  determined  the  foetal  regions,  the  presence  of  which,  at 
the  superior  strait,  constituted  a  presentation,  it  was  equally  necessary  to  under- 
stand the  positions.  For  that  purpose  certain  points  of  departure  were  selected, 
both  on  the  pelvis  and  on  the  presenting  part  of  the  child.  Of  course,  these 
points  varied  according  to  the  presentation ;  thus,  in  a  vertex  one,  Baudelocque 
took  the  occiput  and  forehead  as  the  points  on  the  foetal  head ;  he  then  divided 
the  pelvis  into  an  anterior  and  a  posterior  half;  on  the  first  of  which  the  right 
and  the  left  cotyloid  cavities  and  the  symphysis  pubis,  and  on  the  second  the 
right  and  left  sacro-iliac  symphyses,  and  the  sacro-vertebral  angle,  were  selected 
as  the  points  of  departure;  he  next  established  six  positions  of  the  vertex,  in  each 
of  which  the  occiput  corresponded  to  one  of  those  points  on  the  pelvis  just  indi- 
cated. 

In  the  presentations  of  the  breech,  knees,  and  feet,  he  retained  the  same  three 
points  on  the  anterior  half  of  the  pelvis,  but  on  the  posterior  half  he  only  adopted 
one ;  the  sacro-vertebral  angle.  On  the  foetus,  the  heels  were  the  points  of  cor- 
respondence in  foot  presentations,  the  sacrum  for  the  breech,  and  the  front  sur- 
face of  the  legs  for  those  of  the  knee.  Consequently,  but  four  positions  were 
admitted  for  either  the  breech,  feet,  or  knees. 

Lastly,  for  the  presentations  of  the  numerous  regions  indicated  by  the  table 
on  the  anterior,  posterior,  and  lateral  planes  of  the  foetus,  he  selected  on  the 
mother's  pelvis  the  two  extremities  of  the  antero-posterior  diameter  (the  sym- 
physis pubis  and  the  sacro-vertebral  angle),  and  the  two  ends  of  the  transverse 
diameter,  as  the  points  of  departure,  so  that  he  pointed  out  four  possible  rela- 
tions, that  is  to  say,  four  positions  for  each  one  of  these  presentations.  Thus, 
Baudelocque  admitted  altogether  one  hundred  and  two  distinct  positions.  But 
it  was  soon  ascertained  that  so  great  a  number  was  wholly  useless  in  practice; 
and  besides,  it  had  the  serious  disadvantage  of  disgusting  pupils  with  the  study 
of  midwifery.  The  classification  of  Baudelocque  was  therefore  modified  to  some 
extent,  arwi  we  have  successively  traced,  in  our  table,  the  principal  of  those  modi- 
fications ;  still,  even  after  adopting  the  latter,  the  obstetrical  art  was  yet  greatly 
confused,  and  it  remained  for  M.  Nsegele  to  simplify  this  branch  of  medical 
science,  much  more  than  it  had  ever  been  done  before  his  day.  To  him,  there- 
fore, we  must  attribute  this  honor,  as  also  to  Dubois,  and  Stoltz,  of  Strasbourg, 
who  first  endeavored  to  disseminate  throughout  France  the  views  of  the  Heidel- 
berg professor !  It  must  be  acknowledged,  however,  that  the  labors  of  Madame 
Lachapelle,  and  the  teachings  of  Ant.  Dubois,  have  not  been  altogether  foreign 
to  this  improvement. 

We  should  also  observe  that  the  classification  of  !M.  Moreau  is  far  more  simple 
than  all  those  of  Baudelocque  and  his  followers;  indeed,  this  professor  has 
adopted  (as  seen  by  the  table)  most  of  the  ideas  upon  which  the  arrangement 
of  Ngeg^le  is  founded,  and  we  only  regret  that  he  has  considered  the  presenta- 


MECHANISM     OF     LABOK.  409 

tions  of  the  sides  of  the  head  and  certain  of  the  positions  as  distinct,  which  we 
hope  to  demonstrate  hereafter  do  not  deserve  to  be  so  regarded. 

In  fact,  there  is  no  region  of  the  child  which  may  not  present  at  the  superior 
strait  during  the  labor,  and  therefore,  if  we  are  to  consider  all  the  points  of  its 
surfoce  that  may  be  accessible  to  the  finger  as  so  many  distinct  presentations, 
their  number  would  be  very  considerable ;  but  if,  on  the  contrary,  the  expression 
is  only  applied  to  the  presence  of  a  region  large  enough  to  occupy  the  whole 
superior  strait,  more  especially  to  one  requiring  a  notable  difference  either  in  the 
mechanism  of  its  spontaneous  expulsion,  or  in  the  manoeuvres  to  be  resorted  to, 
this  number  would  then  be  much  more  limited. 

Upon  such  opinions,  advocated  long  since  by  Madame  Lachapelle  and  Ant. 
Dubois,  M.  Naegfele  has  founded  the  following  classification,  which  is  now  admit- 
ted and  taught  by  Dubois  and  Stoltz  in  France,  namely,  three  principal  regions 
are  distinguished  in  the  fa^tus :  1.  The  head,  or  cephalic  extremity;  2.  The 
pelvis,  or  pelvic  extremity;  and  3.  The  trunk;  either  of  which  parts  may  offer 
first  at  the  superior  strait. 

When  the  cephalic  extremity  presents,  it  is  ordinarily  flexed  on  the  chest,  and 
the  vertex  then  advances  first ;  but  it  may  also  be  extended  or  thrown  backwards 
on  the  posterior  plane  of  the  foetus,  in  which  case  the  face  engages  first.  We 
have  therefore  to  distinguish  between  a  vertex  presentation  and  one  of  the  face, 
for  the  mechanism  of  labor  is  very  different  in  the  two.  When  the  pelvic  ex- 
tremity presents,  the  legs  are  usually  flexed  on  the  thighs,  and  the  latter  on  the 
abdomen;  but  it  may  happen,  from  a  variety  of  causes  that  we  shall  hereafter 
designate,  that  these  divers  parts,  which  are  usually  folded  up  in  this  manner, 
are  separated  from  each  other;  thus,  they  sometimes  engage  altogether  in  the 
excavation ;  at  others,  either  during  the  course  of  the  labor  itself,  or  some  time 
before,  the  inferior  members  stretch  out  and  lay  along  the  front  of  the  body,  and 
the  nates  then  descend  alone.  Again,  the  legs  may  be  swept  down  either  by  the 
gush  of  the  waters,  or  by  some  other  cause,  and  engage  first ;  hence,  in  this  latter 
instance,  if  the  deflexion  of  the  lower  members  is  complete,  the  feet  are  the  first 
to  clear  the  vulva;  but  if,  on  the  contrary,  the  thighs  be  extended,  and  the  legs 
remain  flexed  on  them,  the  knees  will  be  the  first  to  show  themselves  at  the  ex- 
ternal orifice. 

Now  it  must  be  evident,  on  the  least  reflection,  that  these  latter  circumstances 
can  effect  no  modification  in  the  mechanism  of  the  labor  itself,  and  accoucheurs 
are  certainly  in  error  in  considering  them  as  so  many  distinct  presentations; 
consequently,  we  shall  describe  them  under  the  single  title  of  the  presentation  of 
the  pelvic  extremity;  merely  remarking  that,  when  this  extremity  presents,  all 
its  constituent  elements  may  happen  to  engage  together  at  the  same  time,  or  they 
may  be  separated,  and  then  the  breech,  or  the  knees,  or  feet,  will  offer  first  at 
the  vulva. 

But  before  proceeding  any  further,  we  will  follow  the  example  of  M.  Dubois 
(from  whom  this  article  is  borrowed  almost  verbatim),  by  laying  down  precisely 
the  limits  of  the  foetal  regions  embraced  in  the  double  expression  of  the  cephalic 
and  the  pelvic  extremity ;  thus,  when  the  head  or  the  pelvis  presents  at  the 


410  LABOR. 

superior  strait,  it  usually  does  so  nearly  ''plumb;"  that  is  to  say,  the  long  dia- 
meter of  the  foetus  is  almost  parallel  to  the  axis  of  this  strait ;  so  that  the  sagittal 
suture  in  the  vertex  pi'esentations,  the  facial  median  line  in  those  of  the  face, 
and  the  fissure  between  the  nates  in  those  of  the  pelvic  extremity,  occupy  very 
nearly  the  centre  of  the  abdominal  strait. 

But  very  numerous  exceptions  to  this  rule  occur,  because  the  mobility  of  the 
foetus  in  the  uterine  cavity,  and  the  frequency  of  uterine  obliquities,  may  cause 
the  child's  long  diameter  to  be  inclined  forwards,  backwards,  or  towards  the  sides. 
Hence,  it  is  evident  that  the  presenting  part,  participating  in  this  inclination, 
will  not  be  so  regularly  placed  as  usual ;  thus,  if  it  were  a  vertex  presentation, 
and  the  inclination  were  anterior,  the  summit  would  no  doubt  descend,  though 
it  would  be  accompanied  by  the  forehead  in  consequence  of  this  defective  posi- 
tion ;  or,  if  the  inclination  were  on  the  posterior  plane,  instead  of  the  forehead, 
we  should  have  the  occiput  or  occasionally  even  the  neck.  Again,  if  it  is  lateral, 
that  is,  if  the  foetus  is  bent  towards  one  side,  the  vertex  and  one  side  of  the  head 
may  be  recognized  at  the  same  time ;  and  the  sagittal  suture,  instead  of  corre- 
sponding to  the  axis  of  the  superior  strait,  will  then  be  found  either  behind  or  in 
front,  according  to  the  direction  of  the  inclination  ;  but  such  inclinations  do  not 
deprive  the  vertex  presentation  of  its  character,  they  only  convert  it  into  a  defec- 
tive and  an  irregular  presentation. 

The  observations  just  made  in  regard  to  vertex  presentations,  equally  apply  to 
those  of  the  face  and  breech,  and  we  may  therefore  have  regular  and  irregular 
ones  of  these  parts  just  in  the  same  way.  To  resume,  we  shall  include  in  the 
class  of  vertex  presentations,  all  those  designated  by  Baudelocque  under  the 
names  of  presentations  of  the  occiput,  nape,  and  lateral  parts  of  the  head ;  in 
face  presentations,  those  of  the  forehead,  chin,  cheeks,  front  and  sides  of  the 
neck ;  and  in  the  breech,  those  of  the  sacrum,  genital  parts,  front  of  thighs,  &c. ; 
whence  all  the  surface  comprised  between  the  sinciput  and  the  shoulders  belongs 
to  the  cephalic  presentations,  and  that  between  the  summit  of  the  nates  and  the 
haunches  is  referred  to  the  pelvic  ones. 

If  we  now  take  off  all  the  foetal  parts  included  in  the  cephalic  and  pelvic  ex- 
tremities, there  will  only  remain  the  trunk  proper;  that  is,  the  portion  extending 
from  the  shoulders  to  the  hips,  and  this  part  may  also  present  the  first.  Now 
with  regard  to  this,  Madame  Lachapelle  has  long  since  remarked  that,  when  the 
trunk  offers  at  the  superior  strait,  it  always  does  so  by  one  of  its  sides ;  that  is  to 
say,  the  anterior  or  the  posterior  median  line  of  the  body  never  corresponds  to 
the  axis  of  the  superior  strait.  Therefore,  she  divided  the  trunk  into  two  lateral 
halves,  either  of  which  may  come  down  first ;  hence  there  are  two  trunk  presen- 
tations, one  of  the  right  lateral  plane,  the  other  of  the  left  lateral  plane;  the 
whole  anterior  and  posterior  right  moieties  being  included  in  the  first,  and  the 
same  parts  on  the  left  being  embraced  in  the  second;  and  as  the  shoulder,  which 
is  then  the  most  prominent  part,  is  nearly  always  found  at  the  centre  of  the 
superior  strait,  when  the  lateral  planes  offer  first,  that  skilful  midwife  designated 
them  as  presentations  of  the  shoulder.  M.  Dubois,  however,  still  retains  the 
name  of  the  presentations  of  the  lateral  region;  and  these,  like  the  others,  may 


MECHANISM     OP     LABOE.  411 

either  be  regular  or  irregular.  They  are  regular  when  the  lateral  line  is  directly 
at  the  centre  of  the  abdominal  strait,  but  irregular  where  the  anterior  or  the  pos- 
terior region  of  the  trunk  occupies  this  strait  in  a  great  measure,  owing  to  the 
child  being  more  or  less  inclined  forward  or  backward ;  and  it  is  to  such  irregu- 
larities that  we  must  refer  all  those  presentations  of  the  back,  loins,  front  of  the 
chest  and  abdomen  described  by  the  older  authors. 

On  the  whole,  then,  we  admit  five  presentations,  viz.,  one  of  the  vertex,  one 
of  the  face,  one  for  the  pelvic  extremity,  one  for  the  right  lateral  plane,  and  one 
of  the  left  lateral  plane.  Besides  the  presentations,  Baudelocque,  and  all  those 
who  followed  him,  described  a  great  number  of  jjosi^/ons ;  in  each  of  which, 
according  to  their  account,  the  mechanism  of  the  labor  was  different.  But  ^I. 
NtBgele,  in  consequence  of  a  better-conducted  study  of  this  mechanism,  has  suc- 
ceeded in  changing  entirely  this  branch  of  the  science,  and  has  further  proposed 
a  reform  in  the  positions,  at  least  as  important  as  what  he  has  already  made  in 
the  classification  of  the  presentations.  Thus,  he  simply  divides  the  pelvis  into 
two  lateral  halves,  the  right  and  the  left,  and  these  form  the  only  points  of  de- 
parture at  the  superior  strait ;  on  the  foetus,  the  points  admitted  by  Baudelocque 
are  retained.  For  instance,  in  a  vertex  presentation,  the  occiput  may  ofl'er  at 
any  one  point  whatever  of  the  left  lateral  half  of  the  superior  strait,  thereby  con- 
stituting the  first  position  of  the  vertex;  or  it  may  correspond  in  a  similar  way 
with  the  right  lateral  half,  thus  producing  the  second  position ;  further,  as  the 
mechanism  is  just  the  same,  whether  the  occiput  be  at  first  at  the  front,  in  the 
middle,  or  behind,  we  shall  only  consider  these  circumstances  as  so  many  varieties 
of  the  same  position ,  which  shades  or  varieties,  in  the  great  majority  of  cases, 
do  not  change  the  mechanism  of  the  natural  labor  in  anywise,  and  therefore  do 
not  deserve  to  be  received  as  important  elements  in  a  classification,  but  of  which, 
however,  more  account  should  be  taken  than  appears  to  have  been  done  by  M. 
N^egele,  for  they  may  be  usefully  recalled  in  explanation  of  cei'tain  anomalies,  as 
also  for  successful  intervention  in  some  cases  of  difficult  labor. 

"What  has  just  been  stated  concerning  the  vertex  equally  applies  to  the  posi- 
tions of  the  face  and  breech,  since  in  the  former  the  chin  may  be  directed 
towards  some  point,  either  on  the  right  or  the  left  lateral  half  of  the  pelvis;  and 
in  the  latter  the  sacrum  may  have  a  similar  relation  with  some  jDoint  of  its  right 
or  left  half;  therefore,  we  adopt  a  first,  or  the  ri(/Ju  mento-iliac,  and  a  second,  or 
the  left  mento-iliac  position  for  the  face;  and  likewise  for  the  breech,  we  have  a 
first,  or  the  left  sacro-lateral,  and  a  second,  or  the  right  sacro-latcral  position. 
Lastly,  the  two  presentations  of  the  trunk  have  each  two  positions;  for  example, 
the  right  side  of  the  foetus  presenting,  the  head  may  happen  to  be  placed  either 
above  some  point  on  the  left  lateral  moiety,  or  over  a  similar  part  on  the  right 
one.  Hence,  there  are  two  positions;  first,  the  left  cephalo-iliac,  and  second,  the 
right  cephalo-iliac  ;  or,  if  the  child's  left  side  presents  in  the  same  way,  the  head 
may  be  either  to  the  left  or  the  right,  thus  giving  rise  to  two  new  positions,  the 
left  and  the  right  cephalo-iliac.  position. 

There  is  scarcely  a  necessity  for  adding  that  the  anterior,  transverse,  and  jsos- 
terior  varieties  admitted  for  vertex  positions,  are  also  retained  for  the  two  funda- 
mental ones  of  the  face,  the  breech,  and  the  right  and  left  sides. 


412 


LABOR. 


1.  Vertex  presentation, 


■  \ 


SUMMARY. 


r  Left  occipito-iliac,    . 


2.  Presentation  of  the  face,  .  < 


Right  occipito-iliac. 
Right  mento-iliac,  . 
Left  mento-iliac, 


3.  Presentation  of  the  breech,  < 


Left  sacro-iliac, 


>.  Right  sacro-iliac, 


4.  Presentation  of  the  right  C   Left  cephalo-iliac,   . 
lateral  plane, I  Right  cephalo-iliac, 

5.  Presentation  of  the  left  la-  c  Left  cephalo-iliac,    . 
teral  plane, (  Right  cephalo-iliac, 


{anterior, 
transverse, 
posterior. 
{anterior, 
transverse, 
posterior. 
{anterior, 
transverse, 
posterior. 
{anterior, 
transverse, 
posterior. 
{anterior, 
transverse, 
posterior. 
{anterior, 
transverse, 
posterior. 
The    same  varieties  may 
present ;    that    is,    the    head 
may  either  be  in  front,  in  the 
•<|  middle,  or  behind  ;  but  here 
they  are  much  less  important 
than   in   the  preceding   pre- 
.  sentations. 


But  all  the  presentations  and  positions  just  indicated  have  not  the  same  fre- 
quency, nor  are  they  all  equally  favorable  to  the  spontaneous  expulsion  of  the 
child.  There  are  some  even,  such  as  the  positions  of  the  trunk,  in  which  this  is 
most  generally  impossible,  but  there  is  no  one,  however,  in  which  it  absolutely 
cannot  take  place ;  therefore,  we  shall  have  to  examine  the  mechanism  of  natural 
labor  in  each  of  these  presentations  successively,  reserving  to  ourselves  the  privi- 
le^-e  of  reverting  in  the  fourth  part  of  this  work  to  those  which  usually  offer  an 
insurmountable  difl&culty ;  and  as  the  vertex  presentations  are  the  most  frequent 
and  favorable  of  all,  we  shall  commence  with  a  description  of  them. 


ARTICLE    II. 


OF   THE   VERTEX   PRESENTATION. 

This  presentation  is  far  more  frequent  than  all  the  others  put  together;  thus 
in  20,517  births  reported  by  Madame  Boivin,  19,810  children  were  born  by  the 
vertex;  and  in  2020  cases  reported  by  M.  Dubois,  there  were  1913  of  this 
variety.  Again,  when  the  vertex  presents,  the  occiput  is  much  oftcncr  directed 
towards  the  left  than  the  right  side;  for  instance,  in  the  1913  cases  just  cited, 
M.  Dubois  noticed  1367  left  occipito-iliac,  and  only  546  right  occipito-iliac  posi- 


MECHANISM     OF     LABOR.  413 

tions.  Nor  are  the  three  varieties  pointed  out  for  each  position  equally  frequent ; 
thus,  in  the  1367  cases  where  the  occiput  was  directed  to  the  left  side,  it  was 
inclined  forwards,  that  is,  towards  the  left  cotyloid  cavity  1355  times,  and  only 
12  times  backwards,  in  the  direction  of  the  left  sacro-iliac  symphysis,  or  nearly 
so.  But  in  the  546  instances  of  right  occipito-lateral  positions  an  opposite  result 
was  observed;  for  the  occiput  was  only  found  55  times  at  the  right  acetabulum, 
but  491  times  at  the  right  sacro-iliac  symphysis;  so  that,  contrary  to  the  gene- 
rally-received opinion,  the  posterior  right  oecipito-iliac  position  is  much  more 
frequent  than  the  anterior  one.  We  have  given  these  results  as  ascertained  by 
M.  Dubois  himself,  because  they  are  entirely  consonant  with  our  own  observa- 
tions, and  with  those  of  M.  Stoltz,  of  Strasbourg. 

In  one  hundred  cases  of  vertex  presentations,  it  has  been  found  on  an  average, 
says  M.  Ncegele,  that  in  seventy  the  occiput  is  directed  in  front  and  to  the  left, 
and  behind  and  to  the  right  in  thirty;  he  considers  the  other  varieties  as  being- 
very  rare  and  altogether  exceptional. 

In  these  results,  no  question  seems  to  be  made  of  the  varieties  we  have  desig- 
nated as  the  transverse  ones,  and  it  is  highly  probable  that  they  have  been  ap- 
proximatively  added  to  one  of  the  four  preceding  groups,  for  these  positions  aro 
not  very  unusual ;  indeed,  I  have  often  met  with  them  myself  at  the  Clinique. 

"These  positions,"  says  Madame  Lachapelle,  "are  more  frequent  than  those 
where  the  occiput  corresponds  to  the  left  sacro-iliac  symphysis,"  and,  I  will  add, 
than  those  where  it  is  at  the  right  acetabulum ;  also,  that  the  left  transverse 
occipito-iliac  position  is  more  common  than  the  opposite  one. 

§  1.  Causes. 

As  we  have  already  spoken  of  the  cause  of  the  vertex  presentations,  when 
treating  of  the  child's  attitude  in  the  uterine  cavity,  we  shall  not  now  go  over 
the  same  ground,  but  will  only  remark,  that  most  accoucheurs  attribute  the  fre- 
quency of  the  dependent  position  of  the  head  to  its  own  specific  weight ;  whilst 
M.  Dubois,  after  having  endeavored  to  refute  the  general  opinion,  has  considered 
this  position  as  the  consequence  of  an  instinctive  determination  of  the  foetus 
itself.  (See  art.  Foetus.)  However,  it  is  not  at  all  difficult  to  explain  why  the 
left  anterior,  and  the  right  posterior  occipito-iliac  varieties  are  the  most  frequent 
of  any,  since  it  is  evidently  owing  to  the  presence  of  the  rectum  on  the  left  side. 
The  habitual  distension  of  this  bowel  by  fecal  matters,  obliges  the  forehead  or 
occiput  to  turn  towards  the  front  whenever  either  of  these  parts  is  directed  back- 
wards and  to  the  left.  It  is  far  more  difficult  to  say  why  the  occiput  is  so  much 
more  frequently  found  in  front  than  behind,  although  this  very  probably  depends 
on  the  same  causes  as  those  which  determine  the  vertex  presentation. 

Thus,  the  posterior  half  of  the  head  weighs  far  more  than  the  anterior,  and 
the  same  is  true  of  the  trunk;  further,  when  the  woman  is  standing,  sitting,  or 
on  her  knees,  or  even  lying  on  the  side,  the  anterior  wall  of  the  abdomen  is  the 
most  dependent  portion,  towards  which  the  child's  heaviest  parts,  that  is  to  say, 
its  posterior  plane,  must  necessarily  tend. 


414  LABOR. 

§  2.  Diagnosis. 

Before  labor,  and  even  during  the  last  few  months  of  gestation,  the  vertex  can 
often  be  recognized  as  presenting;  while  in  every  other  presentation  the  part 
tliat  oifers  first,  from  being  irregular,  voluminous,  and  badly  adapted  to  the  form 
of  the  inferior  uterine  segment,  and  of  the  superior  strait,  is  always  so  high  up, 
and  separated  from  the  uterine  wall  by  so  large  a  quantity  of  waters,  as  to  be 
scarcely  accessible  to  the  finger. 

The  vertex,  on  the  contrary,  presenting  a  rounded  spheroidal  surface  reposes, 
almost  without  the  intervention  of  any  liquid,  on  the  uterine  walls,  nay,  even 
presses  them  before  it,  and  engages  in  the  excavation,  descending  in  some  cases 
as  low  down  as  the  floor  of  the  pelvis.  Hence,  whenever  the  vertex  presents,  it 
is  easily  detected  through  the  inferior  portion  of  the  uterine  wall,  unless,  indeed, 
it  should  be  retained  at  the  superior  strait  by  a  considerable  inclination  of  the 
womb,  or  by  a  malformation  of  the  pelvis. 

In  a  word  (and  this  reflection  appears  to  me  essentially  practical),  whenever 
the  accoucheur  does  not  easily  reach  the  presenting  part  in  the  last  few  days  of 
the  gestation,  and  more  particularly  during  the  first  periods  of  labor,  he  should 
examine  the  woman  very  carefully ;  for  it  is  then  exceedingly  probable  that  the 
head  is  not  at  the  superior  strait;  or,  even  where  the  cephalic  extremity  does 
present  flexed,  there  is  reason  to  fear  a  wrong  direction,  or  perhaps  a  vicious 
organization  of  the  head  or  pelvis ;  all  which  circumstances  may  subsequently 
require  the  intervention  of  our  art.^ 

The  form  of  the  uterus  is  then  such  as  we  have  described  as  normal  (page 
103) ;  some  modifications,  however,  being  observable  in  occipito-posterior  posi- 
tions. Thus,  the  womb  is  still  widest  at  its  upper  part,  but  its  fundus  is  not  so 
regularly  rounded,  unless  it  should  contain  a  large  quantity  of  fluid ;  generally, 
says  M.  Stoltz,  the  fundus  has  an  arched  appearance,  whilst  beneath  it  is  a  sen- 
sible depression.  The  anterior  plane  of  the  foetus  being  directed  forward,  the 
inequalities  produced  by  its  extremities  are  perceptible,  which  is  not  the  case  so 
distinctly  in  the  occipito-anterior  positions. 

Auscultation  is  a  resource  of  great  value  in  establishing  the  diagnosis;  in  fact, 
the  reader  may  remember  that,  in  vertex  presentations,  the  pulsations  of  the 
foetal  heart  are  heard  in  one  of  the  iliac  fossae,  the  left  when  the  occiput  is  turned 
to  the  left,  and  the  right  in  the  opposite  case.  Again,  let  it  be  borne  in  mind, 
that  the  active  foetal  movements  felt  by  the  mother  at  the  same  part  of  the  abdo- 
men for  a  long  time,  indicate  the  correspondence  of  this  point  with  the  anterior 
region  of  the  child. 

Supposing  the  labor  has  begun,  if  the  finger  be  introduced  through  the  cervix 

'  A  variety  of  circumstances  may  occur  towards  the  end  of  gestation,  or  at  the  beginning 
of  the  labor,  dependent  on  causes  wholly  foreign  to  any  vicious  positions,  whereby  it  might 
happen  that  no  part  could  be  detected  by  the  touch  ;  thus,  1.  It  is  sometimes  observed  in  women 
who  have  had  several  children,  and  in  whom  the  fundus  uteri  is  strongly  inclined  forwards; 
2.  In  cases  of  twins;  3.  In  breech  presentations;  4.  Where  there  is  a  large  amount  of  water; 
5.  Where  the  uterus  is  not  oval  at  its  inferior  part;  6.  When  the  head  is  hydrocephalous;  and. 
lastly,  where  the  pelvis  is  narrow.     [Nwgble,  translated  by  PigiiS.) 


1 


MECHANISM    OF    LABOR.  415 

uteri,  it  will  immediately  encounter  a  rounded,  smooth,  and  resistant  surface, 
which  is  the  anterior  side  of  the  head ;  and  then,  by  directing  the  index  a  little 
further  upwards  and  backwards,  in  the  direction  of  the  sacro-vertebral  angle,  it 
will  come  into  contact  with  a  membranous  interval,  that  is,  with  the  sagittal 
suture. 

A  vertex  presentation  is  now  ascertained ;  and  the  next  step  is  to  make  out 
the  position.  For  that  purpose  we  first  assure  ourselves  of  the  direction  of  the 
suture,  and  if  it  prove  to  be  oblique,  running  from  before  backwards,  and  from 
the  left  towards  the  right,  the  position  must  either  be  the  left  anterior,  or  the 
right  posterior  occipito-iliac  one ;  but,  on  the  contrary,  if  it  be  oblique  in  the 
other  diameter,  the  position  will  either  be  the  right  anterior  or  the  left  posterior 
occipito-iliac,  &c. 

The  direction  being  once  determined,  we  have  then  only  to  find  out  where  the 
occiput  lies,  to  complete  the  diagnosis ;  therefore,  the  finger,  by  raising  up  the 
margin  of  the  os  uteri,  follows  the  sagittal  suture  until  it  reaches  a  fontanelle, 
which  is  to  be  distinguished  by  the  characters  hitherto  described.  (See  Head 
of  the  Foetus  at  Term.) 

§  3.  Mechanism. 

The  mechanism  by  which  the  expulsion  of  the  child  is  accomplished  in  posi- 
tions of  the  vertex  is  very  nearly  the  same  in  all  cases  where  the  occiput  corre- 
sponds with  one  of  the  points  of  the  left  lateral  half  of  the  pelvis;  but  it  differs 
in  some  respects  from  that  observed  in  the  positions  designated  as  the  right 
occipito-iliac  ones. 

"We  must,  therefore,  examine  it  in  both  of  these  positions;  and  as,  among  the 
admitted  varieties,  there  are  two,  the  anterior  in  the  left  occipito-iliac,  and  the 
posterior  in  the  right  occipito-iliac,  which  are  almost  constantly  met  with,  we 
shall  take  them  up  successively  as  the  types  of  our  description. 

X.  Meclianum  of  Natural  Labor  in  the  left  Anterior  Occipito-iliac  Position. 
(The  first,  or  the  left  occipito-cotyloid  position 

of  authors.) — In  this    position,   the   occiput  ''^^-  °"- 

corresponds  to  the  left  ilio-pectineal  eminence, 
the  forehead  to  the  right  sacro-iliac  sym- 
physis, and  the  sagittal  suture  lies  in  the 
direction  of  the  left  oblique  diameter  of  the 
pelvis.  (In  order  to  avoid  unnecessary  repe- 
titions and  delays,  we  premise,  once  for  all, 
that  we  shall  designate  that  oblique  diameter 

1  •    1  p         ^,1        1    /.,     .  1      ,1  •    1  ,         Represemin?  the  head  in  the  left  anterior 

which  runs  from  the  left  towards  the  right  occ.p.io-iiiac  pos.tion. 

side  and  from  before  backwards,  as  the  hft 

oblique,  and  the  one  passing  from  the  right  towards  the  left,  and  from  in  front 
posteriorly,  as  the  right  oblique  diameter.^  The  posterior  fontanelle  is  found  to 
the  left  and  in  front,  the  anterior  one  is  behind  and  to  the  right.  The  dorsal 
plane  of  the  fcetus  looks  forwards  and  towards  the  left  side ;  while  its  anterior 


416  LABOR.  , 

plane  is  directed  backwards  and  to  the  right;  the  right  slioulder  is  in  front  and 
to  the  right  side;  the  left  one  is  behind  and  towards  the  aiother's  left. 

Before  the  bag  of  waters  is  ruptured,, the  child's  head  is  slightly  flexed  on  the 
front  of  the  chest,  and  the  following  are  the  relations  of  its  diameters  with  those 
of  the  superior  strait :  the  occipito-frontal  corresponds  to  the  left  oblique  of  the 
strait,  and  the  bi-parietal  to  the  right  oblique;*  and,  of  course,  the  occipito-frontal 
circumference  of  the  head  is  parallel  with  the  periphery  of  the  abdominal  strait, 
and  the  axis  of  this  strait  corresponds  with  the  trachelo-bregmatic  diameter'^  of 
the  head. 

When  the  membranes  are  ruptured,  a  variable  quantity  of  liquid  escapes; 
then  the  uterus  contracts  and  applies  itself  more  directly  to  the  foetal  trunk : 
nevertheless,  as  but  little  fluid  passes  away  in  vertex  positions  at  this  time,  there 
usually  remains  a  sufiicient  quantity  of  it  to  render  the  pressure  of  the  uterine 
walls  on  the  child  far  from  being  immediate. 

After  the  rupture,  the  object  of  the  contractions  is  to  expel  it  from  the  womb; 
the  foetus  becomes  more  curved  anteriorly,  and  its  superior  and  inferior  extre- 
mities more  closely  folded  up ;  and,  from  that  moment,  properly  speaking,  the 
mechanical  phenomena  of  labor  began. 

These  phenomena,  or  stages  of  the  mechanism,  are  five  in  number,  as  follows  : 
in  the  first,  the  head  is  more  strongly  flexed  on  the  chest ;  in  the  second,  it  tra- 
verses all  the  space  between  the  superior  and  the  inferior  straits,  and  reaches  the 
floor  of  the  pelvis ;  there  it  experiences  a  movement  of  rotation  which  carries  the 

'  We  may  remark,  however,  with  M.  Dubois,  that  this  last  relation  is  not  absolutely  exact. 
For  instance,  if  the  head  of  a  foetus  at  term  be  found  at  the  superior  strait,  so  that  the  occi- 
pito  frontal  diameter  is  parallel  with  the  left  oblique,  the  shape  of  the  head  will  prevent  the 
bi-parietal  one  from  corresponding  with  the  right  oblique  diameter.  In  fact,  in  this  position 
the  posterior  extremity  of  the  bi-parietal  diameter  is  at  the  left  sacro-iliac  sym[)hysis,  but  the 
anterior  extremity,  instead  of  terminating  opposite  the  ilio-pectineal  eminence,  is  found  very 
near  the  middle  of  the  horizontal  branch  of  the  pubis. 

2  M.  Nregfele  and  Professor  Dubois  (who  adopts,  at  least  in  part,  the  views  of  the  Heidel- 
berg Professor),  do  not  believe  that  the  head  presents  at  the  superior  strait,  in  the  majority 
of  cases,  so  regularly  in  all  its  relations,  as  we  have  just  described,  for  they  say  the  head 
does  not  offer  perpendicularly  to  the  plane  of  the  strait,  but,  on  the  contrary,  in  an  oblique 
direction  ;  whence  the  right  parietal  protuberance,  which  is  also  the  anterior  one,  vvoidd  be 
lower,  relatively  to  the  plane  than  the  left;  and  the  bi-parietal  suture,  instead  of  being  found 
in  the  direction  of  the  axis  of  the  head,  would  be  a  little  behind  it,  according  to  M.  Dubois, 
and  would  even  look  towards  the  second  bone  of  the  sacrum,  agreeably  to  M.  Niegfele. 

But,  notwithstanding  these  imposing  authorities,  we  believe  the  occipito-frontal  circum- 
ference is  closely  parallel  to  the  plane  of  the  strait  in  most  cases,  although  the  parietal  boss 
is  certainly  one  of  the  most  dependent  parts  of  the  head,  and  the  finger  first  strikes  upon  it 
in  practising  the  vaginal  examination.  But  those  facts  by  which  Na^gfele  sustains  his  views 
prove  just  the  contrary ;  because  the  plane  of  the  abdominal  strait,  being  directed  very  ob- 
liquely downwards  and  forwards,  the  portion  of  the  head  in  contact  with  the  anterior  arch  of 
the  pelvis  should  be  its  most  dependent  part ;  and  further,  the  finger  first  encounters  the 
anterior  parietal  protuberance,  because  the  introduction  takes  place  under  the  symphysis 
pubis,  that  is  to  say,  almost  perpendicularly  to  the  superior  strait,  and  therefore  the  index 
can  only  reach,  in  a  very  oblique  direction,  the  anterior  portion  of  the  head,  whose  greatest 
circumference  is  parallel  to  the  plane  of  the  superior  strait. 


MECHANISM    OF    LABOR.  417 

occiput  betind  the  symphysis  pubis,  thus  constituting  the  third  period ;  in  the 
fourth,  the  head  undergoes  the  process  of  extension,  by  which  all  the  superior 
and  anterior  parts  of  the  vertex  and  face  become  completely  disengaged  at  the 
anterior  commissure  of  the  perineum ;  and  then,  after  its  perfect  expulsion,  the 
child's  cephalic  extremity  performs  a  fifth  and  last  movement,  designated  by 
Baudelocque  as  the  period  of  restitution,  but  which  M.  Gerdy  has  proposed  to 
name  the  exterior  rotation. 

A.  Stage  of  Flexion. — After  the  rupture  of  the  membranes,  the  foetal  trunk, 
being  compressed  on  all  sides,  transmits  to  the  head,  through  the  spine,  the  im- 
pulse derived  from  the  uterine  contractions.  The  head,  being  forcibly  pressed 
on,  has  a  tendency  to  clear  the  uterine  orifice,  and  to  engage  in  the  excavation. 
But  it  then  encounters  resistances,  either 
from  the  os  uteri,  which  is  not  yet  sufficiently  -^'S-  ^^• 

dilated,  or  from  the  superior  strait,  or  the 
walls  of  the  excavation;  and  being  thus  placed 
between  a  power  and  a  resistance,  the  head 
must  naturally  become  still  more  flexed  on 
the  chest;  in  fact,  the  force  of  expulsion 
transmitted  by  the  vertebral  column,  falling 
upon  the  occipital  foramen,  that  is,  on  a  point 

r  i      J.U  •       i.   J.I,         ii>         U'  '■'''le  head  in  the  same  position,  thoasrh 

much  nearer  to  the  occiput  than  the  chin,  ^^^^  flexed 

must  necessarily  (the  resistance  being  equal 

at  the  two  extremities  of  the  occipito-mental  diameter)  act  more  powerfully  on 

the  occiput  than  on  the  chin,  in  other  words,  must  press  down  the  occiput  into 

the  excavation.     But,  by  depressing  this  part,  the  chin  is  forced  to  ascend,  thus 

producing  the  flexion  of  the  head.' 

'  In  order  to  prove  that  the  movement  of  flexion  results  from  the  position  of  the  occipital 
foramen,  relatively  to  the  chin  and  occiput,  which  represent  the  two  extremities  of  the  lever 
whereon  the  spine  is  articulated,  let  us  suppose,  for  a  inoment,  that  the  vertebral  column  is 
attached  to  the  occiput  alone,  when  it  is  evident  that  the  latter  only  -wWl  descend ;  on  the 
other  hand,  let  it  be  made  to  the  chin,  which  will  then  descend  the  first,  and  lastly  let  it  be 
done  at  the  centre  of  the  interval  between  these  two  extremes,  and  an  equilibrium  will  be 
produced,  the  same  as  results  from  equal  weights  or  resistances  placed  in  the  dishes  of  a 
balance  having  equal  arms.  But  where  the  articulation  takes  place  nearer  one  extremity 
than  the  other,  the  descent  will  occur  at  this  extremity,  just  as  it  would  happen  in  the 
above-cited  balance,  if,  without  altering  anything  else,  the  arms  were  rendered  unequal  in 
their  length. 

To  conclude,  lest  the  foregoing  should  not  satisfactorily  explain  the  phenomenon,  I  pro- 
pose the  following  rationale :  the  head,  urged  on  by  the  uterine  contraction,  communicated  to 
it  by  the  spine,  meets  with  resistance  from  the  os  uteri,  which  is  not  yet  sufficiently  dilated. 
Let  us  change,  for  an  instant,  the  order  of  forces,  making  the  vertebral  articulation  a  fulcrum, 
and  the  opposition  on  the  part  of  the  neck  the  power;  now,  this  power  is  evidently  equal  in 
all  points  of  the  periphery  of  the  neck;  but  let  us  observe  that,  as  the  interval  between  the  chin 
and  the  occipital  foramen  is  greater  than  that  betwixt  the  latter  and  the  occiput,  the  resist- 
ance against  the  chin  operates  on  a  longer  lever  than  that  against  the  occiput,  and  conse- 
quently the  first  must  be  the  more  powerful  of  the  two,  and  therefore  it  forces  the  chin  to 
ascend  But  raising  the  latter  has  the  same  effect  as  depressing  the  occiput;  that  is,  still 
producing  a  flexion  of  the  head. 

27 


418  LABOR. 

The  head  being  in  this  way  forcibly  flexed,  its  relations  are  changed ;  that  is, 
the  occipito-bregmatic  diameter  has  taken  the  place  of  the  occipito-frontal,  and 
has  become  parallel  to  the  left  oblique  of  the  strait;  but  the  bi-parietal  remains 
unaltered :  the  occipito-bregmatic  circumference  is  now  on  a  level  with  the  peri- 
phery of  the  strait,  and  the  axis  of  the  pelvis,  which  before  corresponded  with 
the  trachelo-bregmatic  diameter,  now  traverses  the  head  very  nearly  in  the  direc- 
tion of  the  occipito-mental  diameter. 

This  movement  of  flexion,  therefore,  evidently  places  the  child's  head  in  the 
most  fiivorable  position  for  its  passage,  by  constraining  it  to  offer  its  smallest 
diameters  to  those  of  the  pelvis. 

B.  Stage  of  Descent. — The  head,  pressed  on  by  the  contractions,  enters  the 
excavation  and  reaches  the  floor  of  the  pelvis.  In  making  this  descent,  the  occi- 
put presses  in  front  against  the  internal  and  anterior  face  of  the  body  of  the 
ischium,  the  obturator  internus  muscle,  and  the  external  obturator  vessels  and 
nerves,  which  pass  out  through  the  upper  part  of  the  obturator  foramen ;  while 
the  forehead  or  bregma  presses  behind  on  the  internal  border  of  the  psoas  and 
pyramidal  muscles,  the  sciatic  plexus  of  nerves,  together  with  the  gluteal  and 
the  internal  pudic  vessels  and  nerves.  The  left  side  of  the  head  likewise  comes 
into  mediate  relation  with  the  same  parts,  and  also  glides  over  the  anterior  sur- 
face of  the  rectum.  But  the  descent  of  the  head  is  not  completed  until  the 
occipito-bregmatic  circumference  is  nearly  parallel  to  the  plane  of  the  inferior 
strait,  that  is,  when  the  two  parietal  protuberances  have  attained  this  level. 
Now,  it  is  evident  that,  to  reach  this  point,  the  left  parietal  boss  (which  is  found 
behind)  must  traverse  the  whole  anterior  face  of  the  sacrum,  whilst  the  anterior 
one  has  only  to  clear  a  much  shorter  space ;  the  first  must  therefore  describe  the 
arc  of  a  much  larger  circle  than  the  second.  Perhaps  a  more  exact  idea  of  the 
actual  movement  of  the  head  will  be  formed  by  imagining  the  anterior  extremity 
of  the  bi-parietal  diameter  to  remain  nearly  stationary  in  front  and  to  the  right, 
while  its  posterior  extremity  descends  rapidly  and  traverses  the  whole  posterior 
plane  of  the  excavation. 

C.  Staye  of  Rotation. — The  head  being  arrested  by  the  floor  of  the  pelvis, 
executes  a  movement  of  rotation,  during  which  the  occiput  passes  from  left  to 
right  behind  the  symphysis  pubis,  or  rather  behind  the  left  ischio-pubic  ramus, 
and  the  bregma  rotates  into  the  concavity  of  the  sacrum,  though  remaining  a 
little  towards  the  right. 

The  posterior  superior  part  of  the  right  parietal  bone  then  appears  plainly 
under  the  pubic  arch ;  the  posterior  fontanelle  is  behind  the  ischio-pubic  ramus ; 
and  the  sagittal  suture  crosses  the  coccy-pubal  diameter  very  obliquely.  Being 
forced  on  by  the  energetic  contractions  of  the  womb,  the  vertex  then  depresses 
the  soft  parts  of  the  perineum,  and  by  gradually  distending  them,  succeeds  in 
converting  the  pelvic  floor  into  a  part  of  a  canal  which  prolongs  the  posterior 
wall  of  the  pelvis  downwards  and  backwards.  It  is  during  this  time  that  the 
rotation  is  accomplished,  that  is,  the  sagittal  suture  becomes  parallel  with  the 
antero-posterior  diameter  of  the  inferior  strait.  The  occiput  engages  in  the  arch 
of  the  pubis,  and  projects  beyond  the  lower  part  of  the  sj-mphysis,  until  the  back 


MECHANISM     OF     LABOR. 


419 


Fvj;.  68. 


part  of  tlie  neck  comes  into  contact  with  it,  when  the  anterior  progression  of  the 
occiput  is  arrested. 

D.  Stage  of  Extension. — Just  at  the  moment  when  the  occiput  engages  in  this 
manner  in  the  pubic  arch,  the  shoulders  and  upper  part  of  the  body  enter  the 
excavation,  and  in  engaging  there,  the  festal  trunk,  which  is  flexible,  accommo- 
dates itself  to  the  direction  of  the  canal,  and  consequently  bends  over  a  little  on 
its  posterior  plane ;  this  movement  causes  the  chin  to  depart  from  the  chest,  and 
then  the  extension  of  the  head  begins. 

But,  in  order  to  understand  how  this  last  is  completed,  we  must  remember 
that  the  force  of  the  uterine  contraction,  transmitted  always  by  the  spine,  falls 
upon  some  part  of  the  occipito-mental  diameter,  and  that,  in  the  beginning  of 
the  labor,  this  power  operated  both  on  the  occiput  and  the  chin,  though  up  to 
the  present  moment  the  occiput  had  felt  its  influence  the  most;  1st,  because, 
from  the  forced  flexion  of  the  head,  it  was  more  in  the  line  of  its  direction;  and, 
2d,  from  the  fact  of  its  falling  on  the  occipital  foramen,  the  impulse  was  much 
nearer  to  the  occiput  than  the  chin ;  but  the  occiput  having  once  engaged  under 
the  pubic  arch,  and  the  back  of  the  neck  being  applied  to  the  symphysis  pubis, 
which,  by  its  resistance,  destroys  all  that  por- 
tion of  the  uterine  force  that  acted  on  the  occi- 
put, there  only  remains  that  portion  of  the  force 
which  operated  on  the  chin.  Now  this  power 
continues  to  act,  and  under  its  influence  the 
chin  is  pushed  down,  and  consequently,  by  a 
continuance  of  the  same  movement,  the  occiput 
ascends,  that  is  to  say,  the  whole  head  is  turned 
up  in  front  of  the  symphysis  pubis. 

During  this  movement  of  extension,  the  fol- 
lowing points  successively  appear  at  the  ante- 
rior commissure  of  the  perineum,  viz.,  the  bi- 
parietal  suture,  the  bregma  (or  fontanelle),  the 
coronal  suture,  the  nose,  mouth,  and  last  of  all, 
the  chin.  During  this  process,  the  head  exactly 
represents  a  lever  of  the  third  kind,  whose  ful- 
crum is  at  the  sub-occipital  point,  lying  behind 
and  under  the  symphysis  pubis,  the  power  at 
the  occipital  foramen,  and  the  resistance  at  the  chin,  which  is  to  be  depressed, 
an  opposition  necessarily  augmented  by  the  resistance  of  the  perineum.  Further, 
the  sub-occipito-bregmatic,  the  sub-occipito-frontal,  and  the  sub-occipito-mental 
diameters  successively  pass  the  antero-posterior  diameter  of  the  inferior  strait. 
As  soon  as  the  occipito-t>regmatic  circumfei^nce  is  beyond  the  vulva,  the  anterior 
border  of  the  perineum,  yielding  to  its  natural  elasticity,  retracts  strongly,  slips 
over  the  foce,  and  embraces  the  neck;  and  just  at  that  moment,  the  head,  which 
was  before  forcibly  turned  up  in  front  of  the  mons  veneris,  falls  back  from  its 
own  specific  weight,  towards  the  anus. 

E.   Stage  of  Exterior  Rotation.     (Restitution). — The  head  remains  for  a  few 


The  head  is  seen  in  various  defiiees 
of  extension,  the  nape  of  the  neck  rest- 
ing first  behind,  and  then  under  the 
symphysis  pubis. 


420  LABOR. 

seconds  in  this  position,  and  then  it  is  seen  to  describe  a  fifth  and  last  move- 
ment, namely,  the  occiput  inclines  towards  the  internal  surface  of  the  left  thigh, 
and  the  face  turns  towards  the  right  thigh.  This  process  is  usually  denominated 
the  restitution,  for  the  following  reason.  Before  the  researches  of  M,  Gerdy,  it 
was  generally  supposed  that  when  the  head  executed  its  movement  of  rotation 
within  the  pelvis,  the  trunk  did  not  participate  therein,  and  that  the  operation 
could  only  take  place  through  the  aid  of  a  certain  degree  of  torsion  in  the  neck ; 
and,  further,  that  the  head  becoming  completely  disengaged,  and  only  retained 
by  the  resistance  of  the  soft  parts,  the  neck  then  untwisted,  and  the  head  was 
restored  to  its  natural  relations  with  the  trunk. 

M.  Gerdy  was  the  first  to  demonstrate  the  faultiness  of  this  explanation ;  for, 
in  fact,  the  trunk  does  participate  in  the  head's  rotation,  in  such  a  way  that  the 
shoulders,  which,  in  the  beginning  of  the  labor,  corresponded  to  the  oblique  dia- 
meter, are  nearly  transverse  after  this  movement  (the  right  shoulder,  neverthe- 
less, remaining  always  a  little  more  in  front  than  the  left).  The  shoulders  then 
reach  the  inferior  strait  in  a  transverse  position,  presenting,  therefore,  their  great, 
or  bis-acromial  diameter,  to  the  smallest  one  of  this  strait; "but  here  they  en- 
counter some  resistance,  under  the  influence  of  which  the  rotation  is  effected  in 
the  opposite  direction  to  that  of  the  head,  the  right  shoulder,  passing  from  the 
right  side  towards  the  left,  approaches  the  apex  of  the  pubic  arch,  while  the  left 
one  gets  into  the  perineal  concavity,  and  the  head,  being  free  externally,  neces- 
sarily follows  the  movement  communicated  to  the  shoulders. 

The  rotation  of  the  head  is  not  therefore  an  isolated  movement  peculiar  to 
itself,  as  Baudelocque  supposed,  but  one  secondary  to  the  rotation  of  the  shoulders. 

I  must  remark,  however,  that,  in  some  cases,  the  head  has  appeared  to  me  to 
execute  a  double  movement;  for,  immediately  after  its  expulsion,  it  turns  very 
slightly ;  the  occiput  passing  a  little  to  the  left,  the  forehead  towards  the  right ; 
after  remaining  some  seconds  in  this  position,  it  then  undergoes  the  secondary 
movement  just  described,  which  is  due  to  the  rotation  of  the  shoulders.  The 
first  of  these  movements  has  always  seemed  to  me  to  result  from  the  untwisting 
of  the  neck,  and  is  the  true  movement  of  restitution  of  Baudelocque. 

The  shoulders  present  at  the  inferior  strait  soon  after  the  head,  and,  as  we 
have  just  stated,  nearly  always  in  a  transverse  position.  The  right  one  gets 
under  the  right  ischio-pubic  ramus,  while  the  left  one  lies  in  front  of  the  left 
sacro-sciatic  ligament.  The  bis-acromial  diameter  is  rarely  found  in  the  direc- 
tion of  the  antero-posterior  diameter  of  the  inferior  strait.  The  anterior  or  sub- 
pubic shoulder  is  the  first  to  appear  in  the  vulvar  fissure,  although,  as  a  general 
rule,  the  posterior  one,  after  having  traversed  the  perineal  curve,  is  first  disen- 
gaged at  the  anterior  commissure  of  the  perineum,  and  the  right  one  is  subse- 
quently delivered.* 

'  Contrary  to  the  generally-received  opinion,  M.  P.  Dubois  supposes  that  the  anterior 
slioulder  is  the  first  delivered.  That  is  certainly  true  in  a  groat  number  of  cases,  but  we 
have  most  usually  observed  the  opposhe  fact;  besides,  there  is  a  theoretical  view  which 
militates  in  favor  of  our  opinion,  that  is,  the  left  shoulder,  being  placed  in  contact  with  the 
posterior  plane  of  the  excavation,  is  situated,  much  more  than  the  anterior  one,  in  the  direc- 


M  E  C  n  A  N  I  S  JI     OF     LABOR.  421 

During  the  disengagement  of  the  shoulders,  the  ftetus  becomes  flexed  on  its 
right  lateral  region  so  as  to  accommodate  itself  to  the  curvature  in  the  pelvic 
canal;  and  very  soon  after  the  remainder  of  the  trunk  is  expelled,  sometimes 
describing  a  very  prolonged  spiral  course  in  its  passage. 

2.  Mechanism  of  Natural  Labor  in  the  right  Posterior  Occipito-iliac  Posi- 
tion.    (The  fourth  of  Baudelocque,  and  the  third  of  M.  Capuron.) 

In  the  vast  majority  of  cases,  the  mechanism  of  labor  in  this  position  scarcely 
differs  from  that  just  described,  and  therefore  we  only  need  allude  here  to  the 
principal  peculiar  phenomena  of  the  travail,  without  repeating  all  the  preceding 
details. 

It,  likewise,  is  composed  of  five  periods,  or  stages ;  before  the  membranes  are 
ruptured,  the  diameters  of  the  head  correspond  with  the  same  diameters  of  the 
pelvis  as  in  the  foregoing  case,  and  the  only  difference  to  be  remarked  is,  that 
the  occiput  corresponds  to  the  right  sacro-iliac  symphysis,  and  the  forehead  to  the 
left  ilio-pectineal  eminence.  The  child's  posterior  plane  looks  backwards  and 
towards  the  mother's  right,  while  its  anterior  plane  is  in  front  and  to  her  left — 
its  left  side  is  placed  in  front  and  on  the  right,  its  right  side  behind  and  to  the 
mother's  left. 

A.  Period  of  Flexion. — The  head  is  flexed  by  the  same  forces  as  in  the  pre- 
ceding case,  and  this  flexion  determines  similar  changes  in  the  relations  of  its 
diameters  with  those  of  the  pelvis. 

B.  Period  of  Descent. — This  stage  presents  nothing  worthy  of  particular 
notice. 

c.  Period  of  Rotation. — The  head  having  reached  the  floor  of  the  pelvis, 
undergoes  a  movement  of  rotation,  in  consequence  of  which  the  occiput  traverses 
the  whole  right  lateral  moiety  from  behind  forwards,  in  such  a  way  that  it  passes 
successively  towards  the  right  extremity  of  the  transverse  diameter,  behind  the 
cotyloid  cavity  and  under  the  right  ischio-pubic  ramus,  while  the  forehead,  or 
bregma,  revolving  in  an  inverse  direction,  goes  from  before  backwards  towards 
the  hollow  of  the  sacrum ;  and  thus,  the  position  which  was  originally  occipito- 
posterior,  becomes  converted  into  an  occipito-pubic,  or  anterior  one,  and  the  labor 
then  terminates  just  as  it  does  in  those  cases  where  the  occiput  was  primitively 
in  front. 

In  some  instances,  which  are  rare,  however,  this  conversion  does  not  take 
place,  and  the  occiput  remains  behind  until  the  termination  of  the  labor.  The 
delivery  is  then  concluded  in  the  following  manner :  the  head  is  strongly  flexed 
on  the  chest,  and  retains  its  oblique  position ;  the  forehead,  corresponding  to  the 

tion  of  the  uterine  axis,  or  the  axis  of  the  superior  strait,  and  therefore  being  subjected  to  a 
more  energetic  uterine  impulse,  consequently  must  be  delivered  first;  further,  it  was  neces- 
sary this  should  be  so,  as  the  posterior  shoulder  has  much  the  longer  course  to  traverse. 
Again,  if  I  might  refer  to  my  own  observations,  I  would  say  that  in  women  who  have  before 
borne  children,  more  especially  in  tliose  who  have  suffered  from  rupture  of  the  perineum  in 
former  labors,  the  posterior  shoulder  is  the  first  delivered ;  and,  on  the  contrary,  in  primi- 
parEe,  the  sub-pubic  one  has  the  precedence,  the  other  being  retained  by  the  resistance  from 
the  soft  parts. 


422 


LABOR. 


Disengaijeinent  of  the  head  in  the 
oi'cipito-poslerior  positions. 


body  of  the  left  pubis,  first  reaches  the  inferior  strait,  and  the  left  coronal  boss 
then  engages  under  the  pubic  arch,  where  we  can  sometimes  distinguish  the 
superciliary  ridge  just  below  the  symphysis;  and  I  even  saw  the  upper  eyelid  in 

one  case.  But  though  the  forehead  first  appears 
at  the  exterior,  the  occiput,  urged  on  by  the  spine, 
which  transmits  the  force  of  the  uterine  contrac- 
tion, traverses  the  whole  curvature  of  the  perineum 
(which  is  greatly  distended  in  such  instances),  and 
becomes  disengaged  the  first  at  the  anterior  com- 
missure. While  the  occiput  is  thus  passing  over 
the  anterior  surface  of  the  sacrum  and  perineum, 
the  coronal  boss  and  eyebrow,  that  originally  ap- 
peared at  the  vulva,  reascend  and  become  con- 
cealed behind  the  symphj'sis. 

The  occiput  is  scarcely  clear,  when  the  peri- 
neum, by  gliding  over  the  inclined  plane  formed 
by  the  nape  of  the  neck,  retracts  strongly,  and  thus 
facilitates  the  subsequent  delivery  of  the  anterior 
portions  of  the  head;  therefore,  the  head  may  be  observed  to  undergo  the  process 
of  extension  around  the  nape  as  a  centre,  and  to  appear  below  the  symphysis  iu 
the  following  order,  namely,  the  anterior  fontanelle,  the  coronal  suture,  the  fore- 
head, nose,  mouth,  and  chin. 

Lastly,  the  head,  placed  in  the  right  posterior  occipito-iliac  position,  may, 
when  once  down  in  the  excavation,  depart  from  the  chest,  and  the  vertex  pre- 
sentation be  thus  spontaneously  converted  into  one  of  the  face,  at  the  inferior 
strait:  we  witnessed  a  case  of  this  kind  at  the  Clinique  iu  1838. 

This  transmutation  takes  place,  says  M.  Guillemot,  in  the  following  manner : 
the  occiput  being  arrested  by  some  point  on  the  posterior  part  of  the  excavation, 
instead  of  advancing  along  the  perineum  towards  the  inferior  strait,  ascends  in 
the  curvature  of  the  sacrum  by  executing  the  movement  of  rotation  backwards, 
and  being  at  the  same  time  thrown  back  upon  the  posterior  part  of  the  chest. 
While  this  is  going  on,  the  forehead  and  face  descend  behind  the  pubis  and  pass 
downwards  and  backwards,  until  the  chin  engages  under  the  arch,  and  then -the 
head,  which  is  completely  turned  back,  traverses  the  perineal  strait,  as  iu  a  face 
presentation. 

The  disposition  which  the  inclined  plane  of  the  cervix  uteri  impresses  on  the 
vertex  in  this  position,  continues  M.  Guillemot,  is  a  frequent  cause  of  a  similar 
transmutation  above  the  abdominal  strait:  The  slight  backward  inclination  of 
the  head  which  always  exists  in  these  positions,  may  correct  itself  when  the 
uterine  contractions,  by  acting  on  the  foetus,  keep  the  chin  applied  to  the  neck; 
but,  on  the  other  hand,  the  reversion  may  be  carried  still  further,  or  be  entirely 
completed,  if  any  obstacle  impedes  the  descent  of  the  occiput  into  the  excavation; 
finally,  in  cases  of  uterine  obliijuity,  where  the  inclination  of  the  vertex  is  greater, 
the  backward  tendency,  instead  of  disappearing,  would  be  increased,  and  the 
occiput  would  then  ascend  and  the  forehead  descend. 


MECnANISM    OF    LABOR.  .  423 

Like  the  author  quoted,  I  admit  the  fact,  though  I  think  it  rare,  but  I  cannot 
acknowledge,  like  him,  the  truth  of  the  following  proposition,  i.  e.,  that  if  the 
conditions  of  transmutation  which  then  exist  may  be  appreciated  by  a  comparison 
of  the  face  labors  with  those  of  the  occipito-posterior  positions,  we  should  not 
depart  far  from  the  truth  (7  believe  it  would  he  a  xo'ule  departure')  by  announcing 
that,  in  every  three  occipito-posterior  positions,  one  of  them  would  give  rise  to  a 
face  presentation. 

Lastly,  whatever  may  be  the  mode  of  the  delivery  of  the  head  in  the  right 
posterior  occipi to-iliac  position,  the  occiput  always  inclines  towards  the  internal 
surface  of  the  right  thigh,  and  the  face  is  directed  to  the  left  one ;  this  external 
movement  Q-estitution)  results  from  the  internal  rotation  of  the  shoulders,  in  con- 
sequence of  which  the  left  shoulder,  which  was  originally  the  anterior,  gets  under 
the  arch  of  the  pubis,  and  the  right  one  into  the  hollow  of  the  sacrum,  and  then 
the  shoulders  and  the  remaining  part  of  the  trunk  are  expelled  in  the  manner 
already  stated. 

The  great  care  we  have  taken  in  describing  the  natural  labor  in  these  two 
varieties  of  the  two  fundamental  positions,  will  absolve  us  from  repeating  it  anew 
in  the  other  varieties. 

In  fact,  the  left  transverse  occipito-iliac  position  does  not  diifer  from  the  ante- 
rior one ;  unless,  perhaps,  the  movement  of  rotation,  which  "brings  the  occiput  in 
front,  is  somewhat  more  extended;  and  what  we  have  stated  concerning  the  two 
modes  of  termination  in  the  right  posterior  occipito-iliac  position  applies  equally 
well  to  the  left  posterior  one ;  but  we  must  add  that  the  movements  of  rotation 
will  then  take  place  from  left  to  right,  since  the  occiput  is  primitively  turned 
towards  the  left  side. 

Lastly,  in  the  other  two  varieties,  the  right  anterior  and  the  right  transverse 
occipito-iliac  ones,  the  mechanism  is  still  the  same  as  in  the  corresponding  varie- 
ties of  the  left  occipito-lateral  position. 

Eemarks. — From  the  foregoing,  the  reader  will  see  that,  in  order  to  study  the 
mechanism  of  labor  in  the  vertex  positions,  we  have  been  obliged  to  consider 
each  of  the  periods,  or  stages,  composing  it  separately.  Thus,  we  first  examined 
the  movement  of  flexion,  then  of  descent,  next  the  internal  rotation,  the  exten- 
sion, and  the  external  rotation ;  but  it  must  not  be  supposed  that  these  different 
movements  occur  successively,  one  after  the  other,  in  the  order  just  described. 
1.  The  forced  flexion  spoken  of  as  happening  before  the  descent,  frequently  only 
takes  place  simultaneously  with  the  latter.  Often,  indeed,  the  head  is  not  flexed 
until  the  descent  is  completed,  and  it  encounters  the  resistance  from  the  floor  of 
the  pelvis;  and  then  only,  in  the  majority  of  cases,  is  the  flexion  carried  to  its 
highest  degree.  We  can  imagine  that  this  would  nearly  always  be  the  case, 
since  the  head  is  engaged  in  the  excavation  in  most  women  long  before  the  com- 
mencement of  labor;  and  even  in  those  cases  where  it  is  still  above  the  superior 
strait  at  the  time  of  the  membranes  being  ruptured,  the  presenting  diameters 
will  allow  it  to  traverse  the  upper  part  of  the  excavation  without  meeting  any 
marked  resistance. 

The  movement  of  flexion  likewise  presents  some  irregularities  j  for  instance,  it 


424  LABOR. 

is  not  at  all  unusual,  more  especially  in  the  occlpito-posterior  positions,  for  the 
chin,  instead  of  approaching  the  chest,  to  depart  from  it;  and,  consequently, 
for  the  head  to  become  extended,  and  the  anterior  fontanelle  gradually  to  get 
towards  the  centre  of  the  excavation.  However,  this  anomaly  is  usually  tempo- 
rary, for  the  head  is  flexed  anew  when  it  reaches  the  pelvic  floor. 

In  some  rare  cases,  the  opposite  of  the  preceding,  the  posterior  fontanelle  occu- 
pies the  centre  of  the  excavation,  either  because  the  flexion  has  gone  beyond  its 
usual  limits,  or  else,  because  the  trunk  is  inclined  backwards;  but  here,  also,  the 
resistance  from  the  perineum  gradually  brings  back  the  head  to  its  regular  situa- 
tion. (P.  Dubois.) 

2.  The  rotation  sometimes  commences  prior  to  the  arrival  of  the  head  at  the 
inferior  strait,  and  before  the  descent  is  completed.  So  that,  in  such  cases,  the 
three  first  stages  of  the  labor  occur  at  the  same  time ;  thus  the  head  is  flexed, 
descends,  and  rotates  all  at  once. 

Some  curious  varieties  of  rotation  are  occasionally  met  with,  which  should  be 
known  to  the  student.  For  instance,  it  may  be  incomplete,  the  head  still  retain- 
ing a  great  obliquity  pending  the  whole  duration  of  its  disengagement ;  or  it  may 
not  take  place  at  all,  which  happens,  as  we  have  already  seen,  in  certain  occipito- 
posterior  positions,  or  it  may  also  occur  in  the  transverse  ones.  In  this  latter 
variety,  which  is  the  rarest  of  all,  the  occiput  and  the  forehead  disengage  along- 
side of  the  internal  surface  of  the  ischiatic  tuberosities ;  the  occiput  escapes  first, 
and  then  the  forehead  by  a  movement  of  extension  analogous  to  the  ordinary 
mechanism.  IMadame  Lachapelle  reports  having  observed  three  cases  of  this 
kind.  In  some  exceptional  instances,  the  rotation  exceeds  the  ordinary  limits  ; 
thus,  for  example,  if  the  occiput  is  placed  in  relation  with  the  right  sacro-iliac 
symphysis  at  the  beginning  of  the  labor,  it  may  successively  correspond  with  the 
right  extremity  of  the  transverse  diameter,  the  posterior  face  of  the  right  aceta- 
bulum, the  symphysis  pubis,  and  the  left  cotyloid  cavity ;  and  then,  after  a 
moment  of  repose,  it  retrogrades  and  places  himself  once  more  behind  the  sym- 
physis. M.  P.  Dubois  originally  pointed  out  this  fact,  and  I  have  twice  since 
had  an  opportunity  of  verifying  its  truth. 

Again,  the  rotation  by  which  the  occiput  is  brought  in  front,  sometimes  only 
takes  place  just  as  the  head  is  overcoming  the  final  resistances  from  the  soft 
parts;  on  one  occasion,  I  observed  and  pointed  out  this  fact,  in  a  primiparous 
woman,  to  all  the  students  then  present  at  the  Clinique ;  the  child's  head  was  in 
the  right  posterior  occipito-iliac  position,  and  it  had  descended  to  the  pelvic  floor 
and  had  cleared  the  inferior  strait  without  rotation  taking  place;  the  perineum 
was  forcibly  distended,  the  vulva  widely  dilated,  the  parietal  protuberances  were 
engaged,  and  the  occiput  had  but  a  few  lines  to  pass  over  in  order  to  escape  at 
the  anterior  perineal  commissure ;  when,  under  the  influence  of  a  new  pain,  the 
head  rotated  briskly,  the  occiput  gained  the  front,  the  forehead  simultaneously 
rolling  into  the  perineal  concavity,  and  the  labor  terminated  almost  immediately. 
The  rotation  within  the  excavation  is  certainly  one  of  the  most  curious  move- 
ments executed  by  the  foetal  head  durins  the  whole  process  of  a  natural  labor ; 
indeed,  from  what  we  have  hitherto  stated,  it  must  be  evident  that,  whatever  be 


MECHANISM    OF    LABOR.  425 

the  primitive  relations  of  the  occiput  with  the  various  points  of  the  circumfer- 
ence of  the  superior  strait,  it  finally  succeeds  in  getting  under  the  symphysis 
pubis.*  Now,  the  physical  cause  of  this  movement  is  nowhere  given  in  the 
writings  that  have  been  published  on  the  subject  prior  to  M.  P.  Dubois,  who  has 
paid  particular  attention  to  this  point,  and  who,  after  refuting  the  influence  of 
the  inclined  planes,  advanced  by  the  older  accoucheurs,  as  the  cause  of  the  move- 
ment, adds,  "  This  cause  evidently  resides  in  the  combination  of  a  great  number 
of  elements,  viz.,  on  one  hand,  the  size,  form,  and  mobility  of  the  parts  which 
are  expelled,  and,  on  the  other,  the  capacity,  the  shape,  and  the  resistance  of  the 
canal  traversed  by  them  j  and  such  is  the  influence  of  this  association,  that  the 
foetal  parts  place  themselves  in  the  most  favorable  conditions  for  delivery ;  thus, 
if  an  active  resistance  is  made  to  them  at  one  point,  they  withdraw  from  that, 
and  seek  another  where  there  is  more  space  and  liberty.  The  mobility  of  the 
traversing  parts,  and  the  extreme  lubricity  of  those  which  are  traversed,  ren- 
der all  this  very  simple  and  intelligible.  In  fact,  every  accoucheur  must  have 
remarked  that,  in  those  instances  where  the  sacro-pubic  diameter  is  contracted, 
the  foetal  head,  if  oblique  before  the  labor,  constantly  places  itself  then  in  a  trans- 
verse direction,  that  is,  in  the  one  ofi"ering  the  least  possible  dimension  to  the 
shortened  diameter;  and  this  fact  is  nothing  else  than  a  very  simple  eff'ect  of 
those  same  causes,  of  which  the  rotation,  when  extensive," is  a  very  complicated 
consequence."     (Journal  des  Connaissances  Medico- Chirurc/icales.^ 

M.  P.  Dubois  further  relates  the  following  experiment  in  support  of  his  ex- 
planation of  the  process  of  rotation  :  ''  The  flaccid  and  voluminous  uterus  of  a 
woman  who  died  soon  after  delivery,  was  freely  opened  near  the  os  uteri,  and  her 
foetus  was  placed  in  it  near  the  soft,  gaping  orifice,  in  the  right  posterior  occipito- 
iliac  position  of  the  vertex ;  then  several  midwife  students,  by  pushing  the  child 
from  above  downwards,  caused  it  to  enter  the  excavation  without  difficulty ;  but 
it  required  a  much  greater  efibrt  to  make  the  head  traverse  the  perineum  and 
clear  the  vulva ;  and  it  was  not  without  some  surprise  that  we  noticed,  in  three 
different  trials,  that,  as  soon  as  the  head  passed  the  external  genital  parts,  the 
occiput  was  in  front  and  to  the  right,  while  the  face  turned  backwards  and  to  the 
left.  Again,  we  repeated  the  experiment  a  fourth  time ;  but  now  the  head  passed 
the  vulva,  with  the  occiput  remaining  posteriorly.  We  then  took  a  stillborn 
child,  delivered  the  preceding  day,  which  was  much  larger  than  the  other,  and 
placed  it  in  the  same  conditions  as  the  first,  and  on  two  successive  trials  the  head 
cleared  the  vulva  after  having  performed  the  rotation ;  on  the  third  and  succeed- 
ing essays  it  was  disengaged  without  executing  this  movement;  that  is,  the  pro- 
cess of.  rotation  continued  until  the  perineum  and  vulva  had  lost  the  power  of 
resistance  that  produced  it,  or  which,  at  least,  had  determined  its  accomplish- 
ment."   (^Loc.  cit.) 

•  M.  Nrpgele  has  only  known  the  occiput  to  disengage  posteriorly  seventeen  times  out  of 
twelve  hundred  and  forty-four  occipito-posterior  positions ;  and  even  in  those  cases  it  was 
always  possible  to  appreciate  the  exceptional  circumstances  that  had  favored  this  irregu- 
larity; such  as  an  amplitude  of  the  pelvis,  or  numerous  former  labors,  lacerations  of  the 
perineum,  or  the  softness,  flexibility,  reductibility,  and  want  of  consistence  of  the  head,  or  an 
extreme  sniallness  of  the  child,  the  presence  of  twins,  &c.  &c. 


426  LABOR, 

I  do  not  know  whether  the  explanations  and  experiments  of  M.  P.  Dubois  will 
render  the  cause  of  rotation  very  simple  and  {ntelligihle  to  every  reader;  but,  as 
to  myself,  I  am  constrained  to  admit  that  they  describe  and  confirm  the  fact,  but 
that  they  do  not  explain  it.  True,  there  can  be  no  doubt  that  the  cause  of  rota- 
tion is  to  be  sought  for  in  the  form  and  direction  of  the  canal,  and  in  the  shape 
and  size  of  the  foetal  head ;  but  let  us  see  if  it  would  not  be  possible  to  ascertaia 
the  influence  of  those  divers  circumstances  more  precisely. 

The  uterus  is  situated  very  nearly  in  the  axis  of  the  superior  strait,  and  there- 
fore the  sum  of  its  expulsive  forces,  or,  to  speak  more  clearly,  the  sum  of  the 
contractions,  may  be  represented  as  operating  according  to  the  direction  of  its 
axis.  Now,  supposing  the  head  to  be  in  the  right  posterior  occipito-iliac  posi- 
tion, the  occiput,  urged  on  by  the  uterine  contraction  transmitted  by  the  spine, 
will  descend  in  the  line  of  its  axis;  that  is,  from  above  downwards,  and  from 
before  backwards;  and  it  will  continue  on  until  it  is  arrested  by  the  resistance 
from  the  inferior  and  lateral  parts  of  the  pelvis,  or  from  the  soft  parts  constitu- 
ting the  floor  of  the  perineum.  There  it  is  arrested,  provided  the  resistance  be 
considerable,  and  thenceforth  the  occiput  must  necessarily  change  its  direction. 
In  fact,  the  resistance  may  be  represented  by  a  force  operating  in  a  direction 
perpendicular  to  the  surface  whereon  the  head  strikes,  and  which  is  applied  to 
the  foetal  cranium  at  its  point  of  contact  with  the  posterior  plane  of  the  excava- 
tion. This  point  of  contact,  in  the  case  before  us,  is  evidently  the  right  lateral 
and  posterior  part  of  the  head,  which  strikes  against  some  point  in  the  hinder 
wall  of  the  excavation ;  the  child's  head,  or  rather  the  occipital  extremity  of  it, 
is  from  that  time  subjected  to  two  difi'erent  forces,  one  of  which  acts  from  above 
downwards,  before  backwards,  and  slightly  from  left  to  right  (this  is  the  uterine 
contraction),  and  the  other  from  behind  forwards,  and  a  little  from  below  upwards 
(this  is  the  resistance,  or  force,  represented  by  the  perpendicular  to  the  surface 
impinged  upon  by  the  head).  By  representing  this  force  derived  from  the  re- 
sistance, and  that  from  the  uterus  communicated  through  the  spine  in  the  line  of 
axis  of  the  superior  strait  by  a  parallelogram,  we  obtain  a  diagonal  or  resultant 
from  these  two  forces  that  points  out  the  direction  of  the  movement  that  is  to 
take  place.  Now,  by  constructing  such  a  parallelogram,  we  observe  that  the 
occiput  must  evidently  pass  forwards,  downwards,  and  to  the  right ;  since  the 
diagonal  or  resultant  of  the  forces  is  directed  from  behind  forwards,  from  above 
downwards,  and  from  left  to  right. 

The  extent  of  this  downward  progress,  and  the  rapidity  of  its  execution,  are 
always  proportionate  to  the  energy  and  duration  of  the  contraction  and  to  the 
resistance  offered  by  the  pelvic  floor.  This  also  explains  why  the  rotation,  after 
being  a  long  time  delayed,  is  sometimes  suddenly  and  completely  effected  during 
a  violent  pain ;  as  also  why,  under  other  circumstances,  and  more  particularly  in 
those  instances  where  the  pains  are  feeble  or  short,  this  movement  only  takes 
place  gradually,  and  requires  for  its  entire  completion  a  much  longer  period  and 
more  numerous  contractions.' 

'  This  movement  takes  place  gradually,  says  M.  Nsegele,  in  a  slow  spiral  direction ;  for  if 
the  vaginal  touch  be  resorted  to  during  the  pain,  the  small  fontanelle,  which  was  originally 


MECHANISM     OF    LABOR.  427 

Lastly,  this  theory  enables  us  to  explain  those  differences  noticed  in  the  rota- 
tion according  to  the  part  of  the  excavation  where  it  commences ;  thus,  it  has 
been  stated  that  usually  the  process  only  begins  when  the  child's  head  reaches 
the  pelvic  floor;  indeed,  this  could  hardly  be  otherwise,  since  until  that  period 
the  head,  from  being  strongly  flexed,  and  offering  its  smallest  diameters  to  those 
of  the  strait,  had  encountered  no  resistance  whatever  from  the  osseous  portion  of 
the  pelvic  canal ;  but  we  can  readily  imagine  that  if  the  head  be  voluminous,  the 
pelvis  rather  small,  the  superior  strait  too  much  inclined,  or  the  uterus  too 
oblique,  the  resistances  might  be  felt  much  sooner,  and  the  occiput  hardly  have 
entered  the  excavation,  before  it  would  strike  against  the  posterior  wall  and  be 
compelled  to  follow  the  new  direction  impressed  upon  it  by  the  resultant  (dia- 
gonal) of  the  forces. 

This  explanation  accounts  readily  for  the  absence  of  rotation,  and  the  disen- 
gagement of  the  head  in  the  posterior  position.  What,  according  to  M.  Naegele, 
are  the  kinds  of  cases  in  which  this  exception  has  been  observed  ?  We  have 
already  stated  them :  they  are  those  in  which  the  large  size  of  the  pelvis,  the 
slight  resistance  of  the  soft  parts,  occasioned  by  previous  labors  or  ruptures  of  the 
perineum,  or  else  the  small  size  of  the  foetus,  or  the  reductibility  of  its  head,  per- 
mit its  passage  through  the  canal  without  encountering  resistance,  and,  conse- 
quently, without  any  alteration  of  the  first  direction  of  the  uterine  force  by  a 
new  one. 

3.  The  trunk  participates,  as  we  have  elsewhere  stated,  in  the  rotation  of  the 
head ;  this,  however,  may  not  occur ;  at  least  two  cases  reported  by  M.  P.  Dubois 
would  seem  to  prove  as  much. 

4.  The  rotation  of  the  shoulders  after  the  head  is  delivered  may  also  present 
two  opposite  conditions ;  that  is,  it  may  either  take  place  in  a  partial  manner  or 
else  not  at  all,  the  shoulders  then  disengaging  transversely.  This  last  circum- 
stance is  not  very  unusual,  and,  in  my  opinion,  clearly  tends  to  confirm  the  views 
of  M.  Gerdy  on  the  process  of  rotation;  for  when  it  does  not  occur  the  head 
undergoes  no  rotation.  But  the  latter  should  always  execute  this  movement, 
however  great  the  immobility  of  the  shoulders,  if  the  process  is  a  consequence,  as 
Baudelocque  supposed,  of  the  untwisting  of  the  neck. 

Sometimes,  on  the  contrary,  the  same  movement  that  rendered  the  shoulders 
transverse  before  the  delivery  of  the  head,  continues  after  the  expulsion  of  this 
latter  in  such  a  way,  that  the  shoulder  which  was  originally  anterior  instead  of 
retrograding  towards  the  pubic  arch  passes  behind,  while  the  other  that  was 
primitively  posterior  gains  the  apex  of  this  arch,  and  the  face  then  turns  towards 
the  internal  surface  of  the  right  thigh  in  the  right  occipito-iliac,  and  to  the  left 
thigh  in  the  left  occipito-iliac  positions, 

directed  to  the  right  and  posteriorly,  will  then  be  found  to  place  itself  altogether  to  the  right, 
towards  the  descending  branch  of  the  ischium;  but,  in  proportion  as  the  pain  diminishes,  it 
returns  step  by  step  to  the  place  it  occupied  before.  Again,  if  the  finger  be  kept  in  contact 
with  the  head,  the  posterior  fontanelle,  which  in  the  absence  of  a  pain  is  wholly  to  the  right, 
will  be  observed,  during  the  latter,  to  turn  forwards  towards  the  obturator  foramen,  from 
whence  it  again  departs  as  the  pain  goes  off;  and  it  keeps  up  these  alternate  movements 
for  some  time,  until  finally  it  becomes  fixed  opposite  this  foramen. 


428  LABOR. 

§  4.  Inclined,  or  Irregular  Vertex  Presentations.  • 

Under  the  name  of  inclined,  or  irregular  presentations  of  the  vertex,  we  have 
designated  those  (page  410)  in  which  the  sagittal  suture,  instead  of  being  placed 
very  nearly  in  the  axis  of  the  superior  strait,  looks  either  to  the  fore  or  hinder 
part  of  the  pelvis,  as  well  as  those  in  which  the  forehead  or  the  occiput  is  placed 
at  the  centre  of  the  strait,  in  consequence  of  the  incomplete  or  exaggerated 
flexion  of  the  head.  Baudelocque,  and  his  school,  have  considered  these  as  so 
many  distinct  presentations,  which  they  have  accordingly  denominated  the  pre- 
sentations of  the  side  of  the  head,  or  ear,  forehead,  and  occiput;  but  we  shall 
follow  the  example  of  Lachapelle,  Naegele,  Stoltz,  and  P.  Ihibois,  by  including 
them  all  in  the  general  term  of  vertex  presentations.  In  fact,  they  scarcely  ever 
impede  the  course  of  the  labor,  and  seldom  modify  its  mechanism. 

For  example,  let  us  take  the  first  position  (the  left  anterior  occipito-iliac),  and 
suppose  it  to  be  inclined  on  its  anterior  (right)  parietal  region ;  then  the  right 
parietal  protuberance  corresponds  to  the  centre  of  the  strait,  and  the  sagittal 
suture  looks  towards  the  first  bone  of  the  sacrum.  When  the  contractions  take 
place,  the  head  will  descend  just  as  in  a  natural  position,  excepting  that,  upon 
its  entrance  into  the  excavation,  or  during  the  first  half  of  the  descent,  it  will 
undergo  a  movement  of  correction,  in  consequence  of  which  the  posterior  parie- 
tal protuberance  will  describe  an  arc  of  a  circle  around  the  anterior  one  as  a 
centre,  and  both  will  soon  appear  on  the  same  plane,  and  the  labor  terminate  as 
usual.  Of  course,  this  process  of  correction  would  operate  in  the  opposite  direc- 
tion if  the  inclination  were  on  the  posterior  parietal  region  instead  of  the 
anterior;  however,  the  rectification  is  then  much  more  difiicult,  owing  to  the 
direction  of  the  expulsive  force,  which  has  a  continual  tendency  to  augment  the 
inclination. 

In  those  cases  where  the  flexion  of  the  head  is  incomplete,  as  in  the  forehead 
presentations  of  Baudelocque,  it  will  become  perfected  during  the  descent,  and 
the  same  will  occur  when  it  is  exaggerated  (the  presentation  of  the  occiput  of 
Baudelocque) ;  the  forehead  becoming  lower  and  lower. 

§  5.  Prognosis. 

The  vertex  presentations  are  the  most  favorable  of  all,  and  this  statement  will 
be  more  fully  verified  when  we  study  the  prognosis  of  the  other  presentations. 

But  the  vertex  positions  are  not  all  equally  advantageous;  and  we  may  lay  it 
down  as  a  general  proposition  that  those  in  which  the  occiput  is  turned  towards 
some  point  of  the  anterior  half  of  the  pelvis,  at  the  beginning  of  the  labor,  are 
more  favorable  than  those  in  which  it  looks  posteriorly. 

In  the  latter  case,  as  hitherto  demonstrated,  the  labor  may  terminate  by  two 
varieties  of  mechanism  which  are  altogether  different  from  each  other;  that  is, 
the  occiput  either  comes  in  front,  so  as  to  get  behind  the  symphysis  pubis,  or 
else  it  remains  posteriorly  throughout  the  labor. 

Whenever  the  posterior  position  converts  itself  into  an  occipito-pubic  one,  the 
very  considerable  extent  of  the  rotation  then  demands  a  rather  more  energetic 


MECHANISM    OF    LABOR.  429 

contraction  on  tlie  part  of  the  womb  than  where  the  occiput  was  originally  nearer 
to  the  anterior  arch  of  the  pelvis,  and  the  labor  is,  therefore,  somewhat  more 
painful,  though  in  general  it  is  not  serious. 

But  the  expulsion  becomes  particularly  diflScult  when  the  head  maintains  its 
primitive  position,  and  does  not  rotate,  as  we  shall  endeavor  to  prove ;  though 
first,  let  us  establish  as  an  axiom,  the  evidence  of  which  no  one  can  deny,  that, 
whenever  a  straight  and  an  inflexible  trunk  has  to  pass  through  a  curved  canal, 
it  will  do  so  the  more  readily  as  the  canal  is  shorter  and  less  curved,  or  the  trunk 
itself  is  the  more  diminutive. 

Now,  in  the  folded  condition  exhibited  by  the  child's  body  in  vertex  pre- 
sentations, the  trunk,  which  represents  the  great  longitudinal  axis,  may  be 
divided  into  two  portions ;  one  of  which,  constituted  by  the  spine  and  the  infe- 
rior extremities,  is  flexible,  and  can  accommodate  itself  to  the  pelvic  curvature  j 
and,  therefore,  its  expulsion  should  offer  no  difficulty,  while  the  other,  corre- 
sponding to  all  the  space  between  the  vertex  and  the  atloido-axoid  articulation, 
forms  a  straight,  inflexible  stem.  Now,  it  is  evident  that  in  the  primitive  oeci- 
pito-anterior  positions,  or  in  the  posterior  ones,  which  afterwards  become  con- 
verted into  anterior,  that  portion  of  the  straight  inflexible  stem  which  the  long 
axis  of  the  foetus  represents,  is  reduced  to  its  smallest  possible  dimensions, 
and  it  only  has  to  traverse  the  shortest  and  least  curved  part  of  the  canal,  I  mean 
the  symphysis  pubis ;  whence  one  extremity  is  clear  at  the  inferior,  while  the 
other  is  scarcely  engaged  at  the  superior  strait.  But  does  the  same  thing  occur 
in  those  occipito-posterior  positions  that  remain  posterior  until  the  end  of  the 
labor  ? 

We  know  the  occiput,  in  this  latter  case,  is  the  first  to  escape  at  the  anterior 
perineal  commissure,  and  it  therefore  has  to  traverse  all  the  front  surface  of  the 
sacrum  and  of  the  greatly-distended  perineum.  But  as  the  child's  neck  is  not 
long  enough  to  thus  measure  the  whole  posterior  wall  of  the  pelvic  canal,  the 
chest  must  engage  in  the  excavation  soon  after  the  head,  and  the  latter,  as  a 
necessary  consequence,  must  be  forcibly  flexed  on  the  breast.  Owing  to  this 
forced  flexion,  the  straight  inflexible  stem  extends  not  only  from  the  vertex  to 
the  atloido-axoid  articulation,  but  even  to  the  first  dorsal  vertebrae,  and  it  is, 
therefore,  much  longer  than  usual ;  yet  more,  it  has  to  traverse  the  whole  ante- 
rior face  of  the  sacrum  prolonged  by  the  perineum,  that  is  to  say,  tJie  longest  and 
the  most  curved  part  of  the  pelvic  walls. 

Whence  it  is  evident  that  the  expulsion  of  the  fcetus  in  this  case  must  be 
much  more  tedious  and  painful  than  in  the  others ;  however,  we  cannot  admit 
that  the  delivery  is  absolutely  impossible.  M.  Capuron,  who  still  professes  this 
latter  belief,  supposes  (the  occiput  remaining  posteriorly)  that  the  labor  can  only 
take  place  when  the  foetal  head  is  unusually  small,  or  the  pelvis  very  large;  but 
this  opinion  is  opposed  at  the  present  day  by  too  great  a  number  of  facts,  to 
require  us  to  refute  the  theoretical  proofs  upon  which  he  relies. 

There  is  yet  another  reason  for  the  occipito-posterior  positions  being  more  diffi- 
cult than  the  anterior  ones ;  a  reason  to  which  sufficient  importance  has  not,  in 
my  estimation,  been  attached  :  I  allude  to  the  mode  in  which  the  uterine  contrac- 


430  LABOR. 

tions  are  transnutted.  Observe,  in  fact,  when  the  occiput  is  in  front,  that  these 
are  communicated  to  it  by  the  spine,  nearly  in  a  direct  line,  whilst  they  only 
reach  it  when  this  part  is  posterior  at  the  close  of  labor,  by  describing  a  well- 
marked  curve,  owing  to  the  extreme  flexion  of  the  head  on  the  chest. 

Hence,  there  would  be,  as  every  one  knows,  a  great  loss  of  force ;  and  observe 
further,  that  such  loss  coincides  precisely  with  an  occipito-posterior  position, 
which,  for  the  reasons  before  stated,  occasions,  of  itself,  still  greater  difficulties 
in  the  delivery. 

Now,  to  have  demonstrated  that  the  labor  is  longer  and  more  difficult  in  those 
cases  in  which  the  occiput  remains  posteriorly,  is,  in  eifect,  to  prove  that  it  was 
at  the  same  time  more  dangerous  both  to  the  mother  and  child. 

In  fact,  it  is  in  such  instances,  especiall}^,  that  a  rupture  of  the  perineum  is  to 
be  feared ;  it  being  very  difficult  indeed  to  prevent  such  an  accident;  it  is  then, 
also,  those  central  lacerations  of  the  perineum  are  apt  to  take  place,  in  which  the 
posterior  commissure  of  the  vulva  and  the  sphincter  ani  remain  intact,  while  the 
foetus  forces  a  way  for  itself  through  the  distended  perineum. 

Such,  indeed,  is  the  effect  of  the  length  of  the  straight  stem  represented  by 
the  fcetus,  and  of  the  length  of  the  curve  represented  by  the  canal,  that  in  order 
for  expulsion  to  be  effected,  it  becomes  necessary  either,  1.  That  the  straight 
stem  should  break,  or  bend,  so  as  to  accommodate  itself  to  the  curvature  of  the 
canal,  which  is  impossible;  2.  That  the  curved  canal  should  be  straightened  out; 
3.  That  the  walls  of  the  canal  should  be  ruptured;  4,  or,  finally,  that  the  deli- 
very should  become  impossible.  " 

Happily,  in  the  majority  of  cases,  the  soft  parts  which  form  the  continuation 
of  the  posterior  wall,  allow  themselves  to  be  straightened  out;  but  when  they 
resist,  nothing  but  their  rupture  can  allow  of  a  spontaneous  delivery,  their  con- 
siderable thickness  affording  the  only  explanation  of  the  rarity  of  this  accident.' 

The  head,  by  remaining  a  long  time  in  the  excavation,  compresses  the  neigh- 
boring parts,  thereby  giving  rise  to  retention  of  the  urine,  to  eschars,  and  to 
urinary  or  stercoral  fistulae. 

Ajid  apart  from  all  these  inconveniences,  it  is  well  known  that  the  labor  cannot 
be  prolonged  without  danger;  that  the  woman  becomes  fatigued  and  exhausted, 
and  that  the  child  remains  compressed  and  painfully  flexed. 

Whenever  a  foetal  head  is  examined  just  after  its  delivery  in  a  vertex  position, 
there  is  always  to  be  found  a  more  or  less  considerable  tumefaction  on  some  point 
of  the  vertex,  provided  the  labor  has  lasted  long  after  the  membranes  were  rup- 
tured; and  the  size  of  this  tumor  bears  a  direct  proportion  to  the  more  or  less 
rapid  progress  of  the  labor.  Its  seat  is  so  constant  that  it  is  easy  to  determine 
in  what  position  the  child  was  born  by  a  simple  inspection. 

For  instance,  when  the  occiput  escapes  under  the  pubic  arch,  the  tumor  is 
always  located  on  the  superior  posterior  angle  of  one  of  the  parietal  bones,  i.  e., 
on  the  right  parietal  in  the  left  occipito-iliac,  and  on  the  left  one  in  the  right 

'  For  an  idea  of  the  resistance  sometimes  presented  by  the  perineum,  see  the  article  in  the 
fifth  part  of  the  book  on  The  Application  of  the  Forceps  in  Occipito-posterior  Positions. 


MECHANISM     OF    LABOR.  431 

oecipito-iliac  positions;  and  in  those  rare  cases,  where  the  occiput  is  disengaged 
posteriorly,  it  is  usually  situated  about  the  centre  of  the  vertex,  often  indeed  on 
the  anterior  fontanellc ;  in  a  word,  it  is  mostly  developed  at  the  point  which  cor- 
responded originally  with  the  os  uteri,  and  subsequently,  with  the  void  under  the 
pubic  arch.  The  mechanism  of  its  production  is  very  easily  understood,  for  the 
whole  circumference  of  the  head  is  strongly  compressed,  leaving  only  a  single 
point  corresponding  to  the  void  in  the  pelvis  or  arch,  which  is  not  subjected  to 
that  pressure,  and  which  must,  therefore,  become  the  seat  of  a  sero-sanguinolent 
infiltration,  just  in  the  same  way  as  the  skin  does,  when,  by  the  application  of  a 
cupping-glass  and  the  creation  of  a  vacuum,  it  is  thereby  protected  from  the 
atmospheric  pressure  that  operates  on  every  other  part  of  the  body. 

This  tumor,  when  large,  is  the  result  of  a  slow  and  painful  labor;  it  is  always 
single ;  and  may  be  distinguished  from  the  cephaljematoma,  with  which  it  was 
for  a  long  time  confounded,  by  the  following  characters  :  the  former  (or  the  tume- 
faction caused  by  labor)  is  irregularly  circumscribed,  whilst  the  limits  of  the 
latter  are  very  distinct;  in  the  former,  the  hairy  scalp  is  of  a  well-marked  violet 
color,  the  tumefaction  has  an  oedematous  consistence,  retaining  the  impression  of 
the  finger,  and  is  not  fluctuating,  whilst  the  skin  of  the  cephalhematoma  is  color- 
less, presenting  a  well-marked  fluctuation,  occasionally  even  some  pulsations,  and 
its  base  is  limited  by  a  prominent  osseous  border;  in  some  instances,  however, 
this  border  is  not  developed  for  several  days  after  the  commencement  of  the  dis- 
ease ;  but  the  pulsations  and  the  border  are  never  met  with  in  the  other  variety. 

Lastly,  the  semi-sanguineous  oedema  of  the  cranium  in  new-born  children  ap- 
pears immediately  after  birth,  and  disappears  in  from  twelve  to  forty-eight  hours; 
but  the  cephalajmatoma,  on  the  contrary,  though  it  may  exist  at  the  moment  of 
birth,  scarcely  ever  appears  until  some  hours  after  the  delivery,  and  then  lasts 
for  several  weeks. 

Dr.  Fortin  relates  that  he  was  able,  in  one  instance,  to  detect  the  presence  of 
a  cephalhematoma  as  large  as  a  pigeon's  egg,  before  the  labor  was  terminated;  and 
a  similar  statement  has  been  made  by  several  authors. 

The  sanguineous  tumor  just  spoken  of,  does  not  exist  when  the  foetus  dies 
prior  to  or  during  the  labor,  and  before  the  membranes  are  ruptured ;  the  infer- 
ences which  the  medical  jurist  can  draw  from  this  fact,  in  cases  where  it  is  desi- 
rable to  fix  the  period  of  death  of  a  new-born  child,  are  clearly  obvious. 

ARTICLE    IIL 

OF  THE  PRESENTATION  OF  THE  FACE. 

It  may  happen  when  the  cephalic  extremity  presents  at  the  superior  strait,  that 
the  head  is  not  only  extended,  but  also  turned  back  towards  the  posterior  plane 
of  the  child,  which  situation  constitutes  a  face  presentation.  This  presentation 
is  very  rare ;  thus,  it  has  been  ascertained,  from  the  most  numerous  statistics, 
that  the  foetus  presents  by  the  face,  on  an  average,  once  in  two  hundred  and  fifty 
to  three  hundred  labors. 


432  LABOK. 

We  have  admitted  two  fundamental  positions  for  this  presentation ;  in  one  of 
which,  the  chin  looked  towards  some  point  on  the  right  lateral  half  of  the  pelvis, 
the  right  mev to-iliac;  and  in  the  other,  it  was  directed  to  one  of  the  points  on 
the  left  lateral  half,  the  le/i  mento-iliac  position ;  and  we  may  repeat  for  the  face 
what  was  said  concerning  the  vertex  presentations,  namely,  that  there  is  no  por- 
tion of  the  circumference  of  the  superior  strait  with  which  the  chin  may  not  be 
in  relation  at  the  commencement  of  the  labor ;  nevertheless,  we  shall  include  all 
these  shades  of  position  in  three  principal  varieties  for  each  side ;  that  is,  for 
each  fundamental  one,  we  have  the  anterior,  the  transverse,  and  the  posterior 
varieties. 

The  right  mento-iliac  positions  are  somewhat  more  frequent  than  the  left; 
about  in  the  proportion  of  thirty-one  to  forty-one,  if  we  may  judge  from  the  state- 
ments of  Madame  Lachapelle.  The  transverse  variety  is  rather  more  frequent 
than  the  right  posterior  one,  which  has  been  considered  erroneously  as  the  most 
common. 

The  face  presentations  are  either  classed  as  primitive  or  secondary,  according 
to  whether  they  existed  before  the  commencement  of  labor,  or  were  the  result  of 
ill-directed  contractions.  In  fact,  the  latter  have  generally  been  considered  as 
the  more  frequent  of  the  two ;  but  we  shall  have  occasion  to  show  the  value  of 
this  supposition  hereafter. 

.  §  1.  Causes. 

The  obliquity  of  the  womb,  according  to  most  authors,  is  the  cause  of  face 
presentations,  though  all  of  them  do  not  interpret  its  influence  in  the  same  man- 
ner. According  to  Deventer,  if  the  womb  be  inclined  to  the  right  side,  and  the 
vertex  be  placed  in  the  left  occipito-iliac  position,  the  contractions,  taking  place 
in  the  direction  of  the  uterine  axis  after  the  membranes  are  ruptured,  will  force 
the  fcEtus  from  above  downwards,  and  from  right  to  left,  so  that  the  vertex  will 
strike  against  the  left  border  of  the  superior  strait,  and  the  head,  being  thus  ar- 
rested, will  be  thrown  back  upon  the  posterior  plane  of  the  child.  Baudelocque, 
though  admitting  the  right  uterine  obliquity,  supposes  that  a  right  occipito-iliac 
position  of  the  vertex  exists  at  the  same  time ;  for,  says  he,  a  face  presentation 
is  scarcely  ever  observed,  without  the  obliquity  of  the  womb  being  on  the  side 
which  corresponds  to  the  occiput.  In  this  instance,  the  foetus  is  lying  on  the 
right  lateral  wall  of  the  womb  before  the  labor  sets  in,  and  the  head,  obedient  to 
its  own  specific  weight,  departs  slightly  from  the  chest ;  but  when  the  contrac- 
tions manifest  themselves  after  the  rupture  of  the  membranes  and  the  discharge 
of  the  waters,  the  direction  of  the  forces  transmitted  to  the  head  is  such  that, 
instead  of  falling  on  the  occiput,  as  they  would  were  the  head  flexed,  they  are 
spent  on  the  forehead,  and  tend  to  force  it  down;  but  a  depression  of  the  latter 
compels  the  occiput  to  ascend,  that  is,  causes  an  extension  of  the  head. 

The  reader  will  perceive  that  all  these  explanations  suppose  that  the  face  pre- 
sentations are  uniformly  the  consequence  of  deviations  from  a  vertex  position ; 
but  this,  however,  is  not  always  the  case,  for  the  face  may  often  present  directly 
at  the  superior  strait,  even  before  the  commencement  of  the  labor  or  the  rupture 


MStlHANISM    OF    LABOR.  4&9f 

of  the  amniotic  sac.  For  instance,  Madame  Lachapelle,  when  making  an  autop- 
sical  examination  of  two  women  who  died  at  full  term,  found  the  foetus  present- 
iug  by  the  face ;  moreover,  of  the  eighty-five  face  presentations  collected  by  the 
authors  of  the  Dictionnaire  de  Medecine,  forty-nine  had  been  clearly  made  out, 
and  announced  as  such  before  the  membranes  were  ruptured ;  and  further,  of 
those  eighty-five  women,  there  were  but  three  in  whom  the  uterus  was  in  a  state 
of  well-marked  obliquity,  and  only  one  where  the  quantity  of  the  amniotic  liquid 
was  so  great  as  to  attract  attention.  Whence  the  conclusion  is  evident  from 
these  and  many  other  facts,  that  the  face  presentations,  in  the  great  majority  of 
cases,  are  not  determined  by  a  previous  inclination  of  the  foetus,  nor  by  a  wrong 
direction  of  the  uterine  contractions,  but  that  they  are  primitive,  and  produced 
by  causes  which  are  beyond  our  knowledge. 

The  reason  for  the  greater  frequency  of  the  right  mento-iliac  position  must 
evidently  be  owing,  when  secondary,  to  the  greater  frequency  of  the  right  lateral 
obliquity  that  produces  it.  There  are  several  causes,  according  to  Madame 
Lachapelle,  which  contribute  to  render  the  transverse  positions  more  common 
than  the  others;  as  1,  the  form  of  the  superior  strait  and  the  length  of  its 
diameters,  which  correspond  better  in  this  direction  with  those  of  the  face ;  2, 
the  frequency  of  oblique  or  transverse  positions,  which,  when  the  head  falls  back, 
evidently  give  rise  to  transverse  positions  of  the  face;  3,  the  frequency  of  lateral 
obliquities  of  the  uterus,  or  partial  ones  of  the  child,  if,  as  Gardien  admits,  the 
foetus  can  be  oblique  independently  of  the  womb. 

§  2.  Diagnosis. 

The  diagnosis  of  face  presentations  is  made  out  more  or  less  easily,  according 
to  the  period  of  labor  at  which  the  examination  is  made.  Before  the  membranes 
are  ruptured,  the  head  in  general  is  high,  and  diflScult  of  access,  so  that  it  is 
almost  impossible  to  reach  the  presenting  portion,  provided  the  membranes  are 
the  least  tense.  Again,  the  reversion  of  the  head  not  being  yet  completed,  the 
forehead  is  the  lowest  part,  and  the  one  the  finger  encounters  in  performing  the 
touch ;  whence,  by  feeling  a  hard,  rounded  body  furrowed  by  a  membranous 
interval  (the  coronal  suture),  we  might  very  readily  mistake  it  for  a  vertex  pre- 
sentation. But  if  the  flaccid  and  folded  membranes  can  be  depressed  without 
difficulty,  or  still  better,  if  they  have  been  recently  ruptured,  the  diagnosis  be- 
comes easier.  Then  we  find  towards  one  side  of  the  pelvis  a  rounded,  solid  sur- 
face, the  forehead,  traversed  by  a  suture  leading  to  a  transverse  depression ;  next 
a  triangular  elevation  whose  base,  looking  in  an  opposite  direction  from  the  fore- 
head, exhibits  two  openings,  the  nares,  and  beyond  this,  a  transverse  fissure 
bounded  by  the  superior  and  inferior  maxillary  arches.  Sometimes,  the  finger 
when  introduced  into  the  mouth  of  the  child,  has  been  clearly  sensible  of  an 
effort  at  suction.  On  the  sides  of  the  median  protuberance,  two  little  soft  tumors 
(the  eyes)  are  felt,  surrounded  by  an  osseous  circle ;  and  lastly,  when  the  head 
is  low  down,  an  ear  may  be  detected  behind  the  pubis.  When  the  presentation 
is  once  determined,  the  position  is  easily  made  out,  for  the  opening  of  the  nostrils 
must  evidently  look  towards  that  part  of  the  pelvis  which  corresponds  with  the 

28 


434  LABOR. 

chin.  When  a  long  time  has  elapsed  after  the  rupture  of  the  membranes,  new 
causes  of  difficulty  are  met  with.  Thus,  the  face,  which  now  corresponds  to  the 
open  space  in  the  pelvis,  becomes  the  seat  of  a  considerable  tumefaction,  due  to 
the  same  cause  which  produces  the  tumor  of  the  scalp  in  vertex  presentations. 
The  cheeks,  being  greatly  swollen,  and  at  the  same  time  compressed  on  the  sides, 
project,  and  lie  close  to  each  other  in  front,  thus  leaving  a  deep  fissure  between 
them,  in  the  bottom  of  which  the  distinctive  characters  of  the  face  are  entirely 
concealed ;  this  fissure  might  very  readily  be  mistaken  for  the  one  between  the 
nates,  which  are  then  confounded  with  the  tumefied  cheeks.  Further,  the  lips 
are  also  swelled,  wrinkled,  and  everted,  in  such  a  manner  as  to  ofier  a  rounded 
orifice  instead  of  the  usual  transverse  fissure,  and  this  orifice  has  been  mistaken, 
in  some  instances,  for  the  anus;  hence,  in  such  cases,  a  careful  examination 
seems  to  be  necessary  to  avoid  an  error  which,  according  to  authors,  has  not  un- 
frequently  been  committed. 

§  3.  Mechanism. 

As  those  varieties,  in  which  the  chin  looks  towards  one  extremity  of  the  trans- 
verse diameter,  are  found  to  be  the  most  frequent  of  all,  we  shall  follow  the 
example  of  Nsegele,  Dubois,  and  Lachapelle,  by  taking  one  of  them  as  the  type 
in  our  description  of  the  mechanism  of  natural  labor  by  the  face,  and  shall  com- 
mence with  the  right  mento-iliac,  as  being  the  most  common  of  the  two. 

1.   Mechanism  of  Natural  Labor  in  the  right  Transverse  Mento-iliac  Position. 

Before  the  membranes  are  ruptured,  the  head,  as  a  general  rule,  is  but  mode- 
rately extended,  whence  the  forehead  is  nearly  always  placed  at  the  centre  of  the 
superior  strait;  the  chin  corresponding  to  the  right,  and  the  bregma  to  the  left 
extremity  of  the  transverse  diameter.  The  diameters  of  the  head  hold  the  fol- 
lowing relations  to  those  of  the  pelvis  :  the  mento-bregmatic  corresponds  to  the 
transverse  diameter  of  the  basin ;  the  bi-temporal  to  the  antero-posterior  one, 
and  the  mento-bregmatic  circumference  is  parallel  to  the  periphery  of  the  supe- 
rior strait ;  and,  therefore,  the  pelvic  axis  traverses  the  head  in  the  direction  of 
the  occipito-frontal  diameter. 

The  posterior  plane  of  the  foetus  looks  directly  to  the  mother's  left,  and  its 
anterior  plane  to  her  right;  its  right  side  is  in  front,  and  the  left  one  behind. 

Early  in  the  labor,  the  bag  of  waters  projects  into  the  upper  part  of  the  exca- 
vation, to  an  extent  proportionate  to  the  dilatation  of  the  orifice;  and  its  rupture 
generally  takes  place  suddenly  during  a  contraction,  with  considerable  noise. 
The  rupture  is  followed  by  the  escape  of  a  large  amount  of  amniotic  fluid,  and 
the  foetus,  which  was  before  so  high  as  to  be  felt  with  great  difficulty,  descends, 
and  renders  the  diagnosis  more  easy. 

As  soon  as  the  membranes  are  ruptured,  tRe  mechanism  of  the  expulsion 
begins,  and  here,  as  in  the  case  of  the  vertex,  it  is  composed  of  five  stages,  i.  e., 
the  forced  extension,  the  descent,  the  rotation,  the  flexion,  or  disengagement, 
and  the  external  rotation ;  these  comprise  the  movements  which  the  head  under- 
goes in  face  positions. 

A.  Forced  Extension. — The  head  being  already  moderately  extended  on  the 


MECHANISM    OF    LABOR. 


435 


back,  its  extension  will  be  completed  during  the  first  uterine  contractions  that 
take  place  after  the  discharge  of  the  waters,  owing  to  the  resistance  it  will  then 
meet  with.  This  forced  extension  of  the  head  changes  but  very  little  the  rela- 
tions of  its  diameters  to  those  of  the  pelvis  (Fig.  70) ;  for  instance,  the  fronto- 
mental  has  taken  the  place  of  the  mento-bregmatic,  and  is  now  parallel  to  the 
transverse  diameter  of  the  strait ;  the  bi-temporal  has  not  changed  at  all ;  the 
facial,  or  fronto-mental  circumference,  corresponds  with  the  periphery  of  the 
superior  strait,*  and  the  pelvic  axis  traverses  the  head  in  the  direction  of  a  line 
passing  from  the  posterior  fontanelle  to  the  child's  upper  lip. 


Fig.  70. 


Fig.  71. 


Fig.  70.  The  face  in  the  right  transverse  inento-iliac  position,  after  the  forced  extension. 
Fig.  71.  The  face  in  the  same  position,  though  more  fully  engaged. 

B.  Descent. — As  soon  as  the  head  is  freely  extended,  it  engages  in  the  exca- 
vation, and  descends  as  far  as  the  length  of  the  neck  will  permit.  This  last 
sentence  requires  a  short  explanation.  In  the  vertex  positions,  we  have  already 
seen  that  the  head  descended  to  the  floor  of  the  pelvis  in  such  a  way  as  to  tra- 
verse all  the  space  between  the  superior  and  inferior  straits,  without  changing 
its  position.  But  in  the  transverse  position  before  us,  it  is  clearly  evident  that 
the  face  can  only  reach  the  pelvic  floor  under  one  of  the  following  conditions : 
that  is,  either  the  chest  will  engage  along  with  the  head  in  the  excavation,  or 
else  it  will  remain  above  the  superior  strait ;  the  face  descending  alone  as  far  as 
the  inferior  one ;  that  is  to  say,  the  forehead  reaching  the  level  of  the  left,  and 
the  chin  that  of  the  right  tuber  ischii ;  but  then  the  neck  must  necessarily  elon- 
gate enough  to  measure  the  whole  length  of  the  pelvis  at  its  lateral  portion, 
which  is  three  inches  and  three-quarters.  But  as  neither  of  these  two  conditions 
can  be  realized,  the  head  will  not  be  able  to  reach  the  pelvic  floor ;  and  it  is  for 

'  M.  Naegfele  further  supposes  that  the  face  is  inclined  relatively  to  the  superior  strait,  and 
that  the  anterior  cheek  is  the  most  dependent  part,  &c.  The  reasons  upon  which  our  objec- 
tions were  founded  to  such  an  inclination  in  the  vertex  presentations,  oblige  us  also  to  reject 
it  in  the  positions  of  the  face,  for  we  believe  that  the  facial  circumference  is  most  usually 
parallel  to  the  plane,  as  stated  in  the  text. 


436  LABOR. 

this  reason  that  we  say  the  face  only  descends  as  far  as  the  length  of  the  neck 
toill permit ;  whereby  the  descent  is  interrupted. 

c.  Rotation. — The  head  then  undergoes  a  movement  of  rotation,  during  which 
the  chin  rolls  from  right  to  left,  so  as  to  get  behind  the  symphysis  pubis,  while 
the  forehead  rotates  from  left  to  right,  and  from  before  backwards,  in  order  to 
place  itself  in  the  concavity  of  the  sacrum.  When  this  movement  is  effected,  the 
descent  becomes  completed ;  for  the  shortness  of  the  neck,  or  the  too  great 
extent  of  the  ischium,  formed  heretofore  the  sole  obstacle ;  if,  therefore,  by  the 
process  of  rotation,  the  neck,  which  can  be  no  further  stretched,  is  brought  into 
apposition  with  a  part  of  the  pelvic  wall  short  enough  for  it  to  span  its  whole 
length,  the  descent  may  evidently  be  completed ;  that  is,  the  breast  still  remain- 
ing above  the  superior  strait,  the  chin  may  descend  as  low  as  the  inferior  one, 
and  this  is  precisely  what  does  take  place ;  for,  as  the  trunk  participates  in  the 
rotation  of  the  head,  the  neck  gets  behind  the  symphysis  pubis  at  the  same  time 
that  the  chin  reaches  the  lower  edge  of  this  symphysis,  which  is  short  enough  to 
allow  the  neck  to  subtend  its  whole  length. 

D.  Flexion. — The  process  of  flexion  begins  as  soon  as  the  descent  is  achieved ; 
indeed,  we  may  remark  that  when  the  chin  passes  behind  the  symphysis  pubis, 
the  forehead  goes  into  the  hollow  of  the  sacrum,  and  it  therefore  has  to  traverse, 
in  order  to  arrive  at  the  inferior  strait  simultaneously  with  the  chin,  the  whole 
anterior  face  of  the  sacrum,  that  is,  about  five  and  a  quarter  inches,  whilst  the 
chin  only  descends  the  length  of  the  symphysis,  or  one  and  a  half  inches ;  in  a 
word,  this  is  found  just  in  the  same  condition  as  the  posterior  extremity  of  the 
bi-parietal  diameter  in  vertex  presentations ;  and,  like  it,  the  forehead  has  to 
describe  an  arc  of  a  circle  around  the  chin  as  a  centre.  Now,  this  arc  cannot  be 
described  without  a  certain  degree  of  flexion  of  the  head.  Whence  it  appears 
that,  in  this  transverse  position  of  the  face,  the  descent  is  completed  at  the  same 
time  that  the  rotation  is  taking  place,  and  the  process  of  flexion  beginning. 

If  the  relations  of  the  diameters  of  the  head  to  the  inferior  strait  be  then  exa- 
mined, we  shall  find  that  the  same  ones  are  concerned  as  at  the  beginning  of  the 
labor,  before  the  complete  extension  had  occurred ;  thus,  the  mento-bregmatic 
corresponds  to  the  antero-posterior  diameter,  the  bi-temporal  to  the  transverse, 
and  the  axis  of  this  strait  passes  through  the  occipito-frontal  diameter;  and  thus 
it  should  be  j  since,  by  the  commencement  of  flexion,  the  head  is  replaced  in  the 
state  of  semi-extension  it  had  when  the  labor  began. 

The  chin,  under  the  influence  of  the  uterine  contractions,  next  engages 
beneath,  and  continues  passing  under  the  inferior  part  of  the  symphysis,  until 
the  forepart  of  the  neck,  by  coming  into  apposition  with  the  posterior  surface  of 
the  pubis,  has  its  forward  progression  arrested ;  but,  from  that  time  forth,  the 
expulsive  force  is  exerted  on  the  other  extremity  of  the  occipito-mental  diameter, 
owing  to  its  action  on  the  chin  being  destroyed  by  this  resistance ;  the  occiput  is 
pushed  down,  and  the  head  thereby  compelled  to  complete  its  flexion  or  disen- 
gagement. Of  course,  the  perineum  becomes  greatly  distended,  and  the  fore- 
head, the  bregma,  the  vertex,  and  the  occiput,  successively  appear  before  its 
anterior  commissure. 


MECHANISM    OF    LABOR.  437 

During  the  process  of  flexion,  the  head  resembles  a  lever  of  the  third  kind,  the 
fulcrum  being  at  the  prae-tracheloid  region,  placed  directly  under  the  symphysis 
pubis,  the  power  at  the  occipital  foramen,  and  the 
resistance  at  the  occiput ;  wherefore,  pending  this  "' 

movement,  the  prae-trachelo-frontal,  the  prae-tra- 
chelo-bregmatic,  and  the  prae-trachelo-occipital 
diameters,  clear  in  turn  the  antero-posterior  one  of 
the  inferior  strait. 

E.  Restitution. — ^This  differs  in  nowise  from  the 
external  rotation  described  by  the  head  in  the 
vertex  presentations ;  for  here,  also,  it  is  a  conse- 
quence of  the  movement  executed  by  the  shoulders, 
in  order  to  place  themselves  in  the  direction  of  the 
antero-posterior  diameter  of  the  strait. 

In  addition  to  the  above,  the  mechanism  of  face 
labors  sometimes  presents  a  variety,  which  we  pur-     ,,    .      ".  ^  ,     ^. 

'^  •' '  f  Various  degrees  of  the  diiengage- 

posely  omitted  for  fear  of  interrupting  the  regular  meiitofthehead(iiithe  same  position), 
description  :  thus,  we  stated,  that  the  head  com-  '^"  "^'P"'  "^^f  ^'"^s  """^^  ^"^  """'^ 

,  '  from  the  shoulders. 

pleted  its  extension  and  descended,  but  that  this 

movement  of  descent  was  interrupted  by  the  rotation ;  after  which  the  descent 
was  completed,  and  at  the  same  time  the  flexion  begun.  Now  all  the  difference 
rests  on  this  last  point ;  for  in  practice  a  considerable  number  of  cases,  more  par- 
ticularly of  the  mento-posterior  positions,  are  met  with,  in  which  the  following 
phenomena  are  observed :  the  second  movement,  or  the  descent,  actually  com- 
mences, but  is  checked  by  the  shortness  of  the  child's  neck.  Then  a  certain 
degree  of  flexion  takes  place  before  the  rotation  occurs,  in  consequence  of  which 
the  forehead  descends  to  the  pelvic  floor,  and  the  mento-bregmatic  diameter 
places  itself  anew  parallel  to  the  transverse  diameter  of  the  excavation ;  then  the 
process  of  rotation  occurs,  which  carries  the  chin  behind  the  symphysis,  and  the 
labor  terminates  in  the  manner  just  indicated. 

2.  Mechanism  of  Natural  Labor  in  the  left  Transverse  Mento-iliac  Position. 

In  this  position,  the  expulsion  of  the  foetus  takes  place  in  absolutely  the  same 
manner  as  in  the  preceding  case.  Only  the  chin,  as  well  as  the  anterior  plane  of 
the  child,  is  to  the  left ;  and  hence  the  movement  of  rotation  occurs  from  left  to 
right  instead  of  right  to  left,  but  all  the  rest  is  precisely  similar. 

The  same  is  also  true  of  the  two  varieties  denominated  the  right  and  the  left 
anterior  mento-iliac  positions.  The  two  other  varieties  (the  right  posterior,  and 
the  left  posterior  mento-sacro-iliac)  exhibit  an  identity  of  mechanism  in  a  vast 
majority  of  cases;  that  is  to  say,  the  head,  having  reached  a  certain  depth  in 
the  excavation,  then  undergoes  the  process  of  rotation,  which  converts  the  posi- 
tion into  a  mento-pubic  one ;  indeed,  the  necessity  for  this  movement  is  far  more 
evident  here  than  in  the  mento-transverse  positions,  since  the  depth  of  the  pelvis 
is  much  greater  behind  than  on  the  sides. 

It  may,  therefore,  be  laid  down  as  a  general,  nay,  as  an  almost  absolute  rule, 
that,  in  the  face  positions,  whatever  may  have  been  the  relations  of  the  chia 


438  LABOR. 

with  the  circumference  of  the  superior  strait  at  the  commencement  of  the  labor, 
there  must  be  a  process  of  rotation,  whereby  the  chin  is  brought  under  the  sym- 
physis pubis,  before  the  labor  can  terminate  spontaneously.  The  necessity  for 
this  rotary  movement  may  be  readily  understood.  In  order  that  delivery  may 
be  accomplished  with  the  face  presenting,  it  is  absolutely  necessary  that  the  chin 
should  reach  the  inferior  strait ;  now,  in  the  extended  condition  of  the  head,  the 
chin  cannot  reach  this  strait,  except  the  neck  be  capable  of  measuring  the  depth 
of  that  portion  of  the  wall  of  the  pelvis  to  which  it  corresponds.  If,  therefore, 
the  symphysis  pubis  be  the  only  part  of  the  pelvis  which  is  short  enough  to  allow 
the  neck  to  measure  its  depth,  it  becomes  indispensable  that  the  chin  should  be 
turned  forward. 

In  the  numerous  varieties  of  this  position  before  admitted,  the  mechanism  of 
the  labor  only  differs  in  the  greater  or  the  less  extent  of  the  process  of  rotation; 
an  extent  evidently  varying  according  to  the  point  with  which  the  chin  was 
primitively  in  relation  at  the  upper  strait. 

Remarks. — Nevertheless,  the  mechanism  of  the  face  positions  occasionally 
offers  some  anomalies,  that  require  a  more  special  notice. 

1.  The  rotation  just  described,  whose  object  is  to  bring  the  chin  constantly 
towards  the  symphysis  pubis,  and  which  has  been  spoken  of  as  absolutely  essential 
to  the  spontaneous  termination  of  the  labor,  may  not  be  executed.  But  such 
very  rare  exceptions  do  not  in  the  least  discredit  the  general  principle  before  laid 
down,  for  they  may  all  be  referred  to  those  instances  where  the  dimensions  of  the 
head  are  small  relatively  to  those  of  the  pelvis ;  or  else  to  those  cases  in  which 
the  position  of  the  face  has  been  spontaneously  converted  into  one  of  the  vertex. 
True,  Madame  Lachapelle  has  known  the  face  to  escape  from  the  vulva  in  a 
transverse  direction,  or  nearly  so,  in  two  or  three  instances ;  but  she  carefully 
adds  that  they  were  very  rare  exceptions. 

Now,  to  understand  this  movement  of  rotation,  it  is  only  necessary  to  recall 
our  remarks  concerning  the  mechanism  of  labor;  thus,  it  has  been  shown  that 
the  descent  could  not  be  completed  in  the  transverse  positions,  until  the  chin 
had  turned  towards  the  pubic  symphysis ;  and  further,  that  when  the  head  is 
extended,  the  resultant  of  the  forces  transmitted  by  the  spine,  falls  very  nearly 
on  the  chin,  and  tends  to  engage  it  still  more.  Well,  in  this  situation,  the  ex- 
pulsive force  is  either  perpendicular  or  oblique  to  the  plane  of  the  resistance;  if 
the  former,  the  uterine  efforts  are  lost,  since  they  do  not  contribute  in  any  wise 
to  the  progress  of  the  labor ;  but,  if  the  force  is  oblique  to  the  resistance,  it  is  so 
either  from  before  backwards,  or  from  behind  forwards.  In  the  former  case,  it 
will  have  a  tendency  to  carry  the  chin  backwards ;  but  a  movement  of  this  kind 
will  not  aid  in  the  engagement  of  the  chin,  since  the  pelvic  wall  is  much  higher 
nearer  the  median  line ;  and  hence  the  efforts  are  still  lost. 

In  the  latter,  on  the  contrary,  the  oblique  force,  by  operating  from  behind  for- 
wards, tends  to  carry  the  chin  in  front;  that  is,  towards  a  portion  of  the  pelvic 
wall,  which  becomes  shorter  and  shorter  as  it  advances  anteriorly,  and  thus  faci' 
litates  the  descent. 

But,  after  all,  what  is  the  direction  of  the  uterine  force  ?     Everybody  knows 


MECHANISM    OF    LABOR.  439 

that  it  changes  at  each  instant ;  according  to  the  woman's  position,  or  the  power 
of  the  contractions,  the  womb  may  be  successively  found  in  all  three  of  the  direc- 
tions above  indicated,  relatively  to  the  resistant  plane.  If  it  is  perpendicular  to 
that  plane,  the  efiforts  are  lost ;  or,  if  oblique,  from  before  backwards,  the  con- 
tractions are  useless;  they  can  only  be  fully  efficacious  when  acting  on  the  chin 
from  above  downwards,  and  from  behind  forwards.  But  far  be  it  from  me  to 
attribute  an  intelligent  force  to  the  uterus ;  for  it  is  only  by  groping  along,  so  to 
speak,  that  the  womb  finally  acquires  a  proper  direction,  though,  when  the  im- 
pulsion is  once  given,  the  force  becomes  more  and  more  oblique,  and  consequently 
more  active.  And  it  is  those  gropings  (excuse  the  term)  which  at  times  render 
the  rotation  so  difficult  and  so  tedious. 

It  has  been  asserted,  of  late,  that  the  process  of  rotation  is  quite  as  easy  in  the 
mento-posterior  as  in  the  mento-anterior  positions.  Now,  if  I  have  succeeded 
in  making  my  views  of  the  cause  and  mechanism  of  this  movement  understood, 
the  reader  will  readily  comprehend  that,  in  proportion  as  the  chin  is  turned 
backward,  and  more  especially  if  towards  the  right  at  the  same  time,  the  greater 
will  be  the  difficulty  of  its  accomplishment. 

2.  As  regards  those  varieties  in  which  the  chin  looks  backwards,  we  have 
already  stated  that  it  is  necessary  this  part  should  come  round  in  front,  though 
some  cases  of  mento-posterior  positions,  that  terminated  spontaneously,  are  found 
in  the  books,  where  the  chin  did  not  get  under  the  pubic  arch ;  writers  differ  in 
their  explanations  of  this  anomaly.  M.  Velpeau  takes  as  an  illustration  the 
mento-sacral  variety,  or  the  second  position  of  Baudelocque,  in  which  the  chin 
is  turned  towards  the  anterior  face  of  the  sacrum  (though  we  may  observe,  in 
passing,  that  this  position  is  scarcely  admissible) ;  and  he  remarks  that,  as  the 
chin  does  not  rotate  in  front,  the  following  phenomena  may  then  take  place  :  the 
forehead  engages  behind  the  body  or  the  symphysis  of  the  pubis,  while  at  the 
same  time  the  chin  gets  below  the  sacro-vertebral  angle.  The  whole  head  de- 
scends into  the  excavation  beyond  the  anterior  fontanelle  for  the  anterior  plane, 
and  the  face  drags  after  it  the  front  surface  of  the  neck,  and  even  the  upper  part 
of  the  chest  behind.  The  occipito-mental  diameter,  which  still  represents  the 
axis  of  the  strait  very  nearly,  now  begins  to  perform  a  see-saw  movement  from 
above  downwards  and  from  behind  forwards.  The  chin,  penetrating  further  and 
further  towards  the  bottom  of  the  excavation,  though  at  the  same  time  retained 
by  the  thorax,  which  cannot  advance,  forces  the  sagittal  suture  to  slip  down 
behind  the  pubis,  and  the  forehead  to  gain  the  upper  part  of  the  inferior  strait. 
The  frontal  protuberances  soon  find  a  point  of  resistance  on  the  perineum,  and 
the  posterior  fontanelle  descends  in  turn,  and  ultimately  appears  at  the  summit 
of  the  arch,  when  the  head  finally  escapes  from  the  vulva  as  it  would  in  an 
occipito-anterior  position  ;  whence  it  follows,  adds  M.  Velpeau,  that  the  occipito- 
frontal is  the  greatest  diameter  which  can  present  at  the  planes  of  the  straits. 
But  we  cannot  admit  the  truth  of  this  last  proposition ;  for  if,  as  he  says,  the 
chin  is  in  relation  with  the  anterior  surface  of  the  sacrum,  and  it  descends  more 
and  more,  while  the  occiput  slips  behind  the  pubis,  it  is  evident  that  the  occipito- 
mental diameter  must,  at  a  given  moment,  traverse  the  antero-posterior  one  of  the 


440  LABOR. 

excavation.  Now,  as  this  is  clearly  impossible,  we  have  to  reject  M.  Velpeau's 
explanation  altogether.  Besides,  the  cases  observed  by  Smellie  and  Delamotte, 
which  he  cites  in  support  of  his  theory,  prove  nothing  at  all ;  for,  in  both  of 
those  instances,  the  foetuses  were  small  and  dead,  and  the  toomen  had,  on  former 
occasions,  been  delivered  of  voluminous  children. 

M.  Guillemot  has  explained  the  spontaneous  termination  of  the  labor  in  these 
cases  somewhat  differently ;  for  when  the  chin  does  not  rotate  in  front,  the  labor, 
according  to  his  idea,  may  terminate  in  two  ways,  namely,  1st.  The  forehead 
continues  to  descend  and  to  engage  under  the  branch  of  the  pubis  until  the 
anterior  fontanelle  appears  at  the  vulva,  which  progression  permits  the  chin  to 
advance  forward  and  reach  the  border  of  the  perineum ;  then  the  process  of 
flexion  commences,  &c.  But  we  cannot  conceive  how,  in  the  forced  extension  of 
the  head  on  the  thorax,  it  is  possible  for  the  chin  to  arrive  at  the  anterior  peri- 
neal commissure  by  traversing  the  whole  posterior  plane  of  the  excavation,  be- 
cause, from  all  evidence,  the  breast  must  engage  extensively  along  with  the  head, 
which  is  wholly  impossible,  unless  it  be  a  case  of  abortion. 

2d.  The  labor  by  the  face  may  be  converted  into  one  by  the  vertex ;  and  this 
always  takes  place,  he  continues,  in  the  following  manner:  the  face  being  forcibly 
pressed  on,  and  unable  to  escape  through  the  perineal  strait,  has  a  natural  ten- 
dency to  pass  towards  those  points  that  offer  the  least  resistance.  Here,  this 
condition  is  found  above  and  behind,  whence  the  chin  leaves  the  perineum  and 
approaches  the  foetal  chest  by  ascending  along  the  hollow  of  the  sacrum  towards 
the  sacro-vertebral  angle,  and  the  forehead  following  this  movement  corresponds 
to  the  sacrum  in  turn ;  the  vertex  is  depressed  and  slips  behind  the  pubis,  and, 
just  at  the  moment  when  the  chin  applies  itself  to  the  child's  breast,  the  occiput 
eno-ao-es  under  the  pubic  arch.  He  further  supposes  the  face  to  be  suflBciently 
ensao-ed  for  the  chin  to  come  in  contact  with  the  perineum ;  but,  as  we  have 
already  stated,  this  is  impossible,  on  account  of  the  extent  of  the  conjoint  dia- 
meters of  the  head  and  breast,  both  of  which  would  be  deeply  engaged  in  the 
excavation. 

But,  even  admitting  the  chin  could  descend  so  low,  where  is  the  power  to 
make  it  subsequently  rise  up  in  the  hollow  of  the  sacrum,  the  cavifi/  of  which  is 
occupied,  -whateyer  M.  Guillemot  may  say  to  the  contrary,  by  the  deeply-engaged 
breast?  For  the  uterine  contraction,  which  is  always  transmitted  by  the  spine, 
acts  at  first  on  the  chin  as  a  consequence  of  the  reverted  position  of  the  head  (as 
M.  Velpeau  clearly  recognized),  and  it  is  only  because  its  power  is  inadequate  to 
make  the  latter  descend  any  further,  that  its  action  is  transferred  to  the  other 
extremity  of  the  fronto-mental  diameter,  that  is,  to  the  forehead,  which  it  then 
depresses,  according  to  the  theory  of  Guillemot.  Again,  even  supposing  that 
the  chin  may  remount,  it  is  scarcely  possible  to  believe  that  it  gets  above  the 
sacro-vertebral  angle ;  it  must  therefore  constantly  remain  in  contact  with  the 
anterior  surface  of  the  sacrum ;  and,  consequently,  at  a  given  moment,  the  occi- 
pito-mental  diameter  must  traverse  the  antero-posterior  one  of  the  excavation. 

In  ray  estimation,  therefore,  we  are  not  to  understand  this  as  the  true  mode 
by  which  the  mento-posterior  positions  of  the  face  are  converted  into  occipito- 


MECnANISM    OF    LABOR.  441 

pubic  ones ;  indeed,  among  all  the  cases  I  have  been  able  to  consult,  I  have  only 
found  three  in  which  the  chin  was  in  direct  relation  with  the  anterior  face  of  the 
_  sacrum,  viz.,  those  of  Smellie,  Delamotte,  and  Meza  (reported  by  Guillemot). 
Now,  in  the  one  furnished  by  Smellie,  it  is  positively  stated  that  the  child  was 
small,  that  the  woman  had  a  large  pelvis,  and  that  she  was  usually  delivered 
very  promptly ;  Delamotte  says  nothing  about  the  head  and  the  dimensions  of 
the  pelvis,  in  his  case ;  and,  lastly,  Meza  was  obliged  to  apply  the  forceps,  in  the 
one  reported  by  him ;  so,  of  course,  that  was  no  longer  a  spontaneous  termina- 
tion, for  it  would  be  an  easy  matter  to  demonstrate  that  the  application  of  the 
forceps  may  act  in  an  altogether  different  manner,  and  even  more  advantageously, 
than  the  uterine  contraction  in  this  instance ;  besides,  the  reader  will  not  forget 
that,  in  the  first  two  cases,  the  children  came  away  dead. 

All  the  other  observations  may  be  referred  either  to  the  right  or  the  left  mento- 
sacro-iliac  positions ;  and,  in  these  latter,  it  appears  to  me  that  a  spontaneous  ter- 
mination of  the  labor  might  occur  without  a  simultaneous  engagement  of  the 
chest  and  head ;  for  instance,  let  us  suppose  that  the  child  is  in  a  right  mento- 
sacro-iliac  position ;  then,  after  the  complete  extension  of  the  head,  the  face  will 
descend  into  the  excavation  as  far  as  the  length  of  the  neck  permits,  and  conse- 
quently the  chin  will  reach  the  level  of  the  great  sciatic  notch,  the  more  so,  as 
the  form  of  this  portion  of  the  ilium,  which  is  shaped  like  a  cone,  will  favor  the 
movement  of  downward  progression.  Having  arrived  at  this  notch,  the  chin  will 
there  encounter  soft  parts,  which  it  can  very  readily  depress,  and  this  depression 
will  be  quite  sufficient  to  augment  the  length  of  the  oblique  diameter  of  the  exca- 
vation from  a  quarter  to  half  an  inch,  thereby  permitting  the  occipito-mental 
diameter  to  clear  it,  and  the  head  to  undergo  the  process  of  flexion,  that  will 
gradually  bring  the  occiput  under  the  pubic  symphysis. 

§  4.  Inclined  or  Irregular  Face  Presentations. 

The  face  does  not  always  present  so  regularly  at  the  superior  strait,  as  to  have 
its  fronto-raental  circumference  parallel  to  the  opening  in  the  pelvis,  since  the 
same  causes  that  determine  the  inclination  in  vertex  presentations,  may  also 
render  those  of  the  face  irregular;  and  here,  likewise,  we  may  invoke  the  uterine 
obliquities,  the  partial  obliquity  of  the  child,  or  an  incomplete  or  an  exaggerated 
extension  of  its  head,  to  explain  how  we  sometimes  find  one  of  the  cheeks,  and 
at  others  the  forehead  or  the  chin,  at  the  centre  of  the  upper  strait. 

But  still,  these  are  not  to  be  considered  as  distinct  presentations,  but  rather  as 
varieties  or  shades  of  the  face  presentation,  which  scarcely  ever  render  the  labor 
more  difficult.  In  fact,  the  following  is  the  only  modification  they  are  likely  to 
cause  in  the  mechanism  of  parturition ;  in  the  malar  positions  of  Baudelocque, 
or  those  inclined  towards  the  side,  where  one  cheek  is  at  the  centre,  the  head 
undergoes  a  movement  of  correction  whilst  engaging,  similar  to  what  it  does  in 
the  parietal  inclinations  of  the  vertex,  whereby  the  face  gradually  regains  its 
normal  horizontal  direction.  In  the  so-called  presentations  of  the  forehead  or 
chin,  the  most  elevated  part  becomes  depressed,  and  ultimately  gains  the  same 
level  as  the  other. 


442  LABOR. 


§  5.  Prognosis. 

It  was  for  a  long  time  thought,  and  still  is,  by  some  persons,  that  a  delivery 
by  the  face  cannot  take  place  by  the  powers  of  nature  alone,  and  it  is  only  since 
the  labors  of  Boer,  of  Chevreul,  and  of  Madame  Lachapelle,  that  the  expulsion 
of  the  child  in  the  face  positions  has  been  admitted  to  be  spontaneous  nearly  as 
often  as  it  is  in  the  vertex  positions. 

Nevertheless,  we  must  remark  that,  as  a  general  rule,  the  labor  is  more  tedious, 
more  painful,  and  more  dangerous,  both  to  the  mother  and  the  child,  and  that  it 
much  oftener  demands  the  intervention  of  art.  Besides,  the  reflections  above 
presented  would  naturally  lead  us  to  anticipate  that  the  mento-posterior  positions 
are  much  more  unfavorable  than  the  anterior  ones.  Now,  this  unusual  delay  is 
not  because  the  greatest  diameters  of  the  head  then  present  to  those  of  the  pelvis, 
as  Capuron,  and  many  others,  supposed ;  for  it  is  only  necessary  to  bear  in  mind 
the  relations  before  indicated,  to  understand  that  it  is  the  mento-bregmatic,  and 
the  bi-temporal  diameters  (the  one  three  inches,  and  the  other  three  inches  and 
three-quarters  in  length),  which  are  then  found  to  correspond  with  the  diameters 
of  the  straits ;  but  because  the  dilatation  of  the  os  uteri  takes  place  more  slowly, 
and  because  the  expulsive  forces,  especially  in  the  process  of  flexion  and  of  dis- 
engagement, act,  like  the  arm  of  a  lever  which  is  bent,  nearly  at  a  right  angle. 
Moreover,  it  has  already  been  stated  that,  in  all  other  than  vertex  positions,  a 
very  large  quantity  of  the  amniotic  liquid  usually  existed  between  the  presenting 
.part  and  the  inferior  segment  of  the  uterus.  We  have  also  remarked  (see  the 
Physiological  Phenomena  of  Labor),  that  this  circumstance  singularly  influenced 
the  rapidity  of  the  dilatation  of  the  os  uteri.  On  the  other  hand,  it  is  also  evi- 
dent that,  when  the  chin  is  actually  engaged  under  the  symphysis,  and  the  pro- 
cess of  flexion  has  already  commenced,  the  force  of  the  contraction  transmitted 
through  the  spine  can  only  determine  the  successive  disengagement  of  the  fore- 
head, the  bregma,  and  the  occiput,  by  describing  a  well-marked  flexure,  and, 
consequently,  thereby  losing  a  large  proportion  of  its  force.' 

Certain  authors,  says  Gardien,  have  incorrectly  supposed  that  those  labors  in 
which  the  child  presents  by  the  forehead  are  more  unfavorable  than  those  where 
it  offers  by  the  face ;  for,  if  attention  be  directed  to  this  point,  the  head  will  then 

1  This  is  so  true,  that,  during  the  process  of  extension,  the  uterine  contraction  is  not  trans- 
mitted by  the  spine  alone ;  for  I  believe  that,  in  certain  cases  at  least,  the  thorax,  by  being 
subjected  to  forcible  pressure,  and  therefore  flexed  on  itself,  just  above  the  head,  rests  by  its 
posterior-superior  part  directly  upon  the  occiput,  and  hence  may  immediately  transmit  the 
uterine  force  to  the  latter,  as  I  believe  occurred  in  the  following  case:  In  August,  1839,  I 
was  summoned  to  a  grocer's  wife,  in  the  Rue  du  Bac,  in  whom  the  child  presented  in  the 
left  transverse  mento-iliac  position ;  the  membranes  had  been  ruptured  at  eight  o'clock  in  the 
morning;  it  was  then  five  in  the  afternoon,  and  an  application  of  the  forceps  had  already 
been  attempted.  However,  in  about  three  quarters  of  an  hour  after  my  arrival,  the  labor 
terminated  spontaneously.  The  infant  soon  revived ;  but,  in  examining  its  head,  I  detected, 
near  the  posterior  fontanelle,  what  appeared  to  be  small  splinters  of  bone,  which  crepitated 
under  the  finger,  and  there  were  also  evidetit  traces  of  a  considerable  depression  on  its  dorsal 
region. 


MECHANISM     OF    LABOR.  443 

be  found  to  present  in  reality  by  its  favorable  diameters ;  and,  further,  as  M. 
Stoltz  remarks,  in  the  face  positions,  the  forehead  is  already  the  lowest  part,  and, 
the  more  it  descends  when  the  head  engages,  the  more  easy  will  be  the  labor. 
Again,  the  chin  presentations  are  less  favorable  than  those  of  the  forehead, 
because  the  child's  head  is  then  in  the  most  perfect  state  of  reversion,  and,  if  the 
shoulders  engage  at  the  same  time  with  the  vertical  diameter  of  the  cranium,  a 
wedging  in  must  inevitably  take  place  in  the  excavation.  But  even  these,  also, 
soon  transform  themselves  into  true  face  presentations. 

As  regards  the  foetus,  the  labor,  if  tedious,  may  prove  very  disastrous ;  since 
apoplexy,  or  at  least  a  cerebral  plethora,  and  a  disposition  to  convulsions,  are  but 
too  often,  says  Madame  Lachapelle,  its  unfortunate  result.  The  repeated  and 
prolonged  compression  of  the  child's  neck,  a  compression  which  occurs  just  at 
the  moment  when  the  head  is  clearing  the  cervix  uteri,  or  the  superior  strait,  or, 
still  more  probably,  when  the  front  of  the  neck  is  placed  under  the  symphysis 
pubis,  satisfactorily  accounts  for  the  difficulty  in  the  return  of  the  venous  blood, 
and  the  cerebral  congestion  which  it  occasions.  Consequently,  a  particular 
attention  should  be  given  to  the  constrained  position ;  for  a  case  that  might  be 
abandoned  to  nature,  were  the  mother  alone  regarded,  would  require  the  inter- 
vention of  our  art,  to  relieve  the  foetus  from  its  painful  situation.  In  cases  of 
this  kind,  where  the  face  had  descended  enough  to  be  in  full  view  at  the  vulva, 
Madame  Lachapelle  was  in  the  habit  of  judging  by  the  movements  of  the  infant's 
tongue  and  lips ;  though  it  must  not  be  forgotten  that  these  motions  are  not  con- 
stant ;  but,  when  they  do  exist,  and  are  found  to  grow  weaker,  and  finally  to  dis- 
appear, they  constitute  a  bad  sign,  and  claim  our  immediate  attention.  Further- 
more, the  child  often  exhibits  certain  peculiarities  in  face  deliveries,  which  ought 
to  be  known,  in  order  that  the  family  may  be  advised  of  them  beforehand.  The 
face  corresponds  to  the  open  space  in  the  excavation,  as  also  for  a  long  time  to 
the  void  under  the  pubic  arch ;  and  hence,  it  becomes  affected  with  the  ecchymosis 
and  the  sero-sanguineous  infiltration  before  spoken  of  as  happening  in  vertex 
presentations.  Consequently,  when  the  labor  has  been  somewhat  tedious,  the 
infant's  face  at  birth  is  nearly  black,  its  cheeks  swollen,  its  lips  turned  in,  and 
the  nose  scarcely  visible,  and  nothing  frightens  the  parents  so  much  as  such  an 
object,  if  they  are  not  previously  advised  of  the  possibility  of  such  an  occurrence. 
However,  this  condition  is  generally  dissipated  in  the  course  of  a  few  days,  and 
its  resolution  may  be  hastened  by  lotions  composed  of  a  little  wine,  or  vegeto- 
mineral  water,  or  brandy,  freely  diluted  with  water.  No  alarm  need  be  felt 
about  the  tendency  observed  in  the  head  to  fall  backwards,  as  soon  as  its  support 
is  withdrawn  j  for,  it  only  regains  the  attitude  it  had  temporarily  in  the  pelvis. 
This  feebleness  of  the  muscles  of  the  neck,  is  evidently  due  to  the  prolonged 
extension  they  have  undergone,  and  which  has  momentarily  paralyzed  a  part  of 
their  contractile  force  :  it  ordinarily  disappears  in  the  course  of  two  or  three  days. 


444  L  A  B  0  K. 


ARTICLE   IV. 

PRESENTATION   OF   THE  PELVIC  EXTREMITY. 

We  have  already  had  occasion  to  state  that  most  accoucheurs  describe  three 
distinct  presentations  of  the  pelvic  extremity  of  the  foetus,  to  wit,  the  presenta- 
tions of  the  breech,  of  the  feet,  and  of  the  knees,  according  as  the  breech,  the 
feet,  or  the  knees,  are  the  first  to  engage  in  the  excavation  and  clear  the  external 
parts  of  generation.  We  have  also  explained  why  (following  the  example  of 
Madame  Lachapelle,  Ant.  Dubois,  P.  Dubois,  and  others)  we  consider  these 
three  as  being  only  slight  modifications  of  the  true  pelvic  presentation ;  for  modi- 
fications that  do  not  in  anywise  change  the  mechanism  of  the  natural  labor  ought 
certainly  to  be  included  under  one  and  the  same  title. 

Thus,  it  may  happen,  in  presentations  of  the  pelvic  extremity,  that  this  extre- 
mity, composed  of  all  its  elements,  that  is  to  say,  of  the  thighs  flexed  on  the 
abdomen  and  the  legs  on  the  thighs,  may  engage  in  the  excavation  and  inferior 
strait;  or  that  the  lower  extremities,  carried  along  when  the  membranes  are 
ruptured,  by  the  gush  of  the  waters,  may  be  completely  or  partially  unfolded ;  the 
feet  in  the  former  case,  and  the  knees  in  the  latter,  appearing  first  externally  j  or 
that,  the  inferior  members  being  stretched  out  and  applied  to  the  child's  anterior 
plane,  the  breech  alone  may  descend ;'  or,  lastly,  that  one  of  the  lower  limbs  may 
be  extended  up  along  the  abdomen  while  the  other  remains  down,  and  then  one 
foot  or  one  knee,  as  the  case  may  be,  will  present  at  the  vulva.  We  shall  in- 
clude all  these  varieties  under  the  general  name  of  the  presentation  of  the  pelvic 
extremity  ;  and  we  again  repeat  that,  in  the  presentations  of  this  extremity,  the 
points  of  departure,  taken  on  the  foetus,  are,  the  posterior  face  of  the  sacrum  for 
the  breech ;  the  anterior  face  of  the  tibias  for  the  knees ;  and  the  heels  in  the 
footling  cases.  With  regard  to  the  pelvis,  the  sacrum,  or  the  back  of  the  child, 
may  be  found  in  relation  with  any  one  of  the  various  parts  of  its  superior  strait  j 
but  still,  all  these  shades  of  position  are  included  in  two  principal  ones,  namely,  a 
first,  or  left  sacro-iliac,  and  a  second,  or  right  sacro-iliac  position ;  and,  further, 
each  of  these  exhibits  its  anterior,  transverse,  and  posterior  varieties. 

The  presentations  of  the  pelvic  extremity  are  less  frequent  than  those  of  the 
vertex,  though  much  more  common  than  those  of  the  face.  Thus,  in  thirty- 
seven  thousand  eight  hundred  and  ninety-five  labors,  Madame  Lachapelle  has 
noted  one  thousand  three  hundred  and  ninety  of  this  class ;  in  twenty  thousand 
five  hundred  and  seventeen,  Madame  Boivin  observed  six  hundred  and  eleven ; 
and  in  two  thousand  and  twenty,  M.  P.  Dubois  met  with  eighty-five.     In  order 

'  This  position  of  the  lower  extremities  may  be  primitive ;  that  is,  it  may  exist  before  the 
rupture  of  the  membranes  (indeed,  according  to  M.  P.  Dubois,  this  most  frequently  occurs), 
or  may  be  consecutive  to  the  engagement  of  the  breech.  In  this  latter  case,  the  feet  may 
have  been  arrested  either  by  the  periphery  of  the  cervix  uteri,  or  by  the  superior  strait  at  the 
time  when  the  breech  was  passing  into  the  excavation,  and  hence  the  inferior  members 
would  be  necessarily  pressed  up  along  the  child's  anterior  plane. 


MECHANISM    OF    LABOR.  44S 

to  give  an  idea  of  the  relative  frequency  of  the  cases  in  which  the  nates,  the 
knees,  or  the  feet  are  first  expelled,  we  will  add  that,  in  those  eighty-five  labors, 
the  nates  appeared  first  at  the  vulva  fifty-four  times,  and  the  feet  twenty-six 
times.  The  presentation  of  the  knees,  so  called,  was  not  observed  in  a  single 
instance.  In  fact,  this  is  a  very  uncommon  variety;  for,  in  the  thirty-seven 
thousand  eight  hundred  and  ninety-five  cases  of  Madame  Lachapelle,  the  knees 
came  down  first  only  eleven  times,  or  one  in  three  thousand  four  hundred  and 
forty-five. 

In  a  sum  total  of  sixteen  thousand  six  hundred  and  fifty-four  labors,  Dr.  Col- 
lins has  observed  the  pelvic  extremity  to  offer  once  in  thirty  times ;  and  Rams- 
botham,  Jr.,  from  calculations  founded  on  twenty-seven  thousand  seven  hundred 
and  thirty-nine  labors,  and  twenty-eight  thousand  and  forty-three  births,  occur- 
ring at  the  Maternity  Hospital  of  London,  has  arrived  at  the  conclusion  that 
breech  presentations  are  to  the  others  as  one  to  thirty-five.*  The  left  sacro-iliac 
positions  are  far  more  frequent  than  the  right;  thus,  in  thirteen  hundred  and 
ninety  instances,  the  back  looked  towards  the  left  side  seven  hundred  and  fifty- 
six  times,  and  to  the  right,  four  hundred  and  ninety-four  times;  but  thirteen 
times  in  front,  and  twenty-six  times  directly  backwards  (Lachapelle).  In  the 
eighty-five  positions  of  M.  P.  Dubois,  the  back  was  forty-one  times  towards  the 
mother's  left,  and  forty-four  to  her  right.  As  to  the  varieties  exhibited  by  these 
two  positions,  the  left  anterior  is  a  little  more  frequent  than  the  right  posterior 
one,  but  each  of  them  is  far  more  common  than  all  the  others  put  together.  For 
instance,  in  one  hundred  and  sixty-three  pelvic  presentations,  says  M.  Naegele, 
the  back  was  in  front  and  to  the  left  one  hundred  and  twenty-one  times,  whilst 
it  was  only  forty  times  behind  and  to  the  right. 

§  1.  Causes. 

It  is  wholly  impossible,  in  the  present  state  of  the  science,  to  say  why  the 
breech  should  sometimes  present  at  the  superior  strait ;  true,  numerous  explana- 
tions have  been  offered,  and  the  following,  proposed  by  Madame  Lachapelle  and 
reiterated  by  Velpeau,  is  perhaps  the  least  objectionable  of  any.  The  child, 
they  say,  floats  comparatively  free  in  the  uterus,  until  near  the  eighth  month ; 
then  its  head,  during  certain  movements  on  the  part  of  the  mother,  the  act  of 
lying  down,  in  particular,  is  carried  towards  the  fundus  uteri ;  and,  if  the  infant 
has  then  acquired  a  considerable  volume,  perhaps  its  great  occipito-coccygeal 
diameter  cannot  repass  through  the  small  diameters  of  the  uterine  ovoid,  without 
undergoing  as  forcible  a  movement  as  that  which  changed  its  position ;  and  if 
this  latter  does  not  occur  the  foetus  will  retain  its  new  attitude,  and  at  the  time 
of  the  labor  the  pelvic  extremity  will  present  at  the  passage.  This  explanation, 
I  repeat,  although  liable  to  many  objections,  still  appears  the  most  probable. 

'  By  a  table  in  the  revised  edition,  Dr.  Kamsbotham  furnishes  a  record  of  35,743  deliveries 
that  occurred  between  January  1st,  1828,  and  December  31st,  1843,  in  which  there  were 
930  presentations  of  the  breech,  or  lower  extremities,  thus  showing  the  proportion  to  be  2-6 
per  cent.,  or  1  in  388. —  Translator. 


446  LABOR. 


§  2.  Diagnosis. 

Even  before  the  commencement  of  the  labor,  a  breech  presentation  may  be 
almost  positively  diagnosticated  by  the  following  signs,  namely,  in  thin  women, 
in  whom  the  abdomen,  from  being  previously  distended  by  numerous  pregnan- 
cies, retains  a  certain  degree  of  softness  and  flaceidity  (and  the  womb  containing 
only  a  moderate  quantity  of  liquid),  we  may  more  or  less  readily  detect  the  head 
occupying  the  upper  part  of  the  uterus,  and  inclined  towards  one  or  the  other 
side.  No  part,  however,  can  be  made  out  by  the  internal  exploration,  since  the 
hard,  rounded  tumor  felt  in  the  vertex  presentations  is  always  absent.  Some- 
times, as  has  often  happened  to  myself,  a  little  tumor  (the  foot,  or  a  knee)  can 
be  detected  and  balloted ;  and,  further,  the  heart's  movements  are  revealed  by 
auscultation  at  an  elevated  point  of  the  abdomen,  on  a  level  with,  or  possibly 
above,  the  umbilicus. 

The  shape  of  the  distended  uterus  differs  in  no  respect  from  that  which  it  has 
in  vertex  positions,  though  in  some  cases  it  is  rather  more  oval. 

To  the  foregoing  signs  may  be  added  the  following  as  distinguishable  during 
labor.  The  bag  of  waters  is  very  large,  and  projects  considerably  into  the  upper 
part  of  the  vagina;  sometimes  assuming  the  form  of  an  elongated  tumor,*  which 
may  descend,  even  to  within  a  short  distance  of  the  vulva. 

When  the  membranes  are  ruptured,  a  very  considerable  quantity  of  water 
escapes,  for  the  presenting  part  fills  up  the  neck  but  very  imperfectly,  and  hence, 
all  the  amniotic  liquid  flows  out ;  and  if  the  rupture  should  occur  during  a  strong 
pain,  it  would  probably  be  accompanied  by  a  loud  report. 

Stein  described  the  uterine  orifice  as  being  oval  after  the  rupture,  and  Madame 
Lachapelle  confirmed  this  sign ;  but  I  must  confess  that  I  have  found  great  diffi- 
culty in  verifying  it. 

A  momentary  suspension  or  a  diminution  of  the  pains  often  results  from  a  too 
copious  or  a  too  rapid  discharge  of  the  waters ;  and,  further,  a  flow  of  meconium 
most  generally  takes  place  soon  after  the  membranes  give  way.'' 

But  the  only  characteristic  signs  are  those  furnished  by  the  touch ;  and  they 
will  vary  with  the  presenting  part.  Therefore,  although  we  have  included,  so 
far  as  the  mechanism  is  concerned,  all  the  cases  in  which  either  the  nates,  the 

1  Certain  writers  have  evidently  been  in  error  in  giving  this  particular  form  of  the  am- 
niotic sac  as  a  positive  sign  of  a  presentation  of  the  pelvic  extremity,  since  it  may  be  met 
with  in  other  cases.  I  have  twice  observed  it  myself  in  clear  vertex  presentations  that  were 
engaged,  even  then,  as  far  as  the  middle  of  the  excavation.  I  can  only  explain  this  last  cir- 
cumstance by  supposing  an  extreme  laxity  of  the  membranes. 

2  However,  a  discharge  of  meconium  may  take  place  in  other  than  pelvic  presentations; 
but  then  it  is  an  alarming  sign,  and  one  that  should  receive  the  accoucheur's  immediate 
attention.  In  fact,  it  always  indicates  the  death,  or  at  least  a  suffering  condition,  of  the  child ; 
and,  therefore,  will  most  generally  require  the  intervention  of  art,  since  it  is  particularly  apt 
to  come  on  when  the  labor  has  continued  a  long  time  after  the  rupture,  and  the  fcetus  is  suf- 
fering from  the  protracted  delay ;  or  possibly  it  may  announce  the  compression  of  the  umbi- 
lical cord  (see  Prolapsus  of  the  Cord). 


MECHANISM    OF    LABOR.  447 

feet,  or  the  knees  present,  under  one  general  term ;  yet,  in  the  diagnosis,  we 
must  carefully  distinguish  them  from  each  other. 

1.  When  the  breech  alone  presents,  the  finger  first  encounters  a  soft,  rounded 
tumor,  upon  some  portion  of  whose  anterior  surface  a  hard,  resistant  part,  formed 
by  the  great  trochanter  of  the  thigh  bone,  is  detected.  Thus  far,  it  might  be 
mistaken  for  a  vertex  presentation ;  but  if  the  finger  be  next  carried  upwards 
and  backwards,  so  as  to  reach,  as  it  were,  the  sagittal  suture,  it  will  penetrate  *■ 
into  the  fissure  between  the  nates,  at  the  bottom  of  which  the  most  important 
diagnostic  signs  are  discovered ;  for  the  point  of  the  coccyx  is  felt  towards  one 
side,  surmounted  by  an  irregular  osseous  surface,  constituted  by  the  posterior 
face  of  the  sacrum ;  then  the  anus,  a  small,  rounded,  and  wrinkled  orifice,  into 
which  the  finger  cannot  be  introduced  without  resorting  to  considerable  force, 
whatever  authors  may  say  to  the  contrary;  lastly,  the  external  genital  organs  can 
be  easily  distinguished,  and  thereby  the  sex  of  the  child  may  be  announced  in 
advance.' 

The  prominence  of  the  coccyx  is  not  only  a  certain  sign  of  the  presentation, 
but  it  may  also  serve  to  determine  the  position ;  because  its  point  is  always 
directed  towards  the  side  not  corresponding  with  the  child's  back. 

2.  Where  the  two  feet  present  together  in  the  vagina,  it  is  impossible  to  con- 
found them  with  any  other  part,  and  the  direction  of  the  heels  then  clearly  indi- 
cates the  child's  position.  But  where  a  single  foot  only  is  detected,  and  that 
very  high  up,  it  might  be  mistaken  for  a  hand.  However,  a  little  attention  will 
serve  to  distinguish  them ;  thus  the  toes  are  arranged  in  the  same  line,  are 
shorter,  and  less  movable;  while  the  fingers  are  longer  and  the  thumb  separated 
from  the  others ;  the  internal  border  of  the  foot  is  much  thicker  than  the  exter- 
nal ;  but  the  two  margins  of  the  hand  are  very  nearly  of  the  same  thickness ; 
again,  the  foot  articulates  with  the  leg  at  a  right  angle,  while  the  hand  continues 
out  the  line  of  the  arm. 

The  diagnosis  is  very  difficult  when  the  feet  present  along  with  the  nates,  and 
they  alone  are  accessible.  Sometimes  even  only  one  foot  can  be  felt,  which  ren- 
ders the  case  still  more  obscure ;  then  we  have  first  to  ascertain  which  is  the  foot 
touched ;  though,  for  that  purpose,  it  is  only  necessary  to  pay  attention  to  the 
relation  existing  between  its  internal  border  and  the  heel.  For  instance,  let  us 
suppose  that  the  latter  is  turned  towards  the  symphysis  pubis,  and  its  internal 
border  to  the  right  side  of  the  mother ;  this  is  evidently  the  right  foot ;  if,  on 
the  contrary,  the  heel  be  directed  towards  the  sacro-vertebral  angle,  and  the  in- 
ternal border  to  the  right,  this  would  be  the  left  foot,  &c. ;  now,  the  right  foot 
being  once  distinguished  from  the  left,  it  only  remains  to  determine  towards 

'  The  accoucheur  ought  to  be  exceedingly  careful  not  to  deceive  himself  on  this  point ; 
and,  in  case  of  any  doubt,  it  would  be  much  better  to  abstain  from  all  predictions,  than  to 
expose  himself  to  an  error  that  would  most  certainly  be  retorted  upon  him  afterwards.  It 
is  also  prudent,  where  the  child  is  ascertained,  by  the  touch,  to  be  of  a  sex  different  from 
what  the  family,  and  more  especially  from  what  the  mother  desires,  not  to  communicate 
the  result  of  his  diapnosis,  lest  the  disappointment  she  would  experience  might,  like  any 
other  acute  moral  emotion,  exercise  an  unfavorable  influence  over  the  progress  of  her  labor. 


448 


LABOR. 


what  part  of  the  superior  strait  the  points  of  the  toes  are  directed  (bearing  in 
mind  that  we  always  suppose  the  inferior  extremities  to  be  flexed  on  the  abdomen, 
and  the  feet  crossed  and  turned  inward).  In  this  position  of  the  child,  if  the 
toes  of  the  right  foot  are  turned  towards  any  point  of  the  anterior  half  of  the 
pelvis,  the  back  will  be  directed  to  some  part  of  the  left  lateral  half;  but  if  the 
toes  on  the  left  foot  point  towards  the  anterior  half  of  the  pelvis,  the  child's  back 
will  look  to  some  point  on  the  right  lateral  half,  and  vice  versd. 

3.  The  knees  very  rarely  present  first;  besides,  they  have  such  well-marked 
characteristics  in  their  form,  their  roundness,  their  hardness,  the  size  of  the 
limbs  attached,  and  the  fold  of  the  ham  which  surmounts  them,  a  fold  presenting 
a  transverse  concavity  instead  of  the  convexity  exhibited  at  the  elbow  and  instep, 
that  we  consider  it  useless  to  dilate  further  upon  their  diagnosis. 

§  3.  Mechanism. 

As  the  left  anterior  and  the  right  posterior  are  the  most  frequent  of  the  three 
varieties  admitted  for  both  the  left  and  the  right  sacro-iliac  positions,  we  shall 
select  them  as  the  type  of  our  description. 

1.  Mechanism  of  Natural  Labor  in  the  Left  Anterior  Sacro-iliac  Position. 
(The  first,  of  authors.) 

Before  the  rupture  of  the  membranes,  all  the  parts  of  the  child  are  folded  up 
along  its  anterior  plane ;  the  head  is  slightly  flexed  on  the  chest,  the  arms  are 
applied  to  the  sides  of  the  thorax,  the  forearms  are  bent  on  the  breast,  and  the 
inferior  members  flexed  on  the  front  of  the  abdomen.  In  the  position  before  us, 
the  back  of  the  foetus  looks  forward  and  to  the  mother's  left;  its  anterior  plane 
behind  and  to  her  right;  its  left  side  is  in  front  and  to  the  right,  and  the  right 
side  behind  and  towards  the  left;  the  greater  or  bis-iliac  diameter  of  its  hips  cor- 
responds to  the  right  oblique,  and  its  sacro-pubic  or  antero-posterior  one  to  the 
left  oblique  diameter. 

Prior  to  the  rupture,  the  presenting  part  is  very  high  up ;  but,  at  the  moment 

of  its  occurrence,  a  large  quantity  of  the 
waters  escapes,  and  the  part  then  becomes 
more  easily  accessible.  Then,  also,  the  pre- 
sentation becomes  fixed,  and  one  of  the  varie- 
ties of  it  before  studied  is  thereby  established. 
As  an  example,  we  will  suppose  that  the 
inferior  members  are  stretched  out,  and  ex- 
tended upwards  along  the  anterior  plane  of 
the  foetus.  If  the  os  uteri  be  freely  dilated 
when  the  rupture  takes  place,  the  nates  im- 
mediately engage  by  traversing  the  cervix, 
and  descend  rapidly  into  the  excavation  j 
though,  in  the  contrary  case,  they  remain 
high  up  for  a  long  time.  In  proportion  as 
the  contractions  acquire  more  force  and  energy 
the  buttocks  gradually  descend ;  the  left  slid- 
ino;  on  the  internal  surface  of  the  obturator 


Fig.  73. 


The  presentation  of  the  breech  in  the 
left  anterior  sacro-iliac  position. 


MECHANISM     OF    LABOR. 


449 


foramen  and  the  obturator  internus  muscle,  and  the  right  along  in  front  of  the 
parts  that  are  situated  in  the  left  posterior  quarter  of  the  pelvis.  Having  arrived 
at  the  inferior  strait,  the  child's  pelvis  undergoes  a  movement  of  rotation  thr.t 
carries  the  left  hip  behind  the  right  ischio-pubic  ramus,  and  the  right  hip  in 
front  of  the  inner  half  of  the  sacro-sciatic  ligament.  The  left  or  anterior  hip 
next  engages  under  the  aforesaid  ramus,  and  is  the  first  to  show  itself  through 
the  vulva ;  but  it  is  generally  the  right  or  posterior  hip,  which,  advancing  step 
by  step,  and  describing  an  arc  of  a  circle  around  the  anterior  one  as  a  centre,  and 


Fig.  74. 


Fig.  75. 


The  same  position  after  the  internal 
rotation  is  accomplished. 


Tiie  delivery  of  the  breech. 


traversing  the  whole  anterior  surface  of  the  perineum,  first  succeeds  in  disen- 
gaging itself  at  the  anterior  commissure,  while  the  other  remains  nearly  immov- 
able at  the  summit  of  the  arch.  During  the  delivery  of  the  breech,  the  body  of 
the  child,  by  becoming  strongly  engaged  in  the  excavation,  is  flexed  laterally  on 
its  anterior  (left)  side  in  such  a  way  as  to  accommodate  itself  to  the  curvature  of 
the  pelvis.  As  the  right  buttock  approaches  the  posterior  commissure  of  the 
labia  externa,  and  engages  in  this  opening,  the  breech,  or  rather  the  bis-iliac 
line  of  the  foetus,  which  had  already  cleared  the  lower  strait  in  a  somewhat  dia-. 
gonal  position,  now  assumes  an  exactly  antero-posterior  direction,  so  as  to  corre- 
spond with  that  of  the  longitudinal  diameter  of  the  vulva.  However,  this  is  not 
constant,  as  the  breech  sometimes  retains  its  diagonal  position  throughout;  the 
thighs  closely  applied  on  the  belly  already  begin  to  appear,  and,  pending  the 
disengagement,  the  foetal  trunk,  by  accommodating  itself,  as  above  stated,  to  the 
direction  of  the  pelvic  axis,  is  strongly  flexed  on  its  anterior  (left)  side.  The 
rotation  executed  by  the  hips,  when  they  reach  the  inferior  strait,  may  either  be 
a  partial  movement,  or  else  one  in  which  the  whole  trunk  participates. 

In  the  former  case,  it  can  only  take  place  by  the  aid  of  a  certain  degree  of 
torsion  in  the  lumbar  vertebral  column,  and  then  the  pelvis,  immediately  after 
its  delivery,  undergoes  the  process  of  restitution,  whereby  it  once  more  regains 
its  primitive  diagonal  position. 

As  soon  as  the  hips  are  clear,  the  breast  engages  in  the  excavation,  the  arms 

29 


450  LABOR. 

always  remaining  applied  against  the  anterior-lateral  parts  of  the  thorax,  and  the 
shoulders  soon  arrive  at  the  inferior  strait  in  an  oblique  position,  supposing  they 
have  not  previously  participated  in  the  rotation  performed  by  the  pelvis  of  the 
child. 

The  shoulders  observe  the  same  mechanism  in  disengaging  as  the  hips ;  that 
is,  they  turn  in  such  a  manner  as  to  place  the  anterior  one,  here  the  left,  behind 
the  right  ischio-pubic  ramus,  and  the  posterior  one  just  in  advance  of  the  left 
sacro-sciatic  ligament,  whence  they  both  clear  this  strait  diagonally ;  but  when 
this  is  passed,  and  there  is  no  other  resistance  than  that  of  the  soft  parts  to  over- 
come, they  complete  the  rotation  and  become  placed,  the  one,  directly  in  front ; 
the  other,  behind.  As  to  the  other  parts,  the  sub-pubic  shoulder  and  elbow  are 
the  first  to  appear  externally;  but  it  is  still  the  posterior  ones  that  are  first 
delivered.^ 

Prof  Dubois  contends  that,  in  breech  deliveries,  the  anterior  hip  and  the  front 
shoulder,  in  the  disengagement  of  the  upper  part  of  the  trunk,  are  expelled 
before  the  corresponding  part  in  the  rear ;  but  I  may  be  permitted  to  repeat 
again,  that,  although  matters  often  do  occur  in  the  way  described  by  the  pro- 
fessor, still,  it  has  seemed  to  me  that  the  view  above  given  holds  true  in  the 
majority  of  cases.  Whilst  the  shoulders  are  traversing  the  pelvis  in  the  manner 
just  indicated,  the  head,  being  flexed  on  the  breast,  clears  the  upper  strait  in  the 
direction  of  its  left  oblique  diameter;  that  is,  the  forehead  is  turned  towards  the 
right  sacro-iliac  symphysis,  and  it  retains  that  position  until  it  reaches  the  infe- 
rior strait. 

The  diameters  of  the  head  which  are  then  found  in  relation  with  those  of  the 
inferior  strait,  will  necessarily  vary  according  to  the  greater  or  less  degree  of  the 
flexion  of  the  head.  For  instance,  when  it  is  only  moderately  flexed,  which  is 
generally  the  case,  the  occipito-frontal  diameter  corresponds  to  the  left  oblique 
one,  the  bi-parietal  to  the  right  oblique,  and  the  axis  of  the  inferior  strait  tra- 
verses the  head  very  nearly  in  the  direction  of  its  trachelo-bregmatic  diameter. 

If  we  suppose  the  head  to  be  more  strongly  flexed  on  the  chest,  the  sub-occi- 
pito-bregmatie  diameter  takes  the  place  of  the  occipito-frontal,  and  the  occipito- 
mental corresponds  very  nearly  to  the  axis  of  the  inferior  strait.  In  a  word,  we 
find  the  same  relations  as  in  a  vertex  presentation,  only  the  head  presents  by  its 
base  instead  of  its  summit. 

It  then  performs  a  movement  of  rotation,  whereby  the  face  is  carried  into  the 
hollow  of  the  sacrum,  while  the  occiput  gets  behind  and  the  neck  under  the 

'  Many  books,  on  the  subject  of  shoulder-delivery,  assert  that  the  arms  are  retained  by  the 
borders  of  the  excavation,  and  thereby  get  up  alongside  of  the  head  ;  though,  as  Desormeaiix 
very  justly  remarked,  this  scarcely  ever  happens  when  the  delivery  is  left  entirely  to  nature, 
and  no  traction  whatever  is  made  on  the  pelvic  extremity;  consequently,  when  the  labor 
progresses  regularly,  the  accoucheur  should  overcome  the  temptation  to  aid  nature  a  little  by 
drawing  on  the  parts,  for  such  imprudent  traction  must  certainly  straighten  out  the  arnas, 
since  there  is  no  counteracting  power  in  these  cases  to  press  them  otitwardly;  for,  being 
retained  by  the  friction,  they  remain  above  the  excavation,  and  the  head  descends  between 
them,  rather  than  that  they  mount  up  on  its  lateral  parts:  and  fortunate  indeed  will  it  be  if 
extension  of  the  head  is  not  produced  by  these  tractions! 


MECHANISM    OF    LABOR.  451 

symphysis  pubis;  whence  the  sub-occipito-bregmatic  diameter  approaches  the 
antero-posterior  one  very  closely,  still  retaining,  however,  a  certain  obliquity.  At 
that  time,  the  womb  can  act  but  very  feebly  on  the  head  (see  Prognosis),  which 
is  altogether  down  in  the  vagina,  or  nearly  so ;  but  the  tenesmus,  says  Velpeau, 
occasioned  by  its  pressure  on  the  rectum  and  the  bladder,  constrain  the  woman 
to  collect  all  her  powers,  and  to  redouble  her  courage,  and  then  the  contrac- 
tions of  the  abdominal  muscles  soon  come  to  the  aid  of  the  powerless  womb ;  these 
forces  acting  conjointly,  flex  the  head  more  and  more,  and,  whilst  this  process  of 
flexion  is  going  on  around  the  neck  or  the  sub-occipital  region  as  a  centre,  the 
chin,  the  forehead,  the  bregma,  and  occiput  will  be  found  to  appear  successively 
in  front  of  the  anterior  commissure  of  the  perineum. 

During  the  flexion,  the  head  represents  a  lever  of  the  first  kind,  whose  power 
is  at  the  occiput,  the  fulcrum  at  the  sub-occipital  point,  or  that  portion  of  the 
neck  situated  under  the  arch,  and  the  resistance  at  the  chin,  or  rather  at  the 
forehead,  which,  being  arrested  by  the  perineum,  must  distend  the  latter  and 
render  it  thinner.  Hence,  if  radii  be  drawn  from  the  sub-occipital  point  of  the 
head,  situated  beneath  the  symphysis,  as  a  centre,  and  terminating  at  the  median 
line  of  the  face  and  vault  of  the  cranium,  those  radii  will  exactly  represent  the 
diameters  which  successively  clear  the  antero-posterior  one  of  the  inferior  strait ; 
the  principal  of  which  are  the  sub-occipito-mental,  the  sub-occipito-frontal,  and 
the  sub-occipito-bregmatic. 

2.  Mechanism  of  Natural  Lahor  in  the  right  Posterior  Sacro-iliac  Position. 
(Fourth  of  Baudelocque  and  third  of  Capuron.) — In  this  position,  the  child's 
sacrum  is  turned  towards  the  right  sacro-iliac  symphysis,  its  back  is  behind  and 
to  the  mother's  right,  and  its  anterior  plane  is  to  the  left,  in  front ;  the  right  side 
looks  forward  and  to  the  mother's  right,  while  the  left  side  is  behind  and  towards 
her  left ;  and  the  great  or  bis-iliac  diameter  of  the  child's  pelvis  corresponds  to 
the  right  oblique  diameter. 

Let  us  suppose,  when  the  membranes  are  ruptured,  that  the  lower  extremities, 
swept  along  by  the  gush  of  liquid,  are  completely  unfolded,  and  that  the  feet 
present  first  at  the  vulva.  In  this  case,  the  limbs  are  soon  delivered,  under  the 
influence  of  the  uterine  contractions,  without  ofi'ering  any  peculiarity,  and  the 
hips  easily  reach  the  inferior  strait,  where  they  engage,  sometimes  preserving 
their  primitive  diagonal  position,  while  at  others  the  anterior  one  gets  slightly  in 
advance  towards  the  symphysis  pubis,  and  the  other  or  posterior  goes  behind  to 
the  median  line  of  the  sacrum. 

The  arms  and  shoulders  present  in  turn,  and  their  disengagement  is  nearly  the 
same  as  in  the  preceding  case. 

After  the  delivery  of  the  shoulders,  the  head  alone  remains  in  the  excavation, 
and  its  expulsion  may  take  place  in  several  difi"erent  ways;  sometimes,  indeed, 
the  occiput  remains  posteriorly  throughout  the  whole  delivery,  though  at  others, 
and  indeed  in  the  great  majority  of  cases,  it  comes  round  in  front  so  as  to  place 
itself  behind  the  symphysis  pubis. 

A.  The  Occiput  comes  in  front. — This  conversion  may  begin  as  soon  as  the 
hips  have  cleared  the  inferior  strait ;  thus,  it  often  happens,  as  before  stated, 
that  the  whole  foetal  trunk  participates  in  the  rotation  of  the  haunches,  whence 


452 


LABOR. 


the  posterior  plane  of  the  child,  which  was  primitively  situated  behind,  is  brought 
in  front  by  describing  a  kind  of  a  spiral,  that  commences  in  the  hips  and  termi- 
nates at  the  occiput.  The  head  also  has  participated  in  the  rotation  of  the  trunk, 
so  that,  when  the  former  descends  into  the  excavation,  the  occiput  becomes  placed 
behind  the  symphysis  pubis. 

But  when  the  occiput  retains  its  posterior  position,  after  the  delivery  of  the 
trunk,  this  rotation  of  the  head  may  even  take  place  in  the  pelvis  or  at  the  infe- 
rior strait.  In  such  cases,  after  the  shoulders  are  born,  the  back  of  the  child 
resumes  its  posterior  direction  by  a  sort  of  restitution,  and  the  head,  remaining 
alone  in  the  excavation,  becomes  placed  in  the  direction  of  the  left  oblique  dia- 
meter, the  occiput  being  behind  and  to  the  right,  and  the  forehead  or  bregma 
towards  the  mother's  left,  in  front.  It  then  performs  a  movement  of  rotation, 
by  which  the  occiput,  after  having  traversed  the  whole  right  lateral  half  from 
behind  forwards,  locates  itself  behind  the  symphysis,  and  the  forehead,  by  rolling 

from  front  to  rear,  is  carried  into  the  hollow  of  the  sacrum Though, 

whatever  may  have  been  the  mode  by  which  this  mutation  is  effected,  the  labor 
terminates,  just  as  in  the  preceding  case,  as  soon  as  the  occiput  gets  behind  the 
pubic  symphysis. 

B.  The.  Occiput  remains  behind. — When  the  occiput  remains  behind  until  the 
end  of  labor,  the  delivery  of  the  head  may  take  place  in  two  ways;  thus,  in  the 
majority  of  cases,  this  part  engages  in  the  excavation  in  a  state  of  flexion,  where 
it  soon  undergoes  a  very  slight  movement  of  rotation,  which  carries  the  occiput 
towards  the  concavity  of  the  sacrum,  and  the  forehead  or  bregma  behind  the 
symphysis  pubis;  then,  as  the  uterine  contractions  and  the  abdominal  muscles 
force  the  head  to  become  more  and  more  flexed,  the  following  parts  are  found  to 
appear  in  succession  below  the  symphysis  and  through  the  vulva ;  first  the  whole 
face,  then  the  forehead,  the  bregma,  the  vertex,  and  last  of  all  the  occiput.  The 
head  is  therefore  delivered  by  a  process  of  flexion,  hav- 
ing the  neck,  as  a  centre,  resting  against  the  anterior 
commissure  of  the  perineum. 

Finally,  it  may  happen  that,  instead  of  remaining 
applied  on  the  chest,  the  chin  is  arrested,  and  continues 
above  the  pubis,  while  the  occiput  is  carried  more  and 
more  backwards  by  a  well-marked  movement  of  exten- 
sion. The  head  engages  in  the  strait  by  its  occipital 
extremity,  which  then  traverses  the  whole  posterior  part 
of  the  excavation  by  a  see-saw  movement,  and  is  born 
first  at  the  pei-ineal  commissure  ;  after  it  come,  succes- 
sively, the  vertex,  the  anterior  fontanelle,  the  forehead, 
and  the  entire  face.  Consequently,  the  head  disengages 
by  a  process  of  extension,  having  the  prae-tracheloid 
region  as  a  centre,  which  is  placed  at  first  behind,  and 
then  under  the  symphysis  pubis.  Cases  of  this  kind 
are  reported  by  Leroux,  Michaelis,  and  Asdrubali.  The 
mechanism  of  labor  in  the  left  transverse,  and  in  the 
Delivery  of  the  head  in  the      .^^  anterior,  and  right  transverse  sacro-iliac  positions, 

>acro-po.stenor  positions.  o  ;  o  *  ' 


Fig.  76. 


MECHANISM     OF    LABOR.  453 

is  absolutely  the  same  as  that  just  described  for  the  left  anterior  one ;  and,  again 
the  mechanism  of  the  left  posterior  is  an  exact  counterpart  of  that  of  tbe  right 
posterior  sacro-iliac  position. 

§  4.  Prognosis. 

Breech  presentations  are  not,  usually,  much  more  dangerous  than  those  of  the 
head;  still,  in  order  to  arrive  at  an  intelligent  prognosis,  the  labor  should  be 
studied  in  reference  to  its  effect  upon  the  mother  and  upon  the  child  respectively. 
Though,  from  the  manner  of  its  expulsion  alone,  the  life  of  the  child  is  seriously 
endangered,  the  parturition  is  certainly  less  exhausting  and  less  painful  for  the 
mother. 

1.  As  regards  the  Mother. — As  a  whole,  the  labor  is  somewhat  longer  in  breech 
presentations ;  though,  fortunately,  the  delay  is  experienced  almost  exclusively 
during  the  first  stage,  and  is  the  cause  of  but  little  additional  suffering  to  the 
mother.  The  slowness  of  the  process  of  dilatation  is  readily  explained  by  the 
conditions  which  have  been  already  pointed  out.  Before  the  membranes  are 
ruptured,  the  presenting  part,  having  neither  the  form,  roundness,  nor  regularity 
of  the  top  of  the  head,  cannot  adapt  itself  to  the  regular  concavity  of  the  inferior 
segment  of  the  uterus,  and  being  separated  from  the  neck  by  a  considerable 
amount  of  amniotic  fluid,  is  therefore  incapable  of  hastening  its  dilatation. 
Should  the  membranes  happen  to  rupture  long  before  the  dilatation  is  completed, 
the  size  or  irregularity  of  the  breech  prevents  its  engaging  readily,  and  the  neck, 
not  being  supported  as  it  is  by  the  top  of  the  head  in  vertex  presentations,  col- 
lapses, and  contracts,  so  to  speak,  the  opening  which  it  had  just  before  presented. 
In  cephalic  presentations,  on  the  contrary,  the  head  engages  like  a  wedge,  and 
each  expulsive  effort  tends  to  increase  the  dilatation. 

When  the  neck  is  once  thoroughly  dilated,  the  expulsion  has  always  seemed 
to  me  to  be  effected  more  rapidly  than  in  vertex  presentations.  The  breech,  the 
trunk,  and  the  shoulders,  are  generally  delivered  with  ease,  but  the  head  some- 
times meets  with  obstruction,  and  may  be  arrested  at  the  superior  strait.  Gene- 
rally, however,  it  is  detained  for  but  a  short  time,  for  if  the  efforts  of  the  female 
are  not  capable  of  expelling  it,  it  becomes  the  duty  of  the  accoucheur  to  inter- 
fere promptly,  in  order  to  remove  the  child  from  the  danger  which  threatens  it. 
The  course  to  be  pursued  under  these  circumstances,  exposes  the  mother  to  no 
danger  whatever,  the  entire  risk  falling  upon  the  foetus. 

As  regards  the  mother,  therefore,  the  breech  presentation  is  perhaps  even  more 
favorable  than  that  of  the  vertex ;  I  would  add,  that  it  is  certainly  more  so  for 
her  than  a  face  presentation. 

It  is  important  to  observe,  that  all  the  varieties  of  breech  presentation  are  not 
equally  favorable.  Some  authors  think  that  the  labor  is  usually  longer  when  the 
foetus  presents  by  the  breech,  than  when  the  feet  are  the  first  to  descend  into  the 
excavation. 

The  size  of  the  parts  that  constitute  the  pelvic  extremity,  it  has  been  said,  do 
not  permit  it  to  engage  so  readily;  and  hence  the  uterine  contractions  must 
operate  a  longer  time  in  order  to  adapt  those  parts  to  the  diameter  of  the  pelvis. 


454  LABOR. 

This  is  true ;  but,  as  Madame  Lachapelle  has  observed,  their  softnesF  is  such 
that,  when  once  engaged,  they  easily  conform  to  the  passage;  and  besides,  as  M. 
P.  Dubois  declares,  the  greater  their  volume  is,  the  more  will  the  labor  resemble 
that  of  the  vertex  presentations.  Consequently,  the  professor  teaches,  contrary 
to  the  opinion  generally  adopted,  that  a  delivery  by  the  breech  is  far  preferable 
to  that  in  which  the  feet  come  down  first ;  the  truth  of  which  proposition  will  be 
better  understood  when  we  shall  have  pointed  out  the  inconveniences  attending 
this  latter  circumstance. 

As  the  footling  presentation  does  not  exhibit  the  same  unfavorable  appearances 
in  respect  to  volume,  it  is  preferred  by  some  persons ;  for  then  the  foetus,  pre- 
senting by  its  smallest  extremity,  will,  in  their  estimation,  be  more  easily  expel- 
led, since  the  dilatation  of  the  parts,  from  being  slow  and  gradual,  will  be  much 
shorter  and  less  painful.  If  you  wish,  they  say,  to  drive  a  cork  into  the  neck  of 
a  bottle,  you  would  present  its  smallest  extremity,  and  then  it  would  enter  more 
readily,  and  the  same  is  true  of  the  child  in  .the  foot  presentations ;  for  the  foetal 
ovoid  may  be  considered  as  a  cone,  whose  base  is  at  the  cephalic,  and  whose 
summit  is  at  the  pelvic  extremity.  In  the  case  of  the  bottle  this  is  true,  but 
only  so,  because  the  eflPorts  you  use  to  make  it  penetrate  will  be  redoubled  as  the 
larger  extremity  approaches  the  neck  of  the  bottle ;  that  is,  the  force  will  in- 
crease with  the  difficulties  to  be  overcome ;  but  this  last  condition  does  not  hold 
good  in  the  delivery  by  the  feet.  Because,  as  the  inferior  parts  of  the  child 
become  successively  disengaged,  there  is  less  left  remaining  in  the  uterine  cavity, 
and  there  is  even  a  period  when  the  head,  having  reached  the  excavation,  is 
almost  entirely  out  of  the  cavity  of  its  cervix ;  but  the  uterus,  during  its  evacua- 
tion, retracts,  and,  like  all  contractile  muscles,  loses  a  great  portion  of  its  power 
by  this  retraction ;  and  it  is  therefore  just  at  the  moment  when  the  great  extre- 
mity of  the  cone,  represented  by  the  foetus,  has  to  overcome  the  resistance  of  the 
soft  parts,  that  the  uterine  contractions  are  the  most  enfeebled,  and  often,  indeed, 
they  cannot  aid  at  all  in  the  expulsion  of  the  foetal  head ;  consequently,  the 
powers  here  diminish  in  an  inverse  ratio  to  the  obstacles  in  the  delivery.  If  the 
reader  now  recalls  what  takes  place  in  vertex  presentations,  he  will  readily  com- 
prehend the  difference  between  the  two ;  no  doubt,  the  largest  part  of  the  child 
then  presents  the  first,  and  its  expulsion  requires  violent  and  long-continued 
efforts;  but  remark  that,  up  to  the  moment  when  the  head  clears  the  vulva,  the 
uterus  yet  contains  in  its  cavity  a  considerable  quantity  of  amniotic  liquid,  and 
also  the  largest  part  of  the  foetal  trunk  ;  wherefore,  it  is  still  sufficiently  distended 
not  to  have  lost  its  power  of  contracting,  a  power  that  can  be  exercised  over  a 
large  surface,  and  upon  which  it  is  forcibly  applied  until  the  end  of  labor. 
Again,  the  head  having  once  reached  the  exterior,  the  parts  which  have  been 
freely  dilated  by  its  passage  offer  but  a  feeble  resistance  to  the  expulsion  of  the 
trunk  and  lower  extremities ;  and  hence,  the  retraction  of  the  womb  may  dimi- 
nish its  expulsive  forces  without  this  diminution  having  any  unfavorable  influence 
over  the  termination  of  the  labor. 

2.  As  regards  the  Child.— The  delivery  by  the  pelvic  extremity  is  very  dan- 
gerous to  the  child ;  thus,  the  statistical  results  furnished  by  Madame  Lachapelle 


MECHANISM     OF     LABOR.  455 

prove  that,  in  eight  hundred  and  four  presentations  of  this  class,  one  hundred 
and  two  children  are  born  feeble,  and  one  hundred  and  fifteen  are  stillborn ;  the 
proportion  of  deaths  to  the  whole  being  rather  more  than  one-seventh ;  whilst, 
in  twenty-six  thousand  six  hundred  and  ninety-eight  vertex  positions,  there  were 
only  six  hundred  and  sixty-eight  stillborn  children,  which  gives  one  in  thirty, 
or  about  one-thirtieth.  As  to  the  particular  prognosis  in  each  of  the  three  varie- 
ties of  this  presentation,  it  has  been  remarked  that,  when  the  buttocks  advance 
first,  the  number  of  deaths  is  about  one  in  eight  and  a  half,  or  a  little  less  than 
an  eighth ;  for  footling  presentations,  one  in  six  and  a  half,  rather  less  than  one- 
sixth  -J  and  for  the  knees,  one  in  four  and  a  half,  or  not  quite  one-fourth.  But 
M.  P.  Dubois  has  justly  remarked  that  this  proportion  is  not  perfectly  correct, 
since  all  the  children  born  by  the  pelvic  extremity  are  included  in  the  registers 
of  the  Maternity,  without  making  any  allowance  for  circumstances  foreign  to  the 
position,  but  which  nevertheless  may  have  produced  the  child's  death.  There- 
fore, by  laying  aside  all  the  cases  where  the  children  seemed  to  have  been  lost 
under  the  influence  of  causes  that  evidently  did  not  attach  to  the  presentation 
itself,  he  has  arrived  at  the  conclusion  that,  in  delivery  by  the  pelvic  extremity, 
about  one  child  in  eleven  dies;  whilst,  in  vertex  presentations,  only  one  in  every 
fifty  proved  fatal.     The  difference  still,  as  here  shown,  is  frightful. 

Other  things  being  equal,  the  labor  is  much  more  dangerous  for  the  foetus  in 
primiparse,  than  in  those  who  have  previously  borne  children ;  because  the  re- 
sistance of  the  perineum,  which  is  sometimes  sufficient  in  the  former  to  arrest 
the  labor,  even  in  vertex  presentations,  has  here  a  still  greater  tendency  to  arrest 
the  head,  the  uterine  contractions,  as  just  demonstrated,  being  weaker. 

But  what  is  the  cause  of  the  child's  death  ?  For  a  long  time  it  was  supposed 
that,  when  the  fcetus  presented  its  smallest  extremity,  each  part,  as  it  came 
down,  being  more  voluminous  than  the  one  which  preceded  it,  had  to  overcome 
new  resistances ;  that  it  underwent,  in  consequence,  a  certain  amount  of  com- 
pression, and  this  compression,  being  exercised  from  below  upwards,  would  neces- 
sarily drive  back  the  fluids,  and  thus  give  rise  to  a  cerebral  congestion,  the 
anatomical  signs  of  which  are  detected  at  the  autopsy  of  the  little  corpse.  But 
this  supposed  pressing  back  of  the  fluids  is  altogether  inadmissible  :  1st.  Because 
the  uterine  neck  is  alternately  in  a  state  of  relaxation  and  constriction,  whilst 
such  an  explanation  would  require  it  to  be  permanently  contracted  ;  2d.  Because, 
however  great  the  contraction,  it  would  not  be  sufficient  to  compress  the  large 
vessels  situated  deep  in  the  extremities,  and  in  the  centre  of  the  great  cavities ; 
3d.  Besides,  by  recalling  what  takes  place  in  the  vertex  and  face  presentations, 
we  shall  see  that  it  is  not  in  the  parts  which  are  still  contained  in,  and  com- 
pressed by,  the  uterine  cavity,  that  a  more  considerable  afflux  of  fluid  would  be 
likely  to  occur,  but  rather  in  those  which,  from  being  already  free,  are  thereby 
relieved  from  all  further  compression.  We  think  this  mortal  congestion  can  be 
explained  in  a  much  more  satisfactory  manner  by  a  compression  of  the  cord ;  for, 
after  the  breech  is  disengaged,  the  cord  is  stretched  from  the  umbilicus  to  its 
placental  insertion,  and  is  placed,  both  in  the  excavation  and  uterine  cavity,  be- 
tween the  pelvic  wall  and  the  trunk,  or  even,  a  little  later,  betwixt  this  wall  and 


456  LABOR. 

the  child's  head.  Hence,  we  can  easily  understand  how  liable  it  is  to  be  com- 
pressed ;  and  as  the  delivery  of  the  upper  parts,  and  more  especially  of  the  head, 
often  takes  place  with  diflBculty,  how  this  pressure  may  exist  for  a  long  time,  and 
thus  necessarily  interrupt  the  circulation  in  the  cord.  Indeed,  it  is  now  gene- 
rally admitted  that  the  placenta  is  the  seat  of  the  child's  respiration ;  or,  rather, 
that  the  blood  of  the  foetus  comes  there  directly  into  contact  with  that  of  the 
mother,  whereby  it  experiences  certain  modifications  closely  analogous  to  those 
which  the  blood  of  the  adult  undergoes  in  the  lungs,  by  its  contact  with  the 
atmospheric  air ;  the  circulation  being  interrupted  in  the  cord,  the  foetus  then 
finds  itself  in  the  condition  of  an  adult  deprived  of  respirable  air,  and  it  dies 
asphyxiated ;  now  it  is  well  known  that  cerebral  congestion  is  one  of  the  most 
constant  anatomical  phenomena  of  this  state.'  I  am  of  the  opinion  that  asphyxia 
of  the  foetus  might  take  place  in  still  another  manner,  and  yet  without  the  cord 
being  necessarily  compressed.  It  was  stated  above,  that,  when  the  head  gets 
down  into  the  excavation,  no  portion  of  the  child  is  left  in  the  uterine  cavity, 
and  the  empty  womb  then  retracts  of  its  own  accord ;  which  retraction  deter- 
mines, as  is  well  known,  the  separation  of  the  placenta,  whereby  the  utero- 
placental vessels  are  inevitably  torn,  and  the  foetus  placed  in  the  same  condition 
as  if  the  cord  was  compressed,  and,  should  the  expulsion  of  the  head  be  at  all 
delayed,  it  might  die  asphyxiated. 

It  is  not  necessary,  however,  that  the  placenta  should  be  separated  in  order  to 
produce  this  eff"ect;  for,  as  Van-Huevel  remarks,  if  the  head  be  retained  for  some 
time  in  the  cavity  of  the  pelvis,  the  retraction  of  the  womb  would  of  itself  ob- 
struct, or  even  stop  the  utero-placental  circulation,  and  destroy  the  foetus  by 
asphyxia. 

ARTICLE    V. 

PRESENTATION   OF   THE   TRUNK. 

At  the  commencement  of  this  chapter,  we  gave  the  reasons  that  induced  us, 
like  Madame  Lachapelle,  Nseg^le,  and  Dubois,  to  admit  but  two  presentations 
for  the  trunk,  and  therefore  shall  not  now  repeat  them  ;  for,  doubtless,  the  reader 
will  bear  in  mind  that  all  the  varieties  of  the  trunk  presentations  may  be  referred 
to  the  two  following,  namely,  one  of  the  right  and  one  of  the  left  lateral  plane. 

'  Most  of  the  older  writers  have  explained  the  child's  death  somewhat  differently,  in  these 
cases ;  thus,  according  to  some,  the  pressure  interrupts  the  circulation  in  the  umbilical  arte- 
ries, but  leaves  the  calibre  of  the  vein  entirely  free,  whence  the  foetus  continues  to  receive 
blood  through  the  latter,  without  being  able  to  send  it  back  again  by  the  former;  and  it  then 
dies  from  a  superabundance  of  this  fluid,  from  apoplexy.  Others,  on  the  contrary,  supposed 
that  the  stricture  acted  more  particularly  upon  the  vein,  leaving  the  arteries  free,  and  there- 
fore thattheinfant  died  of  anemia  or  syncope.  Neither  of  these  theories  will  bear  the  slightest 
examination,  since  it  is  all-sufficient  to  examine  the  cord,  and  the  intertwining  of  its  vessels, 
to  be  convinced  that  this  partial  compression  cannot  exist,  except  under  peculiar  circum- 
stances ;  that  such  pressure  must  interrupt  the  circulation,  both  in  the  arteries  and  veins,  and 
that  it  neither  augments  nor  diminishes  the  quantity  of  the  child's  blood.  Death  by  asphyxia, 
therefore,  is  the  only  possible  mode. 


MECHANISM     OF    LABOR.  457 

"When  the  former  presents  at  the  superior  strait,  the  child's  head,  which,  in 
these  cases,  is  taken  as  the  point  of  recognition,  may  be  found  placed  over  some 
portion  of  the  left  lateral  half  of  the  pelvis,  and  this  constitutes  the  first  position 
of  the  right  lateral  plane  (or  of  the  right  shoulder,  Lachapelle) ;  or,  the  head 
may  be  situated  over  some  point  of  the  right  lateral  half,  and  this  is  the  second 
position.  We  have,  therefore,  two  positions  of  the  right  shoulder,  or  right  lateral 
plane ;  and,  in  the  same  way,  there  are  two  for  the  left  shoulder,  or  left  lateral 
plane ;  in  the  one,  the  head  is  to  the  mother's  left  (the  left  cephalo-iliac),  and  in 
the  other  it  is  at  her  right  (the  right  cephalo-iliac). 

It  is  a  very  common  circumstance  in  trunk  presentations,  to  find  the  arm  and 
hand  hanging  down  in  the  vagina,  or  even  the  latter  appearing  at  the  vulva. 
This,  although  regai-ded  for  a  long  while  as  a  much  more  serious  affair  than  a 
proper  shoulder  presentation,  should  be  considered  as  very  nearly  similar  in  its 
character  to  the  defiection  of  the  lower  extremities  in  certain  cases  of  pelvic  pre- 
sentation ;  the  older  accoucheurs  have  therefore  erred  in  describing  it  as  a  dis- 
tinct variety,  under  the  title  of  the  presentation  of  the  arm  and  hand,  it  being 
merely  an  additional  phenomenon  associated  with  the  presentation  of  the  child's 
lateral  region,  and  scarcely  deserving  consideration  as  a  variety  of  these  posi- 
tions; we  shall  see,  further  on,  wherein  they  were  mistaken  on  this  point  of 
doctrine. 

The  trunk  presentations  are  comparatively  rare,  being  a  little  less  so,  however, 
than  those  of  the  face ;  thus,  Madame  Lachapelle  met  with  sixty-eight  cases  in 
fifteen  thousand  six  hundred  and  fifty-two  labors,  or  one  in  about  two  hundred 
and  thirty;  and,  in  the  two  thousand  two  hundred  deliveries  reported  by  M.  P. 
Dubois,  there  were  thirteen  trunk  presentations.  Dr.  Bland  observed  it  in  the 
proportion  of  one  to  two  hundred  and  ten ;  Dr.  Joseph  Clarke,  one  in  two  hun- 
dred and  twelve  j  Merriman,  one  in  two  hundred  and  fifty-five,  in  his  private 
practice;  M.  Naegele,  one  in  one  hundred  and  eighty;  and  Dr.  Collins,  one  in 
four  hundred  and  sixteen. 

As  to  the  relative  frequency  of  the  presentations  and  positions,  it  would  ap- 
pear, from  the  statistical  tables  of  Madame  Lachapelle,  that  the  right  shoulder, 
or  the  right  lateral  plane,  presents  a  little  more  frequently  than  the  left ;  and 
that  the  dorso-anterior  positions,  that  is,  the  first  one  of  the  right  shoulder,  and 
the  second  of  the  left,  in  which  the  back  corresponds  to  the  anterior  part  of  the 
uterus,  are  more  frequent  than  the  dorso-posterior  positions,  or  the  first  one  of 
the  left  and  the  second  one  of  the  right  shoulder,  where  the  child's  back  is 
directed  towards  the  mother's  loins.   (Naegele.) 

§  1.  Causes. 

We  have  but  little  to  say  concerning  the  cause  of  trunk  presentations,  except- 
ing that  the  smallness  and  mobility  of  the  child,  a  rounded  form  of  the  uterus 
produced  by  a  large  amount  of  amniotic  fluid,  obliquity  of  the  womb,  or  of  the 
straits  of  the  pelvis,  and  distortions  of  the  superior  strait,  are  generally  regarded 
as  predisposing  thereto.  We  can  readily  understand  that,  in  the  latter  case,  the 
contraction  of  the  pelvic  entrance  might  render  the  engagement  of  the  head  im- 


458  LABOR. 

possible,  and  by  causing  it  to  glide  toward  one  of  the  iliac  fossae,  favor  a  presen- 
tation of  the  shoulder.  The  insertion  of  the  placenta  upon  the  neck  of  the  uterus, 
also  seems  to  predispose  to  presentations  of  the  trunk,  inasmuch  as  out  of  ninety 
cases  of  this  character,  there  were  twenty-one  in  which  the  shoulder  presented. 
M.  Danyau  thinks  that  a  more  plausible  explanation  may  be  found  in  the  shape 
of  the  uterus,  whose  transverse  diameters  he  supposes  to  be  greater  under  these 
circumstances  than  usual.  In  support  of  his  view,  he  alleges  the  following  case 
of  Dr.  Lecluyse.  A  woman  bad  her  children  to  present  the  shoulder  in  three 
successive  labors,  and  on  the  third  occasion,  the  latter  physician  discovered  that 
the  womb,  so  far  from  being  pyriform  in  the  vertical  direction,  was  shaped,  so  to 
speak,  like  an  ellipsoid,  whose  major  axis  was  transverse,  whilst  the  fundus  of  the 
organ  was  but  slightly  elevated  above  the  pubis. 

The  same  explanation  was  proposed  long  ago  by  Wigand.  How  is  it  possible, 
says  he,  for  a  well-formed  child,  whose  body  represents  an  oval,  to  assume,  with- 
out being  compressed  or  incommoded,  an  oblique  or  transverse  position,  in  a 
womb  of  an  ovoid  shape  ?  Supposing  that,  impelled  by  certain  causes,  it  should 
assume  these  defective  positions  for  a  moment,  what  magical  power  could  keep 
there  a  foetus,  whose  mobility  is  so  highly  favored  both  by  the  fluid  in  which  it 
swims,  and  the  polish  of  the  internal  surface  of  the  ovum  ?  What  is  there  to 
prevent  it,  in  obedience  to  physical  laws,  from  changing  its  inconvenient  position 
by  bringing  its  long  diameter  to  coincide  with  the  longitudinal  one  of  the  uterus  ? 
No  better  reply,  he  adds,  can  be  given  to  ^hese  questions,  than  by  admitting  that 
these  defective  positions  are  due  to  an  irregular  shape  of  the  womb,  rather  than 
to  the  movements  which  it  may  have  performed. 

Remembering  the  unfortunate  perseverence  with  which  defective  positions 
recur  in  the  cases  of  certain  females,  there  is  a  strong  disposition  to  seek  for  the 
cause  in  a  peculiar  shape  of  the  uterus ;  and  had  a  peculiar  conformation  of  the 
organ  been  discovered  before  the  first  gestation,  it  might,  perhaps,  be  admitted, 
that  notwithstanding  the  development  undergone  during  pregnancy,  the  irregu- 
larity of  shape  would  be  preserved. 

Still,  we  may  be  allowed  to  ask  whether  the  increase  in  size  transversely,  near 
the  end  of  gestation  and  at  the  beginning  of  labor,  may  not  be  the  effect  rather 
than  the  cause  of  the  unfavorable  position  of  the  foetus. 

As  to  the  determining  causes,  the  only  ones  recognizable  are  fortuitous  and 
accidental ;  thus,  any  violent  commotion,  any  trifling  shocks,  kept  up  for  a  long 
time,  such  as  those  produced  by  carriage  riding,  or  by  exercise  on  horseback,  the 
perturbation  from  the  upsetting  of  a  coach,  and  even  sudden  fright,  may  change, 
according  to  authors,  the  child's  position  in  certain  cases,  and  convert  sponta- 
neously a  vertex  presentation  into  one  of  the  shoulder.  Indeed,  many  accou- 
cheurs have  supposed  that  irregular  or  partial  contractions  might  convert,  during 
labor,  a  favorable  position  into  one  of  the  trunk ;  this  is  barely  possible.  But  I 
cannot  as  readily  admit  the  supposed  influence  which,  according  to  some  others, 
those  uterine  contractions  may  have,  that  torment  the  woman  during  the  last  few 
days,  or  sometimes  even  weeks  of  her  gestation,  and  which  have  before  been  con- 
sidered as  the  preludes  of  labor.     The  following  is  a  case  in  point :  A  patient,  ia 


MECHANISM     OF     LABOR.  459 

whom  the  foetus  presented  by  the  shoulder  five  times  successively,  had  always 
suffered  from  these  pains  during  the  last  few  days  of  her  pregnancies ;  Professor 
Naeg^le,  under  whose  care  she  came  on  the  sixth  occasion,  endeavored  this  time 
to  calm  the  pains,  which  again  appeared  with  the  same  energy  as  in  the  pre- 
ceding gestations.  After  the  ineffectual  administration  of  various  remedies,  he 
finally  ordered  opiate  injections,  when,  to  his  great  satisfaction,  the  spasms  ceased 
almost  immediately,  and  were  not  again  renewed,  and  the  woman  was  delivered 
at  full  term  of  a  living  child,  which  presented  in  a  favorable  position.  But  what 
does  this  prove  ?  simply  that,  whatever  may  be  the  child's  position,  these  pains, 
the  preludes  of  labor,  may  appear,  and  that  vicious  positions  may  be  reproduced 
in  the  same  woman  with  a  most  deplorable  perseverance.  It  must  be  evident 
that  such  contractions  are  too  feeble  to  change  the  child's  position  in  any  way, 
especially  when  we  remember  that  the  integrity  of  the  amniotic  sac,  and  the  pre- 
sence of  the  waters,  likewise  protect  it  from  any  influence  they  might  have. 

§  2.  Diagnosis, 

There  is  sometimes  reason  to  suspect  a  trunk  presentation,  even  before  the 
commencement  of  labor,  from  the  following  signs :  the  abdomen  is  much  larger 
in  its  transverse  diameter  than  usual,  and  when  its  walls  are  soft  and  flabby,  they 
can  often  be  depressed  enough  to  detect  the  foetal  head  in  one  of  the  iliac  fossae, 
presenting  there  as  a  hard,  rounded,  and  resistant  tumor ;  then,  by  placing  the 
hands  opposite  each  other  in  the  lumbar  regions,  a  greater  and  firmer  resistance 
off"ered  by  the  two  extremities  of  the  foetal  ovoid  will  be  felt  at  these  points,  and 
the  solid  body,  formed  by  the  child,  may  be  readily  moved  from  side  to  side, 
thus  proving  that  its  long  axis  lies  transversely  above  the  superior  strait. 
Finally,  the  tumor  formed  by  the  head,  in  the  vertex  presentations,  is  no  longer 
detected  by  the  vaginal  touch,  and  it  is  almost  impossible  to  reach  the  present- 
ing part ;  in  some  rare  instances,  the  elbow,  or  the  little  hand  of  the  child,  may 
be  recognized  and  balloted,  and  this  sign,  accompanied  by  the  first  two,  renders 
the  diagnosis  quite  probable. 

The  form  of  the  abdomen  is  then  very  irregular,  especially  if  the  uterus  should 
contain  but  a  small  quantity  of  amniotic  fluid.  It  has,  however,  been  observed, 
that  after  the  discharge  of  the  waters,  the  longitudinal  diameter  gradually  becomes 
greater  than  the  other;  because,  as  M.  Hergott  remarks,  the  transverse  position 
has  no  longer  a  real  existence,  for  the  body  of  the  foetus  is  so  curved  upon  itself 
that  one  of  its  extremities  is  lodged  in  the  fundus  of  the  uterus,  although  the 
other  does  not  correspond  to  its  orifice. 

Notwithstanding  what  has  been  said  on  the  subject  of  late,  we  do  not  believe 
that  auscultation  alone  is  capable  of  throwing  any  light  upon  the  diagnosis. 

Sometimes,  however,  it  may  prove  a  useful  auxiliary.  If,  for  example,  a  small 
member  of  the  foetus  be  detected  by  the  touch,  and  the  pulsations  of  the  heart 
are  heard  in  the  hypogastric  region,  we  may  conclude  almost  certainly  that  the 
member  belongs  to  the  upper  extremity.  Should  the  heart  be  heard  on  a  level 
with  the  umbilicus,  it  would  most  probably  prove  a  pelvic  extremity. 


460  LABOR. 

Before  the  membranes  are  ruptured,  the  elevation  of  the  part  renders  the 
vaginal  touch  vei'y  difl&cult;  and  so,  of  course,  the  form  of  the  bag  of  waters,  or 
that  of  the  uterine  orifice,  can  be  of  but  little  service.  According  to  Madame 
Boivin,  the  os  uteri  dilates  more  slowly,  but  as  this  slowness  of  dilatation  is  met 
with  in  all  presentations,  excepting  those  of  the  vertex,  it  forms  a  sign  of  minor 
importance ;  the  touch,  therefore,  can  only  give  a  positive  certainty  after  the  rup- 
ture of  the  membranes.  When  the  side  is  the  presenting  part,  the  shoulder 
(Lachapelle)  is  very  frequently  found  at  the  centre  of  the  superior  strait,  as  also 
the  elbow,  or  the  side  of  the  chest  (P.  Dubois),  and  hence  will  be  the  first 
encountered  by  the  finger  in  making  an  examination ;  and  we  therefore  have  to 
point  out  the  characters,  successively,  whereby  these  several  parts  may  be  recog- 
nized. 

1.  When  the  shoulder  presents,  the  finger  first  detects  the  rounded  tumor 
formed  by  its  summit,  upon  the  surface  of  which  a  small  osseous  projection,  con- 
stituted by  the  acromion,  is  distinguished ;  then,  behind  or  in  front,  according  to 
the  position,  the  clavicle  and  the  spine  of  the  scapula  are  felt,  and  below  the 
clavicle  the  intercostal  spaces  are  easily  made  out,  whilst  under  the  spine  of  the 
scapula  there  is  only  a  plane  surface,  terminated  by  the  acute  inferior  angle  of 
this  bone,  which  is  movable  and  permits  the  finger  to  slip  under  it;  lastly,  on  the 
sides  of  the  tumor  formed  by  the  shoulder,  the  axillary  space  can  always  be  dis- 
tinguished, and  sometimes  also  (though  on  the  opposite  side)  the  depression  in 
the  neck  can  be  felt. 

The  shoulder  being  once  recognized,  we  must  next  determine  which  one  it  is, 
and  what  is  its  position.  I  will  remark,  in  advance,  that  we  have  admitted  but 
four  positions  of  the  trunk,  namely,  two  for  the  right  shoulder  and  two  for  the 
left,  and  that  the  relation  existing  between  the  situation  of  the  head  and  that  of 
the  child's  posterior  plane  is  different  in  each  of  these  four.  Thus,  there  are 
two  positions  where  the  head  is  to  the  left,  namely,  the  first  position  of  the  right 
and  the  first  of  the  left  shoulder;  and  remark  that,  in  the  latter,  the  child's 
back  is  turned  towards  the  mother's  loins ;  in  the  former,  on  the  contrary,  it  is  in 
front ;  and,  therefore,  whenever  the  head  is  to  the  left  and  the  child's  back  is 
behind,  we  have  to  treat  with  a  first  position  of  the  left  shoulder. 

In  the  same  way,  there  are  two  positions  in  which  the  head  is  to  the  right,  to 
wit,  the  second  of  the  right  and  the  second  of  the  left  shoulder;  but  again 
observe,  that  in  the  latter  the  back  looks  forwards,  while  in  the  former,  on  the 
contrary,  it  is  directed  posteriorly.  Hence,  to  recognize  a  second  position  of  the 
left  shoulder,  it  will  only  be  necessary  to  ascertain  that  the  child's  head  is  turned 
towards  the  mother's  right  side,  and  that  its  back  looks  anteriorly.  In  a  word, 
to  satisfy  ourselves  which  is  the  presenting  shoulder  and  what  is  its  position,  we 
only  have  to  find  out  where  the  head  lies,  and  the  position  of  the  posterior  plane 
of  the  child. 

The  shoulder  presenting  and  being  recognized,  it  is  evident  that  if  the  axillary 
space  looks  towards  the  mother's  right,  the  head  will  be  to  her  left,  and  vice 
versd;  consequently,  the  situation  of  the  head  is  readily  known  by  the  direction 


MECHANISM     OF    LABOK.  461 

of  this  space,  and,  as  regards  the  child's  dorsal  plane,  the  omopkte  will  clearly 
indicate  its  position. 

2.  When  the  elbow  alone  is  accessible  to  the  finger,  it  may  be  recognized  by 
the  three  osseous  projections  (the  olecranon  and  the  two  condyles),  which  it  pre- 
sents, by  the  transverse  concavity  in  the  bend  of  the  elbow,  and  by  the  vicinity 
of  the  chest  and  intercostal  spaces.  The  elbow  having  been  distinguished,  it 
will  be  necessary  to  make  out  the  position  to  ascertain  where  the  foetal  head  and 
its  dorsal  plane  lie,  but  this  is  now  comparatively  easy,  since  the  elbow  is  always 
directed  towards  the  side  opposite  to  that  where  the  head  is  found,  and  the  fore- 
arm is  always  placed  on  the  anterior  plane. 

Again,  as  above  stated,  it  happens  at  times  that  the  forearm  is  not  doubled  up, 
but  that,  on  the  contrary,  the  hand  hangs  down  in  the  vagina,  or  even  appears  at 
the  vulva.  Now,  to  determine  which  is  the  presenting  hand  in  those  cases,  it  is 
necessary  to  turn  it  in  such  a  way  as  to  place  its  palmar  surface  in  front  and 
above,  for,  in  this  position,  if  the  thumb  be  directed  to  the  mother's  right  thigh, 
it  is  the  right  hand,  but  if  to  the  left  thigh,  it  is  the  left  hand ;  and  then,  to 
find  out  where  the  head  is,  the  accoucheur  must  slip  his  finger  up  to  the  axillary 
space. 

When  the  hand  comes  out  at  the  vulva,  a  careful  inspection  of  it  will  most 
generally  be  sufiicient  to  establish  the  diagnosis.  Thus,  if  its  dorsal  surface  is 
turned  towards  the  patient's  right  thigli,  the  head  is  at  the  right,  and  if  to  the 
left  thigh,  the  head  is  at  the  left.  The  little  finger,  directed  towards  the  coccyx, 
indicates  that  the  child's  dorsal  plane  corresponds  to  the  mother's  loins,  and  the 
same  finger  pointing  to  the  pubis,  is  an  evidence  of  this  plane  being  in  front. 

We  have  been  thus  particular  in  the  diagnosis,  because  it  is  all-important  in 
trunk  presentations  to  understand  clearly  which  side  presents  at  the  strait,  since 
the  accoucheur  must  always  endeavor  to  turn ;  and  if  the  details  just  given 
prove  diflScult  of  comprehension  from  a  simple  reading,  we  hope  they  will  become 
clearer  by  practising  on  a  mannikin. 

§  3.  Mechanism. 

When  the  trunk  presents  at  the  superior  strait,  the  labor  nearly  always  requires 
the  intervention  of  art;  though,  in  some  rare  cases,  which  may  be  considered  as 
altogether  exceptional,  nature  alone  is  adequate  to  accomplish  the  delivery,  which 
may  then  take  place  in  one  of  two  ways ;  for  either  the  presenting  shoulder  is 
driven  from  the  superior  strait  under  the  influence  of  the  uterine  contractions 
alone,  to  make  room  for  one  of  the  child's  extremities,  thereby  producing  a  change 
in  position,  and  giving  rise  to  what  is  designated  as  spontaneous  version,  or  else 
the  presenting  shoulder  descends  into  the  excavation  and  engages  at  the  inferior 
strait;  notwithstanding  which,  the  breech  sweeps  along  the  whole  anterior  sur- 
face of  the  sacrum  and  of  the  perineum,  and  is  delivered  the  first  at  the  posterior 
vulvar  commissure;  this  latter  mechanism  is  called  spontaneous  evolution. 

1.  Spontaneous  Version. — Where  the  membranes  are  not  ruptured,  though 
the  labor  has  actually  commenced,  the  foetus  sometimes  enjoys  a  great  latitude  of 
motion  in  the  amniotic  cavity,  in  consequence  of  which  it  might,  in  such  cases. 


462  LABOR. 

readily  change  its  position  before  the  discharge  of  the  waters  took  place ;  and  it 
has  been  known  to  present,  in  this  way,  different  points  of  its  surface  during  the 
first  period  of  the  labor.  Sometimes  the  head  ascends  in  the  womb  while  the 
breech  descends;  at  others,  on  the  contrary,  the  nates  mount  up  towards  the 
fundus  uteri,  and  the  head  becomes  located  at  the  superior  strait.  Consequently, 
two  varieties  of  spontaneous  version  have  been  admitted,  i.  e.,  the  cephalic  and 
ihQ  pelvic. 

This  phenomenon  usually  occurs  either  just  before  or  else  soon  after  the  mem- 
branes are  ruptured ;  in  some  instances,  however,  it  takes  place  a  long  time  after 
the  waters  are  discharged.  The  following  case,  reported  by  M.  Velpeau,  will  give 
a  very  correct  idea  of  what  occurs  under  such  circumstances.  "  A  young  woman, 
pregnant  for  the  second  time,  came  into  the  hospital  at  ten  o'clock  in  the  morn- 
ing. The  OS  uteri  was  vei'y  little  dilated;  nevertheless,  I  could  recognize  a 
second  position  of  the  left  shoulder.  The  waters  did  not  escape  until  three  in 
the  afternoon,  and  I  did  not  wish  to  go  after  the  feet,  as  the  pains  were  neither 
very  strong  nor  very  frequent,  and  I  had  some  confidence  in  the  assertions  of 
Denman  on  this  subject.  At  eight  o'clock  in  the  evening,  the  shoulder  had  sen- 
sibly moved  towards  the  left  iliac  fossa,  and  I  could  then  readily  detect  the  ear 
at  the  right.  At  eleven,  the  temple  had  almost  gained  the  centre  of  the  orifice; 
the  contractions  were  augmented  in  energy ;  and  the  cervix  was  entirely  efiaced. 
At  midnight,  the  vertex  had  become  lower;  the  head  engaged ;  and,  in  the  course 
of  an  hour,  the  vertex  was  delivered  in  the  right  occipito-cotyloid  position."* 

This  case,  in  which  the  progress  of  the  labor  has  been  followed  and  described, 
step  by  step,  is  well  suited  for  explaining  the  mechanism  of  spontaneous  cephalic 
version.  The  reader  will  easily  comprehend  that  the  same  phenomena  would 
lake  place,  if  the  breech,  instead  of  the  head,  descended  towards  the  superior 
strait ;  and,  in  the  above  instance,  for  example,  the  shoulder,  instead  of  being 
driven  towards  the  left  iliac  fossa,  would  be  forced  to  the  mother's  right,  and  then 
the  side  of  the  chest,  the  loins,  the  left  hip  and  thigh,  would  successively  appear 
at  the  upper  strait,  and  the  breech  finally  engage  in  the  excavation. 

In  a  shoulder  presentation,  the  arm  and  hand  may  hang  down  in  the  vagina, 
or  even  protrude  beyond  the  vulva;  but  this  last  circumstance  does  not  preclude 
the  possibility  of  a  spontaneous  version,  only  it  is  well  to  bear  in  mind  that  the 
arm  may  then  ascend  again  into  the  uterine  cavity,  and  this  will  almost  certainly 
happen  if  the  pelvic  extremity  descends  into  the  excavation,  but  it  may  also 
lodge  on  one  side  of  the  pelvis,  and  thus  permit  the  head  to  descend  alongside 
of  it ;  the  presentation  of  the  cephalic  extremity  being  then  complicated  by  a 
procidentia  of  the  arm  and  hand.     In  the  present  state  of  our  science,  it  would 

'  With  regard  to  the  case  in  the  text,  I  may  say  briefly,  that  the  course  of  M.  Velpeau  was 
legitimized  by  the  desire  he  had  of  testing  the  opinions  at  that  lime  (1825)  in  dispute;  but 
young  practitioners  should  be  very  cautious  how  they  make  such  experiments;  for  although, 
in  the  hands  of  a  man  like  Velpeau,  the  version,  at  an  advanced  period  of  labor,  would  have 
been  comparatively  easy,  yet  it  must  never  be  forgotten  that,  in  trunk  presentations,  the 
soonest  possible  period  after  the  rupture  of  the  membranes  is  the  most  favorable  for  the  arti- 
ficial version. 


MECHANISM    OF    LABOR.  463 

be  a  very  difficult  matter  indeed  to  point  out  the  various  causes,  under  the  influ- 
ence of  which  it  is  sometimes  the  head,  and  sometimes  the  breech,  •which  thus,  in 
cases  of  spontaneous  version,  take  the  place  previously  occupied  by  the  shoulder, 
at  the  superior  strait.  Nevertheless,  I  am  inclined  to  believe  that  irregu- 
larity of  the  uterine  contractions  is  not  wholly  foreign  to  such  an  effect.  In  fact, 
when  we  shall  speak  hereafter  of  what  the  German  accoucheurs  have  described 
under  the  name  of  Partial  Contractions  of  the  ^Vomh,  it  will  be  seen  that,  in 
some  cases,  the  organ  appears  to  contract  in  but  a  limited  part  of  its  extent,  the 
remainder  contracting  with  much  less  force,  or  even  perhaps  remaining  entirely 
inert.  Now,  without  being  able  to  cite  a  single  instance  in  support  of  my  opinion, 
I  am  strongly  inclined  to  believe,  that  it  is  in  such  a  condition  of  the  uterine 
walls  that  spontaneous  version  would  be  the  most  likely  to  take  place.  Let  us 
suppose,  for  example,  that  when  the  child  is  placed  in  a  left  cephalo-iliac  posi- 
tion of  the  right  shoulder,  the  left  side  of  the  uterus  alone  contracts,  the  right 
remaining  passive ;  it  is  manifest  that  the  whole  expulsory  effort,  being  then 
exercised  on  the  head,  would  necessarily  depress  it  towards  the  centre  of  the 
superior  strait ;  and  this  movement  of  the  cephalic  extremity  will  be  easy,  in 
proportion  as  the  inertia  of  the  right  lateral  wall  of  the  womb  shall  oppose  no 
obstacle  to  the  elevation  of  the  pelvic  extremity.  But  if,  on  the  contrary  (in 
the  same  position  of  the  child),  the  right  side  of  the  womb  only  contracted,  it  is 
evident  the  breech  alone  would  receive  the  impulse  from  the  uterine  efforts,  and 
then  a  spontaneous  podalic  version  would  be  observed  to  take  place. ^ 

2.  Spontaneous  Evolution. — The  mechanism  of  spontaneous  evolution  is  mucli 
better  understood,  and  we  shall  find  embraced  in  its  description  all  the  divisions 
of  the  mechanism  of  natural  labor  in  the  vertex  and  face  presentations.  Here, 
also,  M.  Velpeau  has  admitted  two  varieties,  that  is,  a  spontaneous  cephalic,  and 
a  spontaneous  pelvic  evolution.  But  we  cannot  conceive  how  a  spontaneous 
cephalic  one  can  take  place,  unless  it  be  in  cases  of  abortion,  or  in  those  where 
the  child  is  completely  putrefied ;  hence  we  shall  treat  of  the  pelvic  variety  alone, 
taking,  as  an  example,  the  first  or  left  cephalo-iliac  position  of  the  right  shoulder, 
in  which  the  child's  head  is  placed  in  the  left  iliac  fossa,  the  breech  in  the  right 
iliac  fossa ;  the  dorsal  plane  being  in  front,  and  the  sternal  one  behind,  and  the 
long  axis  situated  very  nearly  in  the  direction  of  the  transverse  diameter  of  the 
upper  strait. 

Under  such  circumstances  nearly  all  the  waters  escape  immediately  after  the 
membranes  are  ruptured ;  then  the  uterus  contracts  forcibly,  and,  by  compressing 
the  foetal  trunk  on  all  sides,  has  a  tendency  to  make  the  presenting  part  engage 
in  the  excavation. 

A.  Under  the  influence  of  the  uterine  contractions,  the  child  is  strongly  bent 
in  the  direction  of  its  long  axis  towards  the  side  opposite  to  the  presenting  one; 
for  instance,  in  the  case  before  us,  the  head  is  bent  to  the  left  side,  and  the 
breech  towards  the  hip  of  the  same  side ;  whence  we  might  designate  this  first 
modification  effected  in  the  situation  of  the  child  as  the  movement  of  lateral 
flexion. 

'  It  is  proper  for  me  to  acknowledge,  that  Wigand  had  already  given  a  similar  explanation. 


464 


LABOR. 


B.  A  second  stage,  the  period  of  descent,  then  sets  in ;  that  is  to  say,  in  pro- 
portion as  the  contractions  are  renewed,  the  shoulder  approaches  more  and  more 
towards  the  inferior  strait,  and  the  foetal  trunk  being  bent  double,  engages  deeply 


Fig.  77. 


Fig.  78. 


First  position  of  the  right  shoulder  with 
the  arm  hanging  down. 


The  same  position  during  the  descent. 


in  the  excavation.  But  the  same  difficulty  is  here  met  with  as  in  the  face  pre- 
sentations (see  Positions  of  the  Face) ;  that  is,  the  body  being  thus  placed  trans- 
versely, it  is  impossible  for  the  shoulder  to  reach  the  lower  strait  unless  the  head 
engages  simultaneously  with  it  in  the  excavation ;  or,  indeed,  unless  the  neck 
should  be  long  enough  to  subtend  the  height  of  the  lateral  wall  of  the  latter, 
which  we  have  already  seen  is  impossible  (see  Mechanism  of  Face  Positions). 
The  descent  of  the  shoulder  is  therefore  limited  to  the  length  of  the  neck. 

c.  A  movement  of  rotation  next  occurs,  by  which  the  long  axis  of  the  child, 
that  was  originally  placed  transversely,  is  brought  very  nearly  into  an  antero- 
posterior direction,  so  that  its  cephalic  extremity  is  placed  above  the  horizontal 
branch  of  the  pubis  close  to  the  spine  of  that  bone,  and  the  breech  above,  or 
rather  in  front  of  the  sacro-iliac  symphysis.  This  process  of  rotation  being  once 
effected,  the  descent  may  now  be  completed,  since  the  side  of  the  neck  is  placed 
behind  the  symphysis  pubis,  whose  whole  length  it  can  subtend ;  consequently, 
the  forearm  and  arm  are  found  to  appear  at  the  vulva,  and  the  shoulder  to  get 
under  the  arch  of  the  pubis. 

D.  The  trunk,  being  now  bent  double,  is  forced  en  masse  into  the  excavation, 
under  the  influence  of  the  powerful  uterine  contractions,  but  the  shoulder  can 
descend  no  further,  because  it  is  arrested  by  the  shortness  of  the  neck;  hence, 
the  expulsive  force  acts  on  the  pelvic  extremity,  which  is  pressed  more  and  more 
towards  the  floor  of  the  basin,  and  traverses  the  whole  anterior  face  of  the 
sacrum.  It  then  rests  against,  depresses,  and  forcibly  distends  the  perineum; 
the  vulva  soon  dilates,  and  the  acromion  remaining  always  fixed  under  the 
symphysis,  the  following  parts  are  observed  to  appear  successively  at  the  anterior 
perineal  commissure;  first,  the  superior  lateral  parts  of  the  chest;  next,  its  infe- 
rior part,  the  loins,  the  hip,  the  thighs,  and  lastly,  the  whole  length  of  the 


MECHANISM     OF    LABOR. 


465 


inferior  extremities ;  and  tliere  remain  only  the  head  and  the  left  shoulder  in 
the  excavation,  which  are  soon  after  extracted  or  expelled  without  difficulty. 
This  last  movement  may  be  considered  as  the  fourth  stage  of  the  labor,  and  it  is 


79. 


Fig.  80. 


Fig.  79.  Position  of  the  child  after  the  rotation,  and  just  at  the  moment  when  the  process  of  disengage- 
ment begins. 
Fig.  80.  The  same  position,  with  the  delivery  more  advanced. 

therefore  named  the  period  of  deflexion  or  disengagement.  It  takes  place  around 
the  shoulder,  situated  under  the  symphysis  as  a  centre,  and  therefore,  if  lines  be 
drawn  from  this  centre,  terminating  at  the  various  points  on  the  child's  side,  we 
shall  have  all  the  radii,  or  the  foetal  diameters,  which  clear  the  antero-posterior 
one  of  the  inferior  strait. 

Such  is  the  exact  mechanism  of  the  spontaneous  evolution  in  those  cases 
where  the  child's  posterior  plane  was  originally  in  front;  or  in  other  words,  in  a 
first  position  of  the  right  or  a  second  of  the  left  shoulder,  for  there  is  no  differ- 
ence in  this  last,  excepting  that  the  movement  of  rotation  must  take  place  in  the 
opposite  direction,  that  is,  the  head  must  pass  from  right  to  left  and  from  behind 
forward,  and  the  breech  from  left  to  right  and  from  before  backwards.  But 
when  the  sternal  plane  of  the  foetus  is  primitively  directed  towards  the  mother's 
front,  as  in  the  first  position  of  the  left,  and  the  second  one  of  the  right  shoul- 
der, the  process  takes  place  somewhat  differently.  M.  P.  Dubois,  who  had  an 
opportunity  of  seeing  two  cases  of  this  nature,  informed  me  that,  at  the  moment 
when  the  breech  disengaged  at  the  anterior  perineal  commissure,  the  child's 
whole  trunk  underwent  a  movement  of  torsion  that  again  brought  its  dorsal  plane 
forwards  and  upwards,  which  plane,  without  this  process  of  torsion,  would  still 
have  been  directed  towards  the  anus;  whence  we  find,  even  here,  remarkable  as 
it  may  seem,  the  influence  of  that  general  law  which  was  observed  to  regulate  all 
natural  labors,  namely,  that,  loliatever  may  have  been  the  original  relations  of  the 
child's  j^osterior  plane  J  it  ultimately  comes  into  coi'respondence  with  the  anterior 
parts  of  the  pelvis. 

As  observed  in  the  commencement  of  this  article,  the  mechanism  of  sponta- 

30 


466  LABOR. 

neous  evolution  may  be  subjected  without  impropriety  to  the  same  divisions  as 
the  delivery  by  the  face.  In  flict,  we  have  a  first  period  o^ flexion  of  the  child's 
trunk  towards  the  side  opposite  to  the  presenting  one;  a  second,  of  descent, 
interrupted  by  the  third  movement,  or  period  o^  rotation  ;  a  fourth,  o^  deflexion, 
or  disengagement,  and  even,  according  to  the  observations  of  M.  P.  Dubois,  we 
might  add,  for  the  dorso-posterior  positions  a  fifth,  the  period  of  external  rotation. 

§  4.  Prognosis. 

We  again  repeat,  for  it  seems  highly  important  that  this  should  be  firmly  im- 
pressed on  the  mind,  that  in  trunk  presentations  a  spontaneous  expulsion  of  the 
child  is  wholly  an  exception  to  the  general  rule,  and  one  upon  which  no  reliance 
can  be  placed,  unless  in  a  case  of  abortion ;  and  that  the  resources  of  our  art 
are  demanded  in  every  case  just  as  soon  as  the  necessary  conditions  exist  for  such 
intervention.     (See  Version.) 

In  fact,  by  consulting  the  published  cases,  or  indeed  by  simply  reflecting  on 
the  mechanism  by  which  the  delivery  is  effected,  we  realize  how  this  must  expose 
the  woman  to  a  very  long  and  painful  labor,  and  the  foetus  to  so  violent  a  com- 
pression that  its  death  must  often  result  in  consequence.  According  to  the 
statistics  furnished  by  M.  Velpeau,  one  hundred  and  twenty-five  children,  in  one 
hundred  and  thirty-seven  were  stillborn.  It  must  not  be  supposed,  however,  as 
some  persons  appear  to  have  done,  that  this  mode  of  delivery  is  only  possible  in 
cases  of  abortion ;  for  facts  too  numerous  militate  against  this  opinion  for  it  to  be 
any  longer  tenable. 

Burns  justly  remarks,  in  endeavoring  to  demonstrate  the  physical  possibility, 
that  the  greatest  diameter  measures  five  inches  and  a  half;  sometimes  the  dis- 
stance  is  barely  five  inches,  and  continued  force  may  make  it  less ;  hence,  pro- 
vided the  dimensions  of  the  pelvis  are  slightly  greater  than  in  their  normal 
condition,  there  is  nothing  here  physically  impossible,  as  has  been  aflBrmed  and 
reafl&rmed,  doubtless  without  mature  reflection.  The  favoring  circumstances 
which  render  a  spontaneous  evolution  easier  and  more  likely  to  take  place  are :  a 
premature  labor,  the  smallness  of  the  child,  a  large  pelvis,  strong  contractions, 
diminished  resistance  from  the  soft  parts,  numerous  antecedent  labors,  and  the 
readiness  with  which  the  woman  has  heretofore  been  delivered  of  large-sized 
children.  The  opposite  circumstances  would  render  it  exceedingly  difficult,  if 
not  wholly  impossible. 


ATTENTIONS    TO    THE    WOMAN.  467 


CHAPTER   IV. 

OF   THE   NECESSARY   ATTENTIONS   TO   THE   WOMAN    DURING   AND 
AFTER   LABOR. 

ARTICLE   I. 

OF  THE  ATTENTIONS  DURING  LABOR. 

When  the  accoucheur  is  summoned  to  a  woman  in  labor,  he  should  always 
provide  himself  with  lancets,  a  female  catheter,  and  the  forceps;  and,  if  in  the 
country,  he  should  have  besides  some  ergot,  either  in  grain  or  else  freshly  pow- 
dered, and  one  or  two  drachms  of  Sydenham's  laudanum.  His  arrival  ought 
always  to  be  announced  before  entering  the  patient's  chamber,  for  the  emotion 
caused  by  a  sudden  entrance  often  proves  sufficient  to  suspend  the  pains  for  a 
considerable  time.  Then,  after  having  made  the  usual  inquiries  as  to  the  time 
at  which  the  pains  began,  their  frequency,  their  duration  and  intensity,  he  might, 
if  he  supposes  from  this  account  the  labor  to  be  somewhat  advanced,  proceed  at 
once  to  the  vaginal  exploration ;  in  the  contrary  case,  he  may  wait  a  few  minutes 
as  well  to  satisfy  himself  of  the  value  of  the  communications  made  by  the  atten- 
dants, as  to  give  the  woman  time  to  prepare  for  the  examination.  When  he 
finally  judges  this  is  necessary,  he  is  to  proceed  with  all  possible  decency,  and 
always  during  the  interval  between  the  pains.  The  object  of  this  is  to  endeavor 
to  ascertain  :  1,  whether  the  woman  is  pregnant;  2,  if  she  is  in  labor;  3,  if  she 
is  at  full  term ;  4,  whether  the  membranes  are  ruptured  ;  5,  whether  the  labor 
is  for  advanced ;  6,  what  is  the  condition  of  the  cervix,  vagina,  and  perineum,  and 
their  degree  of  suppleness  or  resistance;  7,  what  is  the  conformation  of  the 
pelvis ;  8,  lastly,  what  part  of  the  child  presents. 

At  first  sight,  it  may  seem  a  ridiculous  precaution  to  attempt  to  verify  the 
existence  of  the  pregnancy  in  a  woman  who  declares  she  is  actually  suffering 
from  the  pains  of  childbirth ;  but,  to  say  the  least,  this  is  not  altogether  useless, 
since  it  has  unfortunately  happened  that  some  over-confident  accoucheurs  have 
been  imposed  upon  by  women  who  were  themselves  deceived  as  to  the  nature  of 
the  pains  they  felt;  and  we  might  quote  many  instances  where,  after  having 
waited  for  the  delivery  to  take  place  for  several  days,  they  have  ultimately  been 
constrained  to  acknowledge  their  mistake.  Besides,  this  error  is  easily  avoided 
by  bearing  in  mind  the  diagnostic  signs  pointed  out  in  the  article  on  Pregnancy. 

After  observing  the  progress  of  the  pains  for  some  instants,  he  should  next 
endeavor  to  ascertain  their  cause  and  nature,  in  order  to  fjivor  those  which  have 
a  bearing  on  the  labor,  and  to  combat  any  that  are  foreign  thereto.  "Women  are 
not  unfrequently  tormented  by  pains  during  the  latter  stages  of  gestation,  which 
are  dependent  on  some  sympathetic  disorder  of  the  intestines,  or  abdominal 
organs,  and  which  even  a  physician  might  mistake  for  the  commencement  of 
labor;  these  have  been  denominated  the  false  pains,  by  way  of  distinguishing 


468  LABOR. 

them  from  those  produced  by  the  contraction  of  the  womb.  The  true  and  the 
false  pains  may  be  recognized  by  the  following  characters :  the  latter  are  ordi- 
narily seated  in  the  region  occupied  by  the  diseased  organ,  while  those  occasioned 
by  the  commencement  of  the  travail  usually  begin  about  the  umbilicus  and  loins, 
and  die  away  at  the  perineum,  the  anus,  or  the  sexual  parts ;  the  ftxlse  are  almost 
continuous,  and  their  intensity  is  nearly  uniform ;  the  others,  on  the  contrary, 
are  intermittent.  If  the  irregularity  in  the  return  and  progression  of  the  pains 
be  such  as  to  leave  any  doubt  as  to  their  character,  he  should  interrogate  the 
neighboring  organs,  and  by  a  little  attention  he  will  succeed  in  determining  their 
seat  and  nature.  There  are,  however,  certain  pains  which  have  their  seat  in  the 
uterus  itself,  affect  a  certain  degree  of  regularity,  and  simulate  a  true  labor, 
which  are  dependent  on  a  plethoric  condition  of  the  organ,  that  may  be  calmed 
by  rest,  a  resti'icted  diet,  and  bloodletting.  Further,  the  epoch  at  which  they 
occur,  and  the  absence  of  the  other  phenomena  of  labor,  will  serve  to  lessen  the 
difficulties  in  determining  the  diagnosis ;  nevertheless,  it  is  the  touch  alone  that 
can  dispel  all  doubts ;  for  the  hardness  that  comes  on  in  the  uterine  globe,  the 
rigidity  in  the  circumference  of  the  os  uteri,  the  tension  and  protrusion  of  the 
membranes  during  the  pain  itself,  together  with  the  retreat  and  relaxation  of  all 
these  parts  in  proportion  as  it  diminishes,  characterize  the  pains  of  childbirth  in 
an  infallible  manner. 

"By  examining,"  says  Wigand,  "the  course  of  the  true  contractions,  it  will 
be  found  that  they  commence  at  the  cervix,  and  pass  to  the  fibres  of  the  fundus, 
which  are  then  thrown  into  action;  and  hence  all  contractions  that  begin  in  this 
latter  part  of  the  womb  are  anomalous,  and  result  either  from  some  disorder 
having  occurred  in  the  uterine  forces,  or  else  they  are  produced  by  an  inflamma- 
tion, or  a  disturbance  in  the  functions  of  a  neighboring  organ."  When  the  true 
pain  is  manifested,  the  head,, which  reposed  during  the  interval  on  the  cervix, 
sometimes  mounts  up  even  beyond  the  reach  of  the  finger,  but  the  membranes 
enca^'c  more  or  less  in  the  orifice.  In  the  course  of  a  few  seconds,  the  contrac- 
tion extends  all  over  the  uterus,  and  more  particularly  to  the  fibres  of  the  fundus ; 
and  the  head,  which  was  at  first  elevated,  is  forcibly  pressed  down  on  the  neck, 
thus  assuming  the  office  of  a  wedge  for  hastening  its  dilatation ;  and,  as  a  general 
rule,  it  is  only  when  the  fundus  contracts  in  this  manner,  that  the  woman  com- 
plains of  pain.  We  may,  therefore,  consider  the  true  pain  as  constituted  of  a 
series  of  phenomena,  which  succeed  each  other  in  the  following  order :  first,  the 
periphery  of  the  cervix  becomes  tense ;  then,  the  presenting  part  ascends,  and 
the  membranes  bulge  out;  next,  the  remainder  of  the  uterus,  the  fundus  espe- 
cially, becomes  hard,  during  which  the  patient  complains  of  a  sharp  pain ;  and, 
lastly,  the  part  that  presented  endeavors  anew  to  engage.  It  is  unnecessary  to 
add,  that  the  rapidity  with  which  these  phenomena  succeed  each  other,  neces- 
sarily varies  according  to  the  individual,  to  the  irregularities  to  which  the  process 
is  subject  (which  we  shall  hereafter  study),  and  according  to  the  stage  of  the 
labor.  Other  things  being  equal,  the  contractions  will  efi'ect  the  dilatation  so 
much  the  sooner,  in  proportion  as  the  cervix  shall  correspond  more  directly  to  the 


ATTENTIONS    TO    THE    WOMAN.  469" 

fundus  of  the  organ,  and  the  uterine  axis  shall  be  the  more  parallel  to  that  of 
the  pelvis. 

After  having  learned  the  true  character  of  the  pains,  the  accoucheur  next  en- 
deavors to  ascertain  ■whether  the  woman  is  really  at  term,  so  as  not  to  encourage 
a  premature  labor,  which  might  often  be  prevented  if  he  knew  its  cause.  He 
ought,  therefore,  to  recall  the  various  signs,  by  means  of  which  we  have  attempted 
to  characterize  the  different  periods  of  pregnancy.  Thus,  should  he  find  that 
the  cervix  is  not  yet  entirely  effaced,  that  it  still  retains  a  certain  degree  of 
length,  that  it  is  hard  and  resistant  even  during  the  interval  of  the  contractions; 
that  the  latter  are  much  less  regular  in  their  course,  duration,  and  return,  than 
in  parturition  at  full  term;  and  the  belly  not  yet  sunk  down;  he  may  justly 
conclude  that  the  patient  has  not  yet  reached  the  end  of  the  ninth  month;  also, 
that  such  a  premature  labor  is  owing  either  to  some  acute  moral  emotion,  or  some 
antecedent  external  violence.  In  all  cases,  he  ought  to  attempt  the  arrest  of  this 
premature  or  false  labor,  by  rest,  both  of  body  and  mind,  by  venesection,  if  the 
woman's  general  condition  will  admit  of  it,  and,  more  especially,  by  the  adminis- 
tration of  laudanum  in  full  doses,  taking  care  to  empty  the  bladder  when  neces- 
sary, and  to  keep  the  bowels  free  by  mild  laxatives. 

However,  there  is  one  phenomenon,  sometimes  manifested  in  the  latter  weeks 
of  gestation,  which  may  place  the  most  skilful  practitioners  at  fault.  I  allude 
to  what  has  been  designated  as  the  false  labor,  in  which  certain  women,  after 
having  nearly  reached  their  full  term,  experience  the  true  contractions;  the  pains 
are  regular,  the  membranes  bulge  out,  and  the  os  uteri  dilates;  at  times,  these 
pains  last  from  four  to  six  hours,  but  then  they  disappear  all  at  once,  and  every- 
thing goes  on  as  usual.  In  others,  the  false  labor  is  kept  up  at  first  during 
several  hours,  and  then  it  passes  off,  returning  in  this  manner  every  day,  parti- 
cularly towards  the  evening,  and  lasting  one  or  two  weeks.  (See  Uterine  Rheu- 
matism.) 

Where  he  is  very  sure  that  the  woman  is  really  in  labor,  his  attention  must  be 
directed  to  the  frequency  and  the  intensity  of  the  pains,  and  to  the  dilatation, 
the  hardness,  and  thinness  of  the  cervix,  in  order  to  judge  of  its  probable  dura- 
tion. During  the  same  exploration,  he  should  ascertain  the  conformation  of  the 
pelvis,  particularly  if  the  woman  happens  to  be  in  her  first  confinement,  and  if 
any  apparent  deformities  exist;  he  should  also  learn  the  situation  of  the  orifice, 
the  obliquity  of  the  body  and  neck  of  the  womb,  and  the  child's  presenting  part. 
(See  Mechanism  of  Labor.)  If  this  latter  is  so  high  up  as  to  render  the  diag- 
nosis of  the  presentation  difiicult,  its  examination  should  be  deferred  until  a  more 
advanced  period  of  the  labor ;  but  the  bag  of  waters  is  never  to  be  ruptured,  in 
any  case,  for  the  mere  purpose  of  rendering  this  examination  more  easy,  before 
the  entire  dilatation  of  the  neck;  for  such  an  untimely  rupture  of  the  membranes 
would  be  attended  by  very  great  inconveniences,  if  the  position  were  at  all  defec- 
tive ;  for,  all- the  waters  escaping,  the  foetus  might  suffer  from  the  pressure  exer- 
cised directly  upon  it  by  the  uterine  walls ;  the  umbilical  cord  would  be  com- 
pressed ;  and  the  womb,  irritated  by  the  prolonged  contact  of  the  foetal  inequalities, 
might  be  affected  with  spasmodic  contractions ;  and,  finally,  the  intervention  of 


470  LABOR. 

art  becoming  necessary,  long  after  the  evacuation  of  the  waters,  the  necessary 
manipulations  would  be  attended  with  much  greater  diflSeulties. 

The  accoucheur  should  next  ascertain  whether  the  child  is  living  or  dead,  as 
it  is  highly  important  to  determine  this  point,  in  order  to  diminish  his  own  re- 
sponsibility, by  advising  the  family  of  the  fact. 

Before  the  membranes  are  ruptured,  the  diagnosis  may  be  easily  made  out  by 
ascertaining  through  auscultation  the  existence  or  absence  of  the  pulsations  of  the 
foetal  heart,  as  also  the  continuance  or  complete  cessation  of  the  active  move- 
ments, in  regard  to  which,  the  woman  can  always  give  sufficiently  accurate  infor- 
mation. After  the  rupture  of  the  membranes,  the  active  movements  are  feeble, 
and  sometimes  entirely  absent;  in  which  case,  however,  the  pulsations  are  still 
detected  by  auscultation. 

The  touch  also  reveals  certain  signs  which  may  shed  still  further  light  upon 
the  question.  Thus,  when  the  child  is  alive  and  the  head  presenting,  it  often 
becomes  affected  with  a  sanguineous  swelling,  the  size  of  which  depends  upon 
the  length  of  time  which  has  elapsed  since  the  discharge  of  the  waters.  This 
tumor  does  not  form  when  the  child  has  ceased  to  live ;  and  if  its  death  dates 
back  for  several  days,  the  resisting  tumor  formed  by  the  sero-sanguineous  infil- 
tration will  be  replaced  by  a  soft,  flaccid,  and  wrinkled  condition  of  the  hairy 
scalp.  Beside  this,  the  bones  of  the  cranium  will  be  more  movable,  and  the 
overriding  of  their  edges  greater  than  usual ;  a  sort  of  crepitation  is  also  pro- 
duced by  their  rubbing  against  each  other.  A  more  embarrassing  case  is  that 
in  which  the  child  dies  some  time  after  the  mpture  of  the  membranes,  but  not 
before  the  sanguineous  tumor  has  had  time  to  be  developed.  Even  here  the 
uncertainty  will  be  of  short  duration,  for,  provided  the  labor  should  continue 
beyond  three  or  four  hours,  the  tumor  would  lose  its  consistency,  and  its  softness 
and  flaccidity  render  a  mistake  a  matter  of  difficulty. 

Finally,  when  the  pelvis  is  rather  contracted,  the  wrinkling  of  the  scalp  may 
simulate  a  swelling,  whose  diagnostic  importance  it  is  well  to  appreciate.  In 
this  case,  says  ^lerriman,  the  best  means  of  judging  of  the  life  or  death  of  the 
child  by  the  tumor  of  the  scalp  is  as  follows :  when  living,  it  is  observed  that,  at 
the  moment  when  the  head  is  strongly  urged  down  by  the  contraction  of  the 
womb,  the  bones  overlap  each  other,  and,  as  a  consequence,  the  scalp  becomes 
folded,  and  thus  constitutes  a  temporary  tumor;  but  immediately  after  the  pain 
is  over,  the  head  regains  its  primitive  form,  by  the  expansion  of  the  cranial 
bones,  and  the  folds  and  tumefaction  previously  exhibited  by  the  skin  disappear, 
or,  at  least,  considerably  diminish.  On  the  contrary,  however,  if  it  be  dead,  the 
expansibility  of  the  bones  is  destroyed,  and  the  head  does  not  reassume  its  primi- 
tive form  and  volume  after  the  contraction  has  passed  off;  wherefore  the  tumor 
formed  by  the  doubling  of  the  hairy  scalp  still  persists,  in  a  great  measure. 
Now,  in  this  condition  of  affairs,  the  swelling  is  sometimes  greatly  augmented 
by  the  liquids  forced  in  by  the  pressure  from  above,  and  whenever,  in  such  case.?, 
a  perforation  of  the  cranium  has  to  be  resorted  to,  practitioners  well  know  there 
is  half  an  inch  at  least  of  soft  parts  to  be  traversed  before  reaching  the  bone. 
(Merriman's  Synoj)sis.) 


ATTENTIONS    TO    THE    WOMAN.  471 

If  tlie  face  should  present,  the  softness  of  the  lips,  and  the  flaccidity  and  im- 
mobility of  the  tongue,  should  lead  us  to  suspect  that  the  child  is  dead ;  since, 
when  living,  the  firmness  of  all  its  parts,  and  the  motions  of  the  tongue,  are  often 
felt  with  ease. 

In  breech  presentations,  the  introduction  of  the  finger  into  the  anus  will  detect 
a  resistance  and  contractile  power  on  the  part  of  the  sphincter  if  the  child  be 
living,  which  will  be  absent  if  the  child  be  dead. 

Lastly,  in  shoulder  and  arm  presentations,  the  swelling  of  the  member,  and  its 
violet  hue,  will  aiFord  an  indication  in  favor  of  its  life. 

Should  the  cord  hang  in  the  vagina,  its  softness,  withered  condition,  and  the 
absence  of  pulsation  in  the  umbilical  arteries,  would  justify  a  belief  that  the  child 
was  dead. 

A  thick  and  fetid  condition  of  the  amniotic  fluid,  and  a  discharge  of  meco- 
nium, have  been  regarded  as  indicating  the  death  of  the  child.  The  importance 
of  the  latter  sign  has  been  discussed  already.  The  altered  condition  of  the  waters 
is  of  no  great  importance,  since  it  has  sometimes  been  found  to  coincide  with 
perfect  integrity  of  the  foetal  life. 

Of  all  these  signs,  the  best,  doubtless,  is  that  furnished  by  the  auscultation  of 
the  pulsations  of  the  heart,  which  are  always  perceptible  when  the  foetus  is  living. 
It  may  indeed  happen  that  the  pulsations  of  the  cord  are  imperceptible,  without 
our  being  able  to  conclude  therefrom  that  the  child  has  ceased  to  live.  It  some- 
times happens  that  they  stop  during  the  pain,  only  to  reappear  again  in  the 
interval  of  the  contractions.  Consequently,  to  render  the  diagnosis  more  certain, 
the  cessation  in  the  pulsation  should  last  for  some  time,  at  least  for  ten  or  fifteen 
minutes. 

But  it  is  not  always  so  easy  a  matter  as  one  might  imagine  to  ascertain 
whether  the  membranes  are  ruptured  or  are  still  intact;  for  instance,  where  the 
vaginal  examination  is  resorted  to  between  the  pains,  in  a  vertex  presentation, 
they  are  often  applied  so  directly  to  the  scalp  that  it  is  impossible  to  distinguish 
them.  A  pain  should  then  be  waited  for,  because,  as  soon  as  the  uterus  con- 
tracts, it  drives  the  waters  towards  the  lower  parts,  and  the  finger  is  observed  to 
be  raised  up  by  a  small  quantity  of  this  fluid  that  insinuates  itself  between  the 
head  and  the  amniotic  sac,  the  integrity  of  which  latter  is  thereby  easily  verified; 
but  where  the  head  is  more  deeply  engaged,  this  aflJux  of  liquid  is  very  incon- 
siderable, and  the  tension  of  the  membranes  can  scarcely  be  distinguished.  Con- 
sequently, attention  should  be  given  to  the  state 'of  the  tumor  both  during  and 
after  the  contraction.  Where  the  waters  have  escaped,  and  the  finger  comes 
directly  upon  the  child's  cranium,  it  will  detect  the  hairy  scalp  puckering  up, 
while  the  pain  lasts,  and  becoming  smooth  and  even  as  soon  as  it  shall  have 
ceased ;  though  the  contrary  will  take  place  when  the  membranes  are  intact,  for 
they  are  never  more  smooth  or  more  tense  than  during  the  contraction  itself. 

It  is  diflicult  a!t  times  to  reach  the  cervix  uteri  in  the  commencement  of  the 
labor,  because  it  is  then  carried  so  far  backwards,  that  the  plane  of  its  orifice 
actually  looks,  towards  the  anterior  face  of  the  sacrum.  I  have  often  seen  young- 
practitioners  who  were  unable  to  get  at  it  at  all,  and  others,  who,  not  finding  the 


472  LABOR. 

OS  uteri,  and  distinctly  feeling  the  child's  head  through  the  anterior  inferior  part 
of  the  womb,  which  is  then  rendered  very  thin  by  the  distension  it  has  under- 
gone, have  imagined  that  the  dilatation  was  already  completed,  whereas  it  had 
hardly  commenced ;  the  disastrous  consequences  to  which  such  an  error  might 
lead,  can  be  readily  imagined.  In  fact,  it  is  very  often  necessary  to  pass  the 
finger  around  the  convex  tumor  which  fills  the  excavation,  in  order  to  get  the  index 
far  enough  upwards  and  backwards,  where  the  uterine  orifice  is  to  be  found. 

All  these  questions  being  determined,  the  accoucheur's  attention  should  be 
directed  early  in  the  progress  of  the  confinement  to  having  the  woman  moved 
into  the  most  suitable  place.  The  chamber  intended  for  her  lying-in  should  be 
spacious,  airy,  well-lighted,  and  retired ;  the  air  she  respires  ought  to  be  pure 
and  of  a  moderate  temperature,  and  all  strong  odors,  whether  good  or  bad,  should 
be  excluded.  A  temperature  too  elevated  will  predispose  her  to  nervous  agita- 
tion, and  to  hemorrhagic  accidents ;  and,  on  the  other  hand,  the  impression  of 
cold  is  a  very  frequent  cause  of  acute  inflammation,  or  of  chronic  engorgements, 
such  as  those  that  often  come  on  after  delivery,  which  have  for  so  long  a  time 
been  attributed  to  lacteal  metastases.  But  few  persons  are  to  be  admitted  in  the 
chamber,  and  all  those,  especially,  whose  presence  is  at  all  unpleasant  to  her, 
ought  to  be  rigidly  excluded.  This  latter  point  demands  the  greatest  care  on 
the  part  of  the  physician,  for  it  is  he  alone  who  has  authority  thus  to  dismiss 
such  as  he  may  think  useless  or  injurious,  and  he  must  judge,  from  the  reception 
given  to  each,  of  the  pleasure  or  .otherwise  the  patient  experiences  from  their 
presence.  Some  women  are  almost  ashamed  of  being  delivered  in  the  presence 
of  the  husband ;  with  others,  on  the  contrary,  it  is  one  of  the  greatest  consola- 
tions to  have  him  near  them,  and  the  accoucheur  must  endeavor  to  discover  all 
these  little  shades  of  delicacy  and  feeling,  to  sound,  by  discreet  and  artful  ques- 
tions, a  wish  that  the  woman  herself  at  times  fears  to  express,  and,  after  having 
once  learned  it,  he  should  religiously  comply  with  it.  As  a  general  rule,  the 
mother  and  sister,  or  two  intimate  friends  of  the  patient,  besides  the  nurse,  are 
the  only  ones  that  are  to  be  allowed  to  stay  in  the  room.  With  regard  to  dress, 
her  garments  should  be  full,  sufficiently  so,  as  neither  to  incommode  her  move- 
ments nor  her  respiration. 

If  some  time  has  elapsed  since  she  has  had  a  passage  from  the  bowels,  a  simple 
injection  must  be  given;  and  where  this  does  not  prove  sufficient  to  procure  a 
stool,  a  second  is  to  be  immediately  administered  with  the  addition  of  one  or 
two  ounces  of  the  mlel  mercuricde.^  The  evacuation  of  the  matters  contained 
in  the  rectum  is  the  more  necessary,  as  its  distension  might  subsequently  retard 
the  escape  of  the  head,  and  likewise  pi-event  that  of  the  intestinal  gases,  whose 
accumulation  might  bring  on  colic  and  gripings;  besides,  this  precaution  has 
the  advantage  of  sparing  the  woman  the  shame  and  disgust  which  an  invo- 
luntary expulsion  of  the  feces  during  the  last  moments  of  labor  would  necessarily 
cause,  as  also  of  preventing  the  accoucheur's  hand  from  being  soiled,  while  it 

'  This  preparation  is  only  used  as  an  injection  ;  it  is  prepared  by  taking  equal  parts  of 
clarified  honey  and  the  juice  of  the  mercurialis  annua,  a  plant  belonging  to  the  tribe  of  tho 
Kiiphorbiaceoe,  and  reducing  them  to  the  consistence  of  a  syrup. — Translator. 


ATTENTIONS    TO    THE    WOMAN.  473 

Bupports  the  perineum.     Her  bladder  likewise  requires  attention,  and  the  catheter 
should  be  resorted  to  when  the  emission  of  urine  does  not  take  place. 

He  should  also  attend  early  to  having  everything  prepared  that  may  be  wanted 
somewhat  later;  thus,  the  thread  intended  for  the  ligature  of  the  cord  is  to  be 
laid  out,  and  the  bands  and  linen  for  covering  the  child's  navel  are  to  be  cut; 
for  the  mother,  he  ought  to  procure  some  cold  iced  water,  vinegars,  and  smelling 
salts,  agents  that  will  probably  be  unnecessary,  but  which,  notwithstanding,  he 
ought  always  to  have  at  hand ;  and  lastly,  he  must  direct  the  preparation  of  the 
bed  upon  which  the  woman  is  to  be  delivered.  This  bed  (called  the  lying-in 
bed,  the  bed  of  misery,  or  the  little  bed)  is  arranged  in  the  following  manner : 
one  with  a  sacking-bottom  is  procured,  of  a  moderate  height,  and  about  two  feet 
to  two  and  a  half  in  width,  and  one  end  of  it  is  placed  against  the  wall,  being 
careful  to  keep  it  clear  on  both  sides,  so  that  one  can  pass  freely  all  around  it. 
A  first  mattress  is  placed  on  the  bottom,  and  upon  this  a  second,  which  covers  its 
upper  part,  and  is  folded  double  towards  its  superior  third,  in  such  a  way  as  to 
leave  the  first  one  uncovered  about  the  foot.  An  oil  cloth,  then  a  sheet,  some 
pillows,  and  a  coverlet,  complete  the  furniture  of  the  bed.  A  solid  bar  is  placed 
transversely  across  the  foot  of  the  bed,  so  as  to  give  the  woman's  feet  a  solid 
point  of  resistance  in  the  last  moments  of  labor.  In  France,  the  patient  is 
so  placed  that  the  upper  part  of  her  back  rests  on  the  inclined  plane  formed 
by  the  second  mattress,  and  her  breech  at  the  margin  of  the  same  mattress ; 
the  inferior  extremities  are  slightly  flexed,  and  the  feet  press  against  the  trans- 
verse bar  placed  at  the  foot  of  the  bed.  In  England,  women  are  delivered  on 
the  edge  of  their  beds ;  they  lie  on  the  left  side,  having  their  legs  and  thighs 
flexed,  and  their  knees  separated  by  pillows.  In  Germany,  the  lying-in  chair 
of  the  ancients  is  used ;  the  patient  is  placed  on  an  inclined  plane,  which  can 
be  modified  at  will,  by  lowering  or  raising  the  back,  by  means  of  a  rack ;  the 
woman  then  draws  on  the  arms  of  the  chair,  and  presses  her  feet  against  the 
rounds  with  which  it  is  supplied,  and,  as  she  gives  way  to  the  throes  of  labor, 
the  sexual  parts  are  uncovered,  and  correspond  to  the  opening  made  in  the  edge 
of  the  seat.  But,  on  the  whole,  the  bed,  furnished  as  we  have  described,  ap- 
pears preferable,  the  more  so,  because  it  is  always  at  hand;  and,  as  suggested  by 
Desormeaux,  it  is  particularly  suitable  where  the  woman  must  remain  recumbent 
during  the  whole  progress  of  labor,  as  is  necessary  whenever  she  is  affected  with 
hernia,  or  is  threatened  with  hemorrhage,  prolapsus,  or  a  displacement  of  the 
womb.  In  case  of  necessity,  its  place  might  be  supplied  by  a  table  and  a  few 
chairs  placed  against  the  wall.  It  would  be  much  better,  say  Desormeaux  and 
M.  P.  Dubois,  where  the  family  arc  in  easy  circumstances,  to  make  use  of  an 
ordinary  bed,  taking  care,  however,  to  supply  it  with  a  rather  hard  mattress,  and 
a  hard  cushion  near  the  buttocks,  to  prevent  the  pelvic  region  from  sinking 
down  into  the  substance  of  the  mattress,  and  the  borders  of  the  hole  thereby 
produced,  from  forming  an  obstacle  to  the  extension  of  the  coccyx,  or  the  escape 
of  the  child's  head.  On  this  bed,  the  woman  is  more  at  ease;  she  can  lie  on 
her  side,  or  take  the  most  convenient  attitudes,  and  even  sleep  during  the  inter- 
vals of  the  pains ;  and  then,  after  the  delivery,  she  may  remain  there  some  time 
before  being  transported  to  another. 


474  LABOR. 

Ouglit  the  accoucheur  to  remain  constantly  with  the  patient  ?  This  is  a  ques- 
tion whose  solution  varies  according  to  the  character  of  the  female  herself,  and 
the  greater  or  less  intimacy  existing  between  her  and  her  physician,  for  there  are 
some  timid  women  who  desire  to  have  him  always  close  at  hand,  and  others  again, 
who  are  impatient  and  annoyed  by  his  continual  presence.  But  in  all  cases,  he 
should  bear  in  mind  that,  during  parturition,  the  patient  very  often  wishes  to 
urinate  or  to  empty  her  bowels,  and  he  ought,  therefore,  to  go  from  time  to  time 
into  an  adjoining  chamber,  in  order  to  give  her  the  desired  opportunity.  Again, 
during  the  labor,  a  wife  is  frequently  cheered  up  by  the  caresses  and  consola- 
tions bestowed  by  her  husband ;  the  physician  will  understand  that  his  presence 
at  such  times  must  act  as  a  restraint,  and  he  should  discreetly  withdraw,  or,  at 
least,  not  observe  what  is  going  on.  Further,  he  may  absent  himself  more 
frequently  during  the  period  of  the  dilatation ;  for  instance,  after  having  made 
the  examination,  and  ascertained  that  the  child's  presentation  and  position  are 
both  favorable,  he  might,  if  the  cervix  was  just  beginning  to  dilate,  attend  to  his 
Other  occupations,  and  return  again  in  the  course  of  a  couple  of  hours ;  but  if 
the  diagnosis  of  the  position  had  been  impossible,  or  if  the  latter  had  proved  to  be 
an  unfavorable  one,  he  must  not  quit  her  under  any  pretext,  in  order  to  be  always 
ready  to  ward  off  any  accidents  which  might  subsequently  demand  his  interven- 
tion. When  the  stage  of  expulsion  commences,  the  accoucheur  places  himself 
at  the  right  of  the  bed,  on  a  chair  of  a  suitable  height.  The  part  he  has  to  per- 
form consists,  in  a  natural  labor,  in  ascertaining  its  progress,  from  time  to  time, 
by  the  touch,  in  directing  properly  the  bearing-down  efforts  of  the  patient,  and 
in  sustaining  the  perineum  with  his  hand  while  the  child's  head  is  passing 
through  the  vulva. 

During  the  first  stage,  the  woman  may  lie  down,  sit  down,  or  walk  about,  at 
her  pleasure ;  indeed,  this  frequent  change  of  position  renders  the  slowness  and 
fatigues  of  childbirth  more  supportable;  but,  at  the  end  of  this  stage,  when  the 
dilatation  is  completed,  and  the  amniotic  sac  projects  strongly  and  is  on  the  point 
of  yielding,  she  must  then  resume  her  bed ;  and  this  precaution  is  particularly 
indispensable  in  those  who  have  already  borne  several  children;  because,  in  them, 
the  expulsion  of  the  foetus  sometimes  follows  so  promptly  after  the  rupture  of  the 
membranes,  that  the  patient  has  not  always  the  time  to  regain  her  bed,  and  is 
liable  to  be  delivered  standing.  But  when,  after  the  rupture,  the  progress  of  the 
labor  is  slow,  and  the  head  is  more  or  less  engaged  in  the  excavation,  or  has 
already  descended  as  low  as  the  perineum,  but  does  not  advance,  and  the  pains 
seem  to  become  more  and  more  feeble  and  distant,  it  is  advisable  to  recommend 
her  to  get  up  and  walk  about,  having  her  supported  by  assistants,  if  her  own 
strength  does  not  permit  her  to  walk  alone,  for  it  is  found  by  experience  that 
bodily  motion  seems  to  give  more  activity  to  the  uterine  contractions.  In  the 
contrary  case,  she  must  not  leave  the  bed  without  some  special  indication. 
Where  the  patient  is  tormented  by  pains  in  the  loins,  we  may  relieve  them  by 
stretching  a  folded  napkin  under  the  small  of  the  back,  and  directing  two  per- 
sons placed  at  the  opposite  sides  of  the  bed  to  pull  on  the  extremities  of  the 
towel  during  the  pain.     Attempts  should  also  be  made  to  assuage  the  cramps,  so 


ATTENTIONS    TO    THE    WOMAN.  475 

often  experienced  in  the  thighs  and  calves  of  the  legs,  by  frictions  over  the  suf- 
fering parts. 

Some  nervous  women  are  troubled  with  tremblings  and  chills,  in  the  very  com- 
mencement of  their  labor,  which  are  at  times  sufficiently  marked  to  cause  much 
disquietude.  Dewees  observed  that  they  often  coincide  with  an  unusual  rapidity 
in  the  dilatation  of  the  cervix,  and  he  says,  "  A  lady,  who  every  moment  expected 
her  labor  to  commence,  was  awakened  suddenly  in  the  night  by  a  violent  chill. 
The  nurse  became  alarmed,  and  I  was  immediately  sent  for.  When  I  arrived,  I 
found  her  still  trembling  very  severely,  but  she  had  not  experienced  any  symptom 
of  labor;  she  assured  me  that  nothing  was  the  matter  with  her,  except  what  I  was 
witnessing,  namely,  an  agitation  of  the  whole  body,  which  she  could  not,  by  any 
effort,  control.  In  about  five  minutes,  she  cried  out  she  believed  her  labor  was 
coming  on ;  and  this  really  was  the  case,  and  so  rapidly,  as  not  to  give  me  time 
to  place  her  in  a  proper  situation  for  delivery;  she  was  delivered  in  less  than  five 
minutes  from  the  time  she  first  called  my  attention  to  her."  These  shiverings 
are  sometimes  renewed  during  or  immediately  after  the  labor;  but,  in  no  case/ 
do  they  merit  a  serious  attention. 

Patients  are  often  frightened  at  the  time  the  bag  of  waters  is  torn,  and  it  is, 
therefore,  a  good  plan  to  advise  them  of  it  beforehand;  and  the  precaution 
should  also  be  taken  of  placing  a  sponge  or  some  old  linen  near  the  genital  parts, 
so  as  to  receive  the  liquids  as  they  escape.  Immediately  after  the  discharge  of 
the  waters,  it  is  advisable  for  the  practitioner  to  assure  himself  anew  of  the  pre- 
sentation and  position,  lest  he  might  have  been  deceived  in  the  first  examination. 

The  rupture  of  the  membranes  generally  takes  place  spontaneously,  but  this  is 
not  always  the  case,  and  the  accoucheur  must  sometimes  interfere.  It  is  very 
certain  that,  when  the  uterine  orifice  is  entirely  dilated,  when  the  membranes  are 
forced  into  the  vagina  by  a  large  quantity  of  fluid,  and  the  head  is  movable,  but 
still  the  contractions  do  not  produce  a  spontaneous  rupture  of  the  membranes,  it 
is  evident,  we  repeat,  that  they,  by  their  resistance,  prolong  the  labor.  Although 
this  obstacle  is  never  insurmountable,  by  the  efibrts  of  nature  alone,  yet  the  delay 
in  the  delivery  and  the  dragging  on  the  membranes  may  be  attended  with  some 
inconveniences,  and  it  is,  therefore,  better  to  lacerate  them.  This  is  done  by 
taking  advantage  of  a  strong  contraction,  and,  while  they  are  greatly  distended, 
forcibly  pressing  the  index  finger  against  the  centre  of  the  tumor. 

When  this  rough  pressure  is  not  sufiicient,  we  scratch  the  membranes  with  the 
finger-nail ;  and,  by  gradually  weakening  the  three  tunics,  succeed  in  rupturing 
them.  Sometimes,  however,  they  still  resist,  and  then  some  instrument,  such  as 
a  blunt  probe,  or,  still  better,  the  end  of  a  quill  cut  down,  is  directed  up  to  them 
along  the  finger.  Where  the  waters  are  flat,  that  is,  when  but  little  liquid  inter- 
venes between  the  membranes  and  the  head,  some  care  is  requisite,  in  using  the 
little  instrument,  to  direct  it  obliquely,  so  as  not  to  wound  the  foetus  with  its 
point.  Rupturing  the  membranes  is,  therefoi-e,  a  trifling,  simple  operation ;  still, 
excepting  in  some  rather  rare  cases  to  be  spoken  of  hereafter,  it  ought  not  to  be 
performed  until  after  the  orifice  is  thoroughly  dilated.     Whatever  the  presenting 


476  LABOR. 

part  may  be,  there  is  always  an  advantage  in  retaining  a  large  amount  of  fluid  in 
the  uterus. 

Some  peculiar  circumstances  may,  however,  demand  the  artificial  rupture  before 
the  dilatation  is  completely  eflfected. 

In  a  case  reported  by  Baudelocque,  the  child  was  so  movable  that  it  succes- 
sively presented  every  part  of  the  surface  of  its  body  at  the  os  uteri.  In  a  woman 
whose  belly  was  distended  by  a  great  quantity  of  water,  M.  Martin,  of  Lyons, 
had  recognized  the  feet  and  one  hand  through  the  membranes.  '^  I  then  felt 
disposed,"  says  he,  "  to  terminate  the  labor,  when,  at  the  request  of  her  hus- 
band, I  called  a  friend  in  consultation ;  but,  on  touching  her  again,  before  his 
arrival,  I  detected  the  head  where  I  had  previously  found  the  feet  and  hand, 
when  I  immediately  punctured  the  membranes,  whereby  the  head  was  fixed  at 
the  superior  strait  and  the  delivery  rendered  natural."  (^Comptes  Rendus,  p. 
155.)  Should  a  case  of  this  nature  be  met  with,  the  rule  we  have  just  given 
might  be  laid  aside,  and  the  membranes  be  ruptured,  however  inconsiderable  the 
dilatation.  It  is  scarcely  necessary  to  add  that  an  artificial  rupture  is  only  to  be 
resorted  to  when  the  foetus  shall  be  detected  presenting  by  its  cephalic  extremity; 
for  then  the  discharge  of  a  certain  quantity  of  the  amniotic  liquid,  and  the  re- 
traction of  the  uterus,  will  irrevocably  fix  this  part  at  the  upper  strait. 

Again,  according  to  the  majority  of  writers,  the  membranes  may  be  lacerated 
before  the  entire  dilatation  of  the  cervix,  where  there  is  reason  to  suppose  that 
the  waters,  from  their  too  great  abundance,  distend  beyond  measure,  and  thus 
weaken  the  contraction  of  the  uterine  walls;  but,  even  here,  Gardien  recom- 
mends the  greatest  circumspection,  and  advises  the  previous  employment  of  all 
the  measures  calculated  to  stimulate  the  contraction  of  the  womb. 

Finally,  we  shall  learn  hereafter  that  the  puncture  of  the  ovum  at  an  early 
period  of  labor,  is  one  of  the  most  effectual  means  of  arresting  certain  dangerous 
hemorrhages  which  may  supervene  during  its  progress. 

The  finger  ought  to  be  introduced  into  the  vagina  several  times  in  the  course 
of  the  last  stage  of  the  labor,  both  during  the  pains  and  in  the  interval  between 
them,  to  ascertain  the  progress  of  the  head  in  the  excavation.  Nevertheless, 
this  exploration  is  to  be  resorted  to  as  rarely  as  possible,  and  only  when  the  in- 
terest of  the  mother  seems  to  demand  it. 

Most  women,  supposing  that  they  can  materially  hasten  the  termination  of  the 
labor  by  making  the  most  of  their  pains,  contract  their  muscles,  bear  down 
violently,  and  make  extraordinary  efforts  at  the  beginning;  but  these  uselessly 
exhaust  their  strength ;  for,  so  long  as  the  neck  is  ineffaced,  and  the  bag  of 
waters  unbroken,  all  bearing-down  eff"ort  is  fruitless.  But,  in  the  second  stage, 
where  the  head  descends  into  the  excavation  and  rests  on  the  perineum,  she 
should  be  encouraged  to  aid  the  uterine  forces  by  a  voluntary  contraction  of  the 
muscles  of  the  trunk  and  limbs ;  though,  as  soon  as  the  pain  has  passed  off,  all 
the  auxiliary  efforts  should  be  at  once  suspended.  Again,  in  the  latter  moments 
of  the  travail,  just  when  the  head  is  about  to  clear  the  vulva,  the  pains  are  so 
sharp  that  the  woman  naturally  gives  way  to  incredible  exertions,  which  may 
possibly  occasion  serious  accidents ;  hence  all  the  powers  of  persuasion  should 
then  be  employed  to  induce  her  to  moderate  her  strainings. 


ATTENTIONS    TO    THE    WOMAN.  477 

During  the  last  moments  of  cliildbirtli,  the  pressure  of  the  head  on  the  lower 
part  of  the  rectum  creates  an  urgent  desire  of  emptying  the  bowels ;  and  many 
•women,  yielding  to  a  misunderstood  modesty,  then  wish  to  rise  and  retire  to  the 
closet ;  but  it  would  be  exceedingly  imprudent  to  comply  with  their  demand, 
and  they  must  not  leave  the  bed  under  any  pretext  whatever.  In  the  first  place, 
this  desire  is  often  illusory,  more  especially  where  the  precaution  has  been  taken 
to  empty  the  intestine  at  the  commencement  of  labor;  and  then  it  may  happen, 
as  I  once  witnessed,  that  the  patient,  surprised  by  a  violent  pain,  is  delivered  on 
the  close-stool,  without  the  physician  being  able  in  any  way  to  render  her  the 
necessary  attentions. 

It  is  in  those  last  moments  that  the  accoucheur  must  give  all  his  attention  to 
supporting  the  perineum,  which  is  done  by  pressing  the  whole  perineal  surface 
equally,  and  with  a  moderate  degree  of  force,  by  the  palmar  face  of  the  hand. 
The  latter  is  applied  in  such  a  way  as  to  make  the  radial  border  of  the  index 
finger  cover  the  anterior  margin  of  the  perineum,  the  ends  of  the  fingers  corre- 
sponding to  the  left  side,  and  the  thenar  eminence  of  the  palm  to  the  right  side 
of  this  partition,  while  the  thumb  is  held  to  the  right  of  the  labia  externa.  The 
pressure  should  be  somewhat  greater  near  the  anus,  so  as  to  give  the  foetal  head 
a  forward  direction,  and  facilitate  its  movement  of  extension. 

ARTICLE   II. 

OF  THE  ATTENTIONS  TO  THE  CHILD  DURING  LABOR. 

Immediately  after  the  expulsion,  the  disengagement  of  the  head  is  completed, 
either  by  carrying  it  more  and  more  towards  the  pubis,  or  by  insinuating  the 
index  upon  one  side  of  the  lower  jaw ;  this  being  accomplished,  we  must  next 
ascertain  whether  the  cord  does  not  make  one  or  more  turns  around  the  neck, 
and  if  so,  gentle  tractions  must  be  made  on  its  placental  extremity,  to  avoid  its 
being  dragged  upon,  and  to  prevent  strangulation  of  the  foetus,  &c. ;  and  when  a 
sufficient  extent  of  it  cannot  be  brought  out,  to  render  the  prevention  of  such 
accidents  certain,  we  have  to  cut  it,  and  terminate  the  labor  as  promptly  as  pos- 
sible, by  hooking  one  or  the  other  shoulder  with  the  forefinger.'  After  the  head 
is  born,  the  womb,  exhausted  by  its  last  efforts,  remains  passive  for  some  instants, 
and  it  frequently  happens  that  the  child  begins  to  respire  and  cry,  even  before 
the  delivery  of  the  chest.  "We  may,  therefore,  wait  patiently  until  the  contrac- 
tion is  renewed,  simply  supporting  the  head,  lest  the  mouth  and  nose  be  choked 
up  by  the  cloths  or  blood  found  between  the  woman's  thighs ;  but  if  the  atony  is 
prolonged,  and  more  especially  if  the  face  of  the  new-born  infant  is  observed  to 
be  red  and  tumefied,  as  sometimes  happens  after  painful  labors,  the  remainder  of 

'  These  folds  may  occasionally  be  drawn  so  tightly  as  to  strangle  and  kill  the  infant,  as 
occurred  in  the  following  case:  "Upon  approaching  a  woman  who  had  just  been  delivered, 
I  found  the  child  dead,  and  still  lying  near  the  genital  parts;  the  cord  made  three  turns 
around  its  neck,  and  they  were  so  firmly  tightened  that  a  deep  ecchymosis  was  seen  on  this 
part.'     (Guillemot.) 


478  LABOR. 

the  travail  ought  not  to  be  left  entirely  to  nature,  but  new  pains  should  be 
at  once  solicited  by  frictions  over  the  abdominal  walls,  and  the  patient  be  encou- 
raged to  bear  down ;  and  if  these  measures  prove  insufficient,  the  index  finger, 
curved  like  a  hook,  is  to  be  placed  in  one  of  the  armpits,  and  the  disengagement 
of  the  anterior  shoulder  thereby  first  effected. 

After  the  shoulders  are  disengaged,  the  spontaneous  expulsion  of  the  breech 
and  lower  extremities  may  also  be  delayed  in  consequence  of  inactivity  of  the 
womb.  Here  again,  is  it  especially  proper  to  endeavor  to  excite  the  contractions 
by  frictions  upon  the  abdomen ;  but,  should  the  life  of  the  foetus  appear  to  be  in 
danger,  the  extraction  should  be  effected  immediately. 

The  artificial  extraction  of  the  shoulders  or  of  the  lower  part  of  the  trunk,  we 
see  ought  not  to  be  resorted  to  until  expectation  might  become  dangerous  to  the 
foetus.  When  the  expulsion  is  left  entirely  to  nature,  the  womb  contracts  in 
proportion  as  it  is  emptied,  and  there  is  less  cause  to  fear  the  consecutive  inertia 
which  is  sometimes  produced  by  too  rapid  an  extraction. 

In  those  rare  cases,  where  the  occiput  remains  posteriorly  until  the  end  of  labor, 
most  accoucheurs  have  recommended  that  an  attempt  should  be  made  to  bring  it 
round  to  the  front,  but  we  doubt  whether  this  will  often  prove  successful, 
although  we  have  never  seen  it  tried,  nor  ever  attempted  it  ourselves ;  for  we 
believe  that  where  the  process  of  rotation  does  not  'take  place  spontaneously,  all 
efforts  to  produce  it  artificially  would  be  useless,  not  to  say  injurious.  Neverthe- 
less, most  authors  advise,  when  the  head  has  descended  into  the  excavation, 
immediately  after  the  discharge  of  the  waters,  to  make  it  deviate  either  towards 
the  right  or  the  left  in  the  interval  between  the  contractions  (Yelpeau),  by  slip- 
ping two  or  three  fingers  either  along  the  sacrum,  to  press  the  occiput  forward, 
or  else  upon  the  side  of  the  forehead,  behind  the  pubis,  to  carry  it  backward. 
If  we  should  ever  entertain  the  thought  of  attempting  this  manoeuvre,  we  would 
much  prefer  acting  during  the  contraction,  for  then  we  should  only  aid,  without 
absolutely  supplanting  nature  j  we  would  prefer,  whilst  acting  upon  the  occiput, 
as  indicated  by  Velpeau,  applying,  at  the  same  time,  two  fingers  on  the  temples, 
and  acting  thereupon  in  such  a  way  as  to  turn  the  forehead  posteriorly.  But, 
we  repeat,  this  appears  unnecessary  in  the  great  majority  of  cases,  because  it  only 
hastens  the  process  of  rotation,  which  would  have  subsequently  taken  place 
without  it ;  and  even  hurtful  in  others,  for  the  efforts  used  to  bring  it  about  might 
exert  a  pernicious  influence  both  on  the  mother  and  her  child. 

In  fact,  in  ordinary  cases,  where  the  rotation  is  produced  by  the  natural 
powers,  the  trunk  follows  the  movements  of  the  head ;  but  where  the  latter  has 
been  turned  by  the  fingers,  the  body  remains  immovable,  and  hence  the  process 
of  forced  rotation  may  dislocate  the  atloido-axoid  articulation  and  kill  the  child. 

The  older  accoucheurs  thought  that  a  spontaneous  delivery,  in  face  presenta- 
tions, was  altogether  impossible,  and  consequently  they  advised  an  endeavor  to  be 
made,  in  the  very  outset  of  labor,  to  convert  them  into  vertex  positions;  but  we 
of  the  present  day  understand  better  the  value  of  such  opinions.  However,  the 
rotation  by  which  the  chin  is  brought  under  the  symphysis  pubis,  whatever 
might  have  been  its  primitive  relation  to  the  superior  strait  (see  Mechanism  of 


ATTENTIONS    TO    THE    WOMAN. 


!t9 


Delivery  by  the  Face),  is  difficult,  painful,  and  sometimes,  in  the  men  to-posterior 
positions,  does  not  take  place  at  all.  It  will  be  seen,  further  on,  that  the  non- 
accomplishment  of  this  movement  forms  one  of  the  most  serious  complications 
met  with  in  practice,  and  that  craniotomy  often  becomes  necessary  in  conse- 
quence. Therefore,  whenever  the  attendant  is  fortunate  enough  to  detect  such, 
a  position  before,  or  just  after,  the  membranes  are  ruptured,  and  consequently 
while  the  part  still  retains  a  considerable  degree  of  mobility,  it  seems  advisable 
to  make  an  effort  to  flex  the  head,  and  thus  convert  a  mento-posterior  into  an 
occipito-anterior  position ;  but  we  shall  have  occasion  to  revert  again  to  this 
subject  hereafter.  "When  the  face  is  engaged  at  the  inferior  strait,  and  the  chin 
is  found  under  the  pubic  arch,  the  movement  of  flexion  begins,  and  then,  as  has 
been  shown,  the  pressure  to  which  the  vessels  of  the  neck  are  subjected,  during 
the  fourth  stage,  may  retard  the  circulation  enough  to  determine  death  by  cere- 
bral congestion.  Hence,  we  learn  what  great  precaution  is  necessary  in  support- 
ing the  perineum,  since  it  must  be  evident  that  too  great  a  pressure  made  upon 
this  part  would  necessarily  augment  the  compression  of  the  child's  neck. 

The  delivery  by  the  pelvic  extremity  ought  to  be  abandoned  entirely  to  nature, 
unless  there  are  some  unfortunate  complications.  We  have  already  insisted  upon 
this  point  in  the  note  at  page  450  ;  but  do  not  hesitate  to  repeat  again  the  advice, 
not  to  resort  to  any  traction  in  a  natural  labor  by  the  breech,  because,  as  there 
stated,  a  stretching  out  of  the  arms,  and  sometimes  even  an  extension  of  the 
head,  result  from  such  imprudent  tractions,  whilst  these  complications  are 
scarcely  ever  met  with  where  the  expulsion  is  left  to  the  uterine  contractions 
entirely.  Now,  there  is  no  difficulty  in  comprehending  these  diS"erent  results,  for 
when  the  womb  is  the  sole  agent  of  the  delivery  of  the  child,  the  latter  is  forcibly 
urged  on  by  the  circular  fibres  at  the  superior  part  of  the  organ,  and  at  the  same 
time  is  strongly  pressed  on  its  sides  by  the  longitudinal  fibres.  The  upper  extre- 
mities are  therefore  maintained  against  the  lateral  and  anterior  parts  of  the  chest, 
the  head  is  kept  flexed  on  the  thorax,  and  all  these  parts  descend  together;  but, 
on  the  contrary,  if  any  tractions  are  made,  they  only  act  on  the  trunk,  which 
then  descends  alone,  while  the  arms,  being  arrested  by  the  margins  of  the  cervix 
uteri,  or  by  the  periphery  of  the  straits,  do  not  participate  in  the  descent,  and 
are  ultimately  found  placed  against  the  sides  of  the  head ;  hence,  the  accou- 
cheur's exclusive  duty  consists  in  receiving  and  supporting  the  lower  parts  of  the 
child  as  they  become  disengaged ;  taking  care,  as  soon  as  the  breech  has  cleared 
the  vulva,  to  ascertain  the  condition  of  the  cord.  For  that  purpose,  the  fore- 
finger is  slipped  up  as  far  as  the  navel,  when,  if  the  cord  is  found  to  be  tight- 
ened at  its  umbilical  insertion,  he  joins  the  thumb  to  the  index  so  as  to  produce 
some  traction  on  its  placental  extremity  only,  with  the  view  of  preventing  both 
its  being  dragged  upon,  and  its  possible  laceration.  The  cord  sometimes  gets 
between  the  infant's  thighs;  and,  in  such  cases  also,  the  loop  thereby  formed 
must  be  enlarged  by  pulling  on  the  placental  extremity,  and  then  by  disengaging 
it  from  the  posterior  limb,  bring  it  into  contact  with  the  perineum,  that  is,  with 
soft  parts  whose  compression  will  be  less  severe,  and  consequently  less  dangerous 
to  the  circulation  than  what  it  would  suffer  from  the  symphysis  pubis;  but  if  it 


480  LAB  OK. 

is  too  short  to  be  brouj^lit  to  the  exterior,  it  must  be  cut,  and  have  a  ligature 
applied  on  its  umbilical  extremity,  and  the  labor  be  terminated  as  rapidly  as  pos- 
sible. 

But,  whatever  may  have  been  the  cause,  the  death  of  the  foetus  always  results 
from  the  slowness  with  which  the  shoulders  and  head  are  expelled,  for  it  is  only 
during  this  last  part  of  the  travail  that  the  cord  is  compressed,  or  that  a  separa- 
tion of  the  placenta  takes  place;  hence,  although  we  have  condemned  all  traction 
in  general,  it  must  be  otherwise  under  such  circumstances.  But  how  is  it  pos- 
sible to  determine  the  period  beyond  which  it  would  be  imprudent  to  wait  ?  We 
answer,  that  as  soon  as  asphyxia  comes  on,  the  suffering  condition  of  the  child 
may  easily  be  detected  by  examining  the  portion  of  the  cord  which  has  been  de- 
livered ;  and  if  the  pulsations  still  maintain  their  intensity,  their  frequency,  and 
habitual  regularity,  the  rest  of  the  process  may  be  abandoned  without  danger  to 
the  powers  of  nature ;  but,  on  the  contrary,  if  they  are  found  to  relax,  or  even  to 
become  more  rapid,  though  at  the  same  time  more  feeble,  thread-like,  and  espe- 
cially if  intermittent  or  irregular,  every  effort  must  be  used  to  remove  the  foetus 
from  the  danger  which  threatens  it. 

The  signs  furnished  by  the  irregularity  of  the  pulsations  of  the  umbilical  arte- 
ries, and  to  which  great  importance  has  been  attributed  by  authors,  only  become 
sensible  after  the  asphyxia  has  lasted  for  so  long  a  time  that  it  is  not  always 
possible  to  overcome  it ;  therefore  we  regard  as  much  more  available  the  pheno- 
mena next  to  be  mentioned. 

When  the  head  alone  remains  behind  in  the  pelvic  excavation,  the  child  is 
very  often  observed  to  dilate  its  chest  actively,  and  make  a  violent  inspiratory 
effort,  which  may  be  referred  to  a  rapid  convulsive  contraction  of  the  diaphragm 
and  abdominal  muscles,  repeated  at  irregular  intervals;  now  such  acts  never  take 
place  while  the  foeto-placental  circulation  remains  intact,  since  the  pulmonary 
respiration  is  unnecessary  so  long  as  the  placental  one  is  going  on,  and  therefore 
these  struggles  constantly  announce  a  state  of  suffering,  or  of  imminent  asphyxia, 
from  which  the  infant  must  speedily  be  relieved.  AVhere  the  head  alone  is  un- 
delivered, the  patient  must  be  encouraged  to  bear  down  strongly,  so  as  to  hasten 
the  termination  of  her  labor,  and  avoid  a  prolonged  compression  of  the  cord ;  and 
the  accoucheur  might  facilitate  the  flexion  of  the  head  by  gently  carrying  the 
trunk  up  in  front  of  the  symphysis,  or  when  the  flexion  appears  difficult,  he  may, 
by  insinuating  two  fingers  under  the  symphysis,  press  sHghtly  on  the  occiput; 
for  a  comparatively  light  force  exercised  on  the  posterior  part  of  the  head  is  often 
sufficient  to  reverse  the  great  occipito-mental  diameter,  and  terminate  the  labor. 
When  the  head  resists  all  these  attempts,  other  measures  become  necessary;  but 
they  belong  to  instrumental  delivery,  and  we  shall  treat  of  them  in  the  article  on 
Version. 

Finally,  should  it  be  impossible  to  extract  the  head  immediately,  we  may  en- 
deavor to  introduce  the  fore  and  middle  fingers  into  the  mouth  of  the  child,  and 
then  separate  them  slightly,  so  as  to  leave  an  open  space  through  which  air  might 
find  its  way  to  the  mouth.  The  same  object  would  be  effected  with  still  greater 
certainty,  by  introducing  a  large  catheter  into  the  mouth. 


% 


ATTENTIONS    TO    THE    WOMAN.  481 

It  is  not  at  all  uncommon  to  find  the  meconium  escaping  in  greater  or  less 
quantity  during  parturition ;  and,  as  previously  stated,  this  peculiarity  most  fre- 
quently occurs  in  the  positions  of  the  pelvic  extremity,  and  is  then  of  little  con- 
sequence; but  this  does  not  hold  good  in  any  other  presentation;  for  then  its 
discharge  is  always  an  unfavorable  sign,  one  calculated  to  arouse  the  anxious  soli- 
citude of  the  medical  attendant,  as  it  usually  indicates  a  state  of  suffering  on  the 
part  of  the  child,  which  is  almost  always  due  to  a  compression  of  the  cord.  It 
must  be  apparent,  on  the  least  reflection  upon  the  part  performed  by  the  placenta 
during  the  intra-utcrine  life,  that  an  interruption  of  the  foeto-placental  circulation 
produces  asphyxia,  which  latter  determines  a  cerebral  congestion,  and  sometimes 
even  an  apoplectic  effusion,  whence  a  paralysis  of  the  sphincter  ani  results- 
Now,  if  to  this  palsy  of  the  sphincters,  we  add  the  instinctive  acts  of  respiration^ 
made  by  the  foetus,  which  are  the  more  violent  as  they  are  the  more  ineffectual, 
we  can  understand  without  difficulty  how  an  escape  of  the  meconium  may  result 
from  a  compression  of  the  cord. 

As  regards  the  prognosis,  it  is  important  to  observe  the  precise  moment  at 
which  this  discharge  takes  place,  as  it  is  always  serious  when  it  does  not  occur 
till  some  time  after  the  rupture  of  the  membranes;  though  the  waters,  when 
they  escape,  are  often  colored  yellow,  and  the  presence  of  the  meconium  then  is 
not  necessarily  an  alarming  symptom.  In  some  cases,  it  may  indeed  indicate  an 
actual  compression  of  the  cord ;  but  it  may  also  result  from  a  compression  that 
had  existed  some  time  before  birth,  which  may  have  compromised  the  child's  life 
for  a  few  moments,  and  then  have  suddenly  disappeared  in  consequence  of  some 
brisk  movement  of  the  infant. 

It  is  not  difficult  to  conceive  that  the  cord  might  undergo  a  momentary  com- 
pression during  the  last  months  of  gestation,  as  also  that  it  might  be  displaced 
by  a  sudden  motion  of  the  child,  and  the  foeto-placental  circulation  be  re-esta- 
blished in  consequence.  Now,  this  compression  may  have  lasted  so  long  as  to 
threaten  asphyxia,  and  consequently  to  produce  a  discharge  of  meconium. 

Endeavors  have  been  made  to  determine  by  the  physical  characters  of  the 
meconium,  whether  its  discharge  was  occasioned  by  a  presentation  of  the  breech, 
or  by  the  sufferings  of  the  foetus.  It  has  been  said  that  in  the  latter  case,  the 
meconium  is  very  fetid,  thinner,  and  more  diluted,  than  when  the  breech  is 
above  the  uterine  orifice.     Such  signs,  however,  are  very  inconclusive. 

On  the  whole,  therefore,  a  discharge  of  meconium  in  breech  presentations,  is 
of  little  consequence ;  but,  in  the  other  presentations,  and  where  occurring  some 
time  after  the  rupture  of  the  membranes,  it  is  always  an  unfavorable  sign; 
though,  to  judge  of  its  value  at  the  time  of  the  rupture  itself,  recourse  must  be 
had  to  auscultation.  Finally,  whatever  may  be  the  child's  position,  we  should, 
contrary  to  the  opinion  of  certain  authors,  abstain  from  introducing  the  fingers 
into  the  lower  part  of  the  vagina,  or  making  pressure  on  the  perineum  and 
coccyx ;  in  a  word,  from  performing  what  they  call  their  little  lahor.  There 
are,  however,  a  few  measures  which  may  be  useful ;  for  instance,  when  the  genital 

'  Mayer  has  observed  respiratory  movements  in  embryos,  even  within  the  ovum,  as  soon 
as  he  compressed  the  cord. 

31 


482  LABOR. 

parts  exhibit  great  rigidity,  heat,  and  dryness,  the  emollient  injections,  or  fric- 
tions with  mild  ointments,  such  as  cerate,  or  cucumber  ointment,  emollient  fumi- 
gations, or  bathing  in  lukewarm  water,  may  be  very  advantageous.  This  last 
remedy,  especially,  is  of  marked  utility  where  the  abdomen  is  tender  and  pain- 
ful, and  the  cervix  uteri  is  rigid  and  resistant. 

ARTICLE   III. 

REGIMEN   or   THE   "SVOMAN   IN   LABOR. 

Those  women  whose  labors  are  usually  short,  need  not,  as  a  general  rule,  take 
any  nourishment  whatever ;  but  when  the  travail  drags  along,  it  is  necessary  to 
sustain  their  strength  by  articles  of  easy  digestion ;  thus,  as  many  are  in  the 
habit  of  taking  coffee  with  milk  every  morning,  this  may  be  allowed  them  with- 
out danger;  and  then,  during  the  day,  a  few  cupfuls  of  some  broth  maybe  given, 
though  always  in  small  quantities  at  a  time.  Where  the  stomach  is  disordered 
and  vomiting  takes  place,  as  very  frequently  happens,  even  these  liquid  aliments 
will  have  to  be  restricted.  This  plan,  however,  is  not  applicable  in  all  cases, 
since  some  must  be  allowed  what  we  should  refuse  to  others;  for  example,  there 
is  no  necessity  for  subjecting  robust  country  women  to  the  same  severity  of  regi- 
men as  the  delicate  ladies  of  large  cities.  The  choice  of  drinks  is  also  a  matter 
of  some  importance,  and  we  may  recommend  some  pure  or  sugared  water,  or  a 
weak  infusion  of  lime,  or  orange  leaves,  of  mallows,  violets,  &c.  Lemonade,  or 
wine  diluted  with  water,  will  be  very  agreeable  to  most  women  at  first ;  but  in 
general,  they  soon  produce  a  sour  stomach  and  eructations;  all  hot  cordials  and 
fermented  liquors  should  be  positively  prohibited.  In  the  country  districts,  there 
is  often  much  difiiculty  in  overcoming  the  vulgar  prejudices  on  this  subject;  but 
the  physician  must  insist  upon  it,  for  he  ought  never  to  lose  sight  of  the  distress 
and  agitation  that  follow  the  administration  of  spirituous  beverages,  and  which 
expose  the  patient  to  inflammations  and  active  hemorrhages.  Should  it  happen 
that  her  feeble  condition  requires  any  restoratives,  then  some  good  broth,  or  a 
little  old  wine,  or  a  few  spoonfuls  of  sherry  wine,  are  the  only  and  the  best  means 
that  can  be  employed. 

The  excretion  of  the  fecal  matters  always  demands  attention,  since  pregnant 
women  are  usually  costive,  especially  in  the  latter  periods  of  their  gestation; 
and  it  often  happens  that,  when  labor  comes  on,  they  have  not  had  a  pas- 
sao-e  for  several  davs.  The  feces  accumulate  in  the  rectum  and  obstruct  the 
passage  of  the  head  in  the  excavation;  besides,  the  pressure  the  distended  intes- 
tine is  then  subjected  to,  is  an  occasional  cause  of  inflammation  of  the  gut,  and 
facilitates  the  development  of  hemorrhoidal  tumors.  In  the  last  stages  of  the 
labor,  these  matters  are  pressed  on  by  the  child's  head,  and  the  violent  bearing- 
down  then  made  by  the  woman  occasions  their  involuntary  expulsion ;  whereby 
the  accoucheur's  hand,  which  supports  the  perineum,  is  soiled,  and  the  patient, 
who  is  aware  of  the  circumstance,  is  greatly  mortified.     These  dangers  and  little 


ATTENTIONS    TO    THE    WOMAN.  483 

annoyances  ought,  therefore,  to  be  prevented,  by  taking  the  precaution  to  admi- 
nister an  injection  early  in  the  labor,  so  as  to  empty  the  bowel. 

The  accumulation  of  urine  in  the  bladder  ought  likewise  to  be  prevented,  by 
persuading  the  patient  to  urinate  in  the  very  commencement  of  hpr  parturition ; 
for,  where  she  has  not  observed  this  precaution,  or  the  physician  arrives  too  late 
to  insist  upon  it,  the  emission  of  water  becomes  more  and  more  difficult,  and 
sometimes  quite  impossible,  owing  to  the  compression  which  the  head,  engaged 
at  the  superior  strait,  makes  on  the  neck  of  the  bladder.  In  such  cases,  he 
should  endeavor  to  push  the  head  up  somewhat  by  two  fingers,  so  that  she  can 
urinate ;  and,  if  this  does  not  succeed,  the  catheter  must  be  resorted  to.  We 
have  elsewhere  stated  that  it  was  advisable,  under  such  circumstances,  to  use  a 
male  catheter,  the  curvature  of  which  is  greater;  though,  even  by  taking  this 
precaution,  a  considerable  resistance  is  occasionally  experienced  to  its  introduc- 
tion. This  condition  requires  the  most  careful  manipulation ;  the  woman  must 
lie  flat  on  her  back,  and  then,  while  with  one  hand  the  womb  is  pressed  back- 
wards from  the  strait,  the  other  introduces  the  instrument  into  the  urethra. 

The  accumulation  of  urine  is  attended  with  such  grave  consequences  as  to 
warrant  a  persevering  eflfort  to  introduce  the  catheter.  The  least  .of  all  the  acci- 
dents which  may  result  therefrom,  is  a  relaxation,  or  even  the  total  cessation  of 
the  pains;  for  the  distressing  sensation  caused  by  a  distension  of  this  organ, 
which  is  increased  when  the  abdominal  muscles  contract,  induces  the  woman  to 
suspend  the  contractions  as  much  as  possible;  besides  which,  the  pain  itself  is 
sometimes  so  acute  as  to  paralyze,  as  it  were,  the  action  of  these  muscles ;  and 
again,  as  they  are  separated  from  the  uterine  walls  by  the  mass  of  urine  shut  up 
in  the  bladder,  their  action  is  transmitted  to  the  womb  in  but  a  very  feeble 
manner.  The  paralysis  of  the  bladder,  so  often  met  with  after  labor,  is  a  com- 
mon consequence  of  prolonged  retention  of  the  urine;  and,  finally,  the  walls  of 
this  reservoir  are  occasionally  ruptured  just  at  the  moment  when  the  woman  gives 
way  to  the  most  violent  bearing-down.  Doubtless  this  last  accident  is  rare,  but 
still  it  is  not  without  example,  since  Ramsbotham,  Sr.,  has  observed  two  cases  of 
the  kind.  (Obs.  Pract.,  cases  89,  90.)'  The  tumor  thus  formed  by  the  over- 
distended  organ  may  easily  be  recognized,  more  particularly  after  the  rupture  of 
the  membranes,  by  the  soft,  fluctuating  tumefaction  detected  immediately  above 
the  pubis,  extending  at  times  nearly  as  high  as  the  umbilicus,  at  the  side  of,  and 
behind  which,  the  hard  resistant  mass  constituted  by  the  uterus  can  be  distin- 
guished, whose  consistence  varies  according  to  whether  the  examination  is  made 
during  or  after  a  pain. 

Within  a  few  years.  Professor  Simpson  has  introduced  into  obstetric  practice 
the  use  of  those  anaesthetic  agents,  which  are  daily  productive  of  such  wonderful 

'  The  symptoms  of  this  accident  are  very  similar  to  those  of  a  rupture  of  the  womb,  ex- 
cepting that  the  cliilcl  remains  in  situ.  Tliere  is,  besides,  a  sudden  and  sharp  pain  in  the 
vesical  region,  and  the  patient  complains  of  the  sensation  caused  by  the  effusion  of  the  liquid 
into  the  abdominal  cavity,  syncope,  &c.  The  signs  peculiar  to  the  vesical  rupture,  are  the 
collapse  and  disappearance  of  the  tumor  previously  formed  by  the  bladder  (which  could  be 
felt  above  the  pubis),  and  an  obscure  fluctuation  in  the  belly. 


484  LABOR. 

results  in  surgery.  The  Edinburgh  accoucheur  does  not,  however,  reserve  ether 
and  chloroform  for  difficult  cases,  but  advises  their  use  in  the  most  natural  labors. 
The  importance  of  the  subject  demands  of  us  a  detailed  examination;  and  a  long 
article  will  be  found  appended,  in  which,  after  having  stated  the  known  results, 
we  shall  give  frankly  our  own  opinions. 

ARTICLE   IV. 

or   THE    ATTENTIONS   TO   THE  WOMAN   IMMEDIATELY  AFTER   THE   LABOR. 

The  expulsion  of  the  placenta  and  its  annexes,  whether  spontaneous  or  assisted 
by  the  accoucheur,  generally  follows  very  shortly  after  the  exit  of  the  foetus.  In 
order  to  avoid  separating  the  study  of  this  natural  delivery  of  the  after-birth 
from  that  of  the  difficulties  and  dangers  which  may  attend  it,  we  shall  treat  of 
them  separately.     (See  Delivery  of  the  After-birth.) 

After  the  delivery,  the  accoucheur  should  ascertain,  both  by  the  external  exa- 
mination and  the  vaginal  touch,  whether  the  placenta  has  drawn  down  or 
inverted  the  fundus  of  the  womb,  for  the  purpose  of  rectifying  it  at  once  if  such 
an  accident  has  occurred.  If  everything  proves  to  be  in  its  natural  condition, 
frictions  with  the  hand  are  to  be  made  over  the  hypogastric  region  from  time  to 
time,  in  order  to  excite  the  retraction  of  the  uterus,  and  thus  flxvor  its  disen- 
gorgement,  and  the  expulsion  of  the  coagula  which  may  be  still  contained  there. 
The  patient  is  allowed  to  remain  for  some  minutes  on  the  bed  where  she  was 
delivered,  so  as  to  give  her  a  little  repose,  as  well  as  time  to  the  uterus  and 
vagina  to  clear  themselves  of  the  blood,  which  flows  at  first  in  abundance,  and 
would  soil  the  linen  in  which  she  is  about  to  be  enveloped.  Besides,  a  few 
minutes  are  ordinarily  devoted  to  paying  those  necessary  attentions  to  the  infant, 
hereafter  pointed  out.  In  fact,  she  might  remain  upon  the  same  bed  a  still 
longer  period,  when  the  delivery  has  either  been  preceded  or  followed  by  syncope, 
hemorrhage,  or  any  other  accident,  or  even  where  there  is  reason  to  fear  some- 
thing of  this  nature,  taking  care,  however,  to  substitute  dry  things  for  those  that 
have  been  soiled.  She  ought  to  lie  perfectly  flat,  the  thighs  stretched  out  along- 
side of  each  other,  lightly  covered,  and  be  left  in  silence,  and  the  most  absolute 
rest  both  of  body  and  mind.  In  about  half  an  hour,  the  patient  will  again 
require  special  attention ;  the  genital  organs,  and  upper  part  of  the  thighs,  are  to 
be  first  washed  carefully  and  gently  with  lukewarm  water,  pure  or  mixed  with  a 
little  wine ;  then  they  are  to  be  wiped  with  warm  and  well-dried  towels,  and  all 
the  garments  worn  during  parturition  that  have  been  soiled  by  the  perspiration, 
discharges,  and  fecal  matters,  are  removed,  and  replaced  by  others,  previously 
well  dried  and  warmed ;  their  shape  is  unimportant,  the  only  point  requisite  is 
to  have  them  large  enough  not  to  incommode  the  woman  in  any  way,  and  to 
admit  of  being  changed  easily  and  promptly.  The  greatest  celerity  is  to  be  used 
in  this  toilet,  lest  she  should  be  long  exposed  to  the  air;  the  arms  and  breast 
particularly  ought  to  be  well  clothed,  so  that  the  patient  may,  during  the  day  at 
least,  keep  them  out  of  bed  without  danger  of  taking  cold. 


ATTENTIONS    TO    THE    "WOMAN.  485 

All  these  preparations  being  conipletecl,  she  is  next  to  be  transferred  to  the  bed 
intended  for  her  reception  during  the  lying-in.  Many  females,  finding  them- 
selves well  enough,  want  to  walk  across  to  the  permanent  bed ;  but,  against  such 
an  imprudence,  the  physician  must  interpose  the  whole  weight  of  his  authority. 
The  one  to  which  she  is  to  be  transported  must  be  previously  warmed,  and  pro- 
vided with  a  sufficient  amount  of  covei'ing  that  can  easily  be  changed ;  though 
the  coverlets  should  not  be  thicker  or  more  numerous  than  those  used  before 
pregnancy. 

There  is  a  custom  much  in  vogue  of  surrounding  the  belly  with  a  modei'ately 
tightened  bandage ;  and  the  women,  for  the  most  part,  attach  the  highest  im- 
portance to  this  measure  as  a  preservative  against  the  wrinkles  and  folds  that  are 
found  after  labor  on  the  skin  of  the  abdomen,  as  also  to  prevent  the  latter  from 
remaining  too  voluminous.  Their  desires  may  be  yielded  to  the  more  willingly, 
as  such  a  bandage,  when  moderately  drawn,  supplies  the  pressure  no  longer 
afforded  by  the  abdominal  walls,  and  thereby  prevents  the  afflux  and  stasis  of  the 
fluids,  the  engorgement  of  the  uterine  walls,  and  the  dilatation  of  the  cavity  of 
this  viscus ;  and  it  has  the  further  advantage  of  obviating  the  tendency  to  syn- 
cope, and  of  diminishing  the  after-pains.  But,  in  order  to  obtain  all  these  bene- 
fits, it  should  be  large  enough  to  compress  the  whole  sub-umbilical  region  equally. 
Care  should  be  taken  to  prevent  its  becoming  doubled  up,-  whereby  a  circular 
cord  is  formed,  which,  from  opposing  the  ready  return  of  the  fluids,  would  then 
prove  a  cause  of  hemorrhage. 

Some  women,  influenced  by  a  feeling  of  coquetry,  also  desire  to  compress  their 
mamma)  by  means  of  a  bandage,  with  a  view  of  preventing  their  enlargement, 
and  their  consequent  softness  and  flaccidity,  and  some  even  go  so  fir  as  to  apply 
topical  astringents  for  the  purpose  of  obviating  an  over-abundant  secretion  of 
milk  ;  but  such  measures  should  be  proscribed  in  the  most  absolute  manner,  since 
they  might  prove  very  dangerous.  These  organs  only  require  a  sufficient  amount 
of  covering  to  protect  them  from  the  contact  of  the  external  air,  and  to  maintain 
a  proper  degree  of  heat. 

Before  proceeding  to  the  consideration  of  the  proper  government  of  the  lying- 
in  woman,  it  seems  indispensable  to  first  point  out  the  principal  phenomena  that 
take  place  after  delivery,  as  the  importance  of  the  hygienic  precepts  we  are  about 
to  lay  down  will  then  be  much  better  understood. 


ARTICLE   V. 

OF   THE   PHENOMENA  APPERTAINING   TO   THE   LYING-IN    STATE. 

This  term  is  applied  to  the  period  immediately  following  the  delivery,  during 
which  the  uterus  and  genital  organs,  and  indeed  the  whole  economy,  gradually 
return  to  their  ordinary  condition. 

The  attendant  phenomena  may  be  divided  into  the  natural,  and  the  unnatural 
or  morbid,  including  under  the  latter  head  all  the  diseases  to  which  the  lying-in 
woman  is  exposed;  but  the  former  only  claim  our  attention  here. 


486  LABOR. 

A  feeling  of  depression,  or  lassitude,  such  as  that  experienced  after  an  unusual 
or  an  immoderate  exercise,  succeeds  the  agitation  caused  by  the  labor;  and  it  not 
unfrequently  happens  that  the  patient  has  scarcely  reached  her  bed,  when  she  is 
attacked  by  a  chill,  severe  enough  at  times  to  produce  a  chattering  of  the  teeth; 
but  this  soon  passes  off,  the  pulse  increases  in  strength,  the  heat  of  the  surface 
returns,  the  skin  becomes  humid,  a  salutary  moisture  appears,  and  the  various 
functions  are  re-established,  while  the  most  perfect  calm  and  the  most  delightful 
slumber  replace  the  past  disorder.  Now,  although  this  slumber  of  the  patient  is 
to  be  respected,  nevertheless  it  is  desirable  that  it  should  not  take  place  until  a 
few  hours  after  the  delivery,  unless  the  physician  should  be  at  hand  to  watch 
attentively  over  the  state  of  the  circulation,  and  the  condition  of  the  womb  during 
this  recuperative  repose,  because  some  women  have  been  attacked  when  in  this 
state  with  internal  discharges,  and  have  awakened  exhausted  by  the  loss  of  blood. 
Therefore,  although  on  account  of  the  rarity  of  this  accident,  the  patient  should 
not  be  prevented  from  sleeping,  it  is  necessary  to  watch  over  her  during  her 
slumber,  or  at  least  to  have  her  carefully  observed  by  an  intelligent  nurse. 

After  the  first  nap  is  over,  she  might  sit  up  in  bed  a  few  moments  to  take  a 
little  broth,  as  this  position  refreshes  her,  and  also  facilitates  the  escape  of  the 
lochia  that  had  accumulated  in  the  vagina.  The  pulse,  which  was  frequent  and 
contracted  immediately  after  the  delivery,  now  becomes  soft  and  developed. 
The  patient  is  the  more  enfeebled  as  the  loss  of  blood  has  been  greater,  or  the 
duration  of  the  labor  prolonged. 

The  nervous  susceptibility  is  also  highly  exalted,  and  the  skin,  whose  activity 
was  diminished  during  gestation,  now  regains  a  more  exalted  vitality;  it  is  soft, 
humid,  and  is  alwa3'S  covered  with  a  dewy  perspiration  during  the  first  week. 
This  sweat  is  sometimes  very  abundant,  particularly  when  she  is  too  warmly 
covered,  and  it  is  not  at  all  unusual  to  find  it  followed  by  a  miliary  eruption  and 
a  distressing  pricking  sensation.  Such  eruptions  were  exceedingly  frequent  in 
former  times,  when  it  was  thought  useful  to  push  the  skin,  as  it  was  called,  and 
to  make  the  woman  perspire  by  surrounding  her  with  thick  coverlets ;  now,  on 
the  contrary,  they  are  quite  rare,  and,  where  they  do  show  themselves,  are  easily 
made  to  disappear  by  taking  the  necessary  precautions  to  diminish  the  cutaneous 
secretion.  ^ 

In  general,  the  secretion  and  excretion  of  urine  do  not  present  anything  pecu- 
liar; occasionally,  however,  its  emi.ssion  is  obstructed  by  the  swelling  of  the  mea- 
tus urinarius,  or  the  bladder  is  momentarily  paralyzed  by  the  prolonged  labor, 
and  the  excessive  compression  it  has  undergone,  and  the  catheter  must  then  be 
resorted  to.  Hence,  it  is  always  necessary  to  inquire  whether  the  patient  urinates 
freely  and  easily  during  the  first  two  or  three  days;  for  an  accumulation  of  water 
in  the  benumbed  and  half  paralyzed  bladder  would  often  account  for  the  uneasi- 
ness and  suffering  that  could  not  otherwise  be  explained. 

The  constipation,  that  is  so  common  during  the  last  stages  of  gestation,  often- 
times still  persists  after  the  delivery  for  four,  six,  or  even  eight  days ;  and  this 
prolonged  retention  of  the  fecal  matters  may  give  rise  to  anxiety,  headache,  loss 
of  sleep,  and  sometimes  even  to  a  feeling  of  weight,  or  actual  pain  in  one  of  the 


ATTENTIONS    TO    THE    WOMAN.  487 

iliac  fossae;  all  wliich  symptoms  disappear  like  magic  upon  the  administration  of 
some  mild  laxative.  Where  the  costiveness  continues,  a  state  of  suffering  very 
frequently  results,  which  may  occasion  a  slight  febrile  movement;  and  the  fre- 
quency of  pulse,  thus  produced,  coinciding  with  the  pain  caused  by  an  unusual 
retention  of  the  fecal  matters,  which  pain  is  most  commonly  located  in  some  part 
of  the  hypogastric  region,  and  is  augmented  l)y  pressure,  may  give  rise  to  sus- 
picions of  a  peritoneal  inflammation  that  really  does  not  exist;  and  I  have  known 
this  eri'or  to  be  committed  where  the  pain  and  fever  that  had  resisted  the  appli- 
cation of  leeches,  rapidly  disappeared  after  the  exhibition  of  a  purgative.  The 
retention  of  the  feces  may  also  result  from  a  paralysis  of  the  rectum,  which  para- 
lysis is  itself  a  consequence  of  the  pressure  made  upon  it  by  the  head  during  its 
prolonged  sojourn  in  the  excavation.  I  have  known,  says  M.  Martin,  of  Lyons, 
the  feces  to  be  retained  more  than  twenty  days  after  a  laborious  delivery,  and 
to  accumulate  in  such  large  quantities,  and  acquire  such  a  firm  consistence 
as  to  equal  the  size  of  a  child's  head  at  term ;  and,  as  all  the  usual  laxatives 
failed,  I  was  obliged  to  introduce  a  scoop,  and  bring  the  hardened  matters  away 
piecemeal ;  -but  even  then  the  gut  did  not  at  once  regain  its  functions,  though  a 
fresh  accumulation  was  prevented  by  the  use  of  irritant  injections,  and  the 
contractility  of  the  intestine  was  not  perfectly  re-established  until  twenty-nine 
days  afterwards,  at  which  period  the  patient  left  the  hospital.  (^Comptes  Rendus, 
p.  32.) 

Let  us  now  study  the  important  modifications  that  take  place  in  the  genital 
organs,  as  they  gradually  tend  towards  a  return  to  their  primitive  state.  There 
is  then  a  rhythmical  contraction  established  in  the  womb,  that  is,  an  alternation 
of  expression  and  retraction,  until  the  latter  finally  reaches  the  point  where  it 
ceases  altogether :  thus,  if  we  examine  the  relaxed  walls  of  the  abdomen  imme- 
diately after  the  child's  birth,  the  uterus  will  be  found  constituting  a  tumor  above 
the  pubis,  about  ten  inches  in  length  by  seven  in  breadth ;  but  in  the  course  of 
a  few  days,  this  length  diminishes  to  six  inches ;  and  though  in  thin  women, 
particularly  those  who  have  often  had  children,  the  womb  still  remains  at  the 
end  of  two  weeks  about  two  fingers'  breadth  above  the  pubis,  yet  the  fundus  in 
primipara;,  more  especially  in  such  as  are  at  all  inclined  to  embonpoint,  cannot 
be  distinctly  felt  after  a  week ;  and  by  the  end  of  the  sixth  week  this  organ  has 
nearly  regained  its  primitive  condition,  being  still,  perhaps,  a  little  larger,  and 
more  relaxed  than  usual. 

The  rapidity  with  which  the  uterus  after  delivery  tends  to  resume  the  volume 
and  dimensions  which  it  possessed  before  impregnation,  is,  to  say  the  least,  quite 
as  surprising  as  the  rapidity  with  which  it  underwent  its  enoi'mous  hypertrophy 
during  gestation.  An  examination  of  the  various  changes  through  which  this 
rapid  absorption  is  effected,  induced  M.  Retzius,  of  Copenhagen,  to  conclude,  that 
it  is  preceded  by  a  fatty  degeneration  of  the  muscular  fibres.  He  asserts  that, 
during  the  lying-in,  a  larger  amount  of  globules  of  fatty  matter  are  detected  in 
the  blood  by  the  microscope  than  is  the  case  under  ordinary  circumstances. 

This  diminution  in  the  size  of  the  uterus  is  not  always  so  regularly  graduated, 
for  it  will  be  seen  hereafter,  that  when  the  contractility  of  the  tissue  has  been 


488  LABOR. 

feeble  after  delivery,  the  walls  of  the  uterus  often  preserve  a  considerable  thick- 
ness for  four  or  five  days,  the  fundus  being  found  all  this  time  close  up  to  the 
umbilicus.  The  same  observation  may  be  made  at  a  still  later  period,  in  cases 
where  an  inflammation  of  the  peritoneum,  of  the  uterine  mucous  membrane,  or 
of  the  neighboring  organs  has  supervened.  Again,  it  happens  that,  after  having 
been  diminished,  its  volume  augments  anew,  for  some  hours,"  at  times,  even  for  a 
day  or  two,  and  then  soon  returns  to  its  former  size.  I  can  explain  this  cir- 
cumstance only  by  supposing  some  local  congestion,  which  has  not  been  acute 
enough  to  produce  an  active  hemorrhage,  but  whose  action  has  been  limited  to 
distending  and  engorging  the  uterine  vessels,  and  consequently  to  increasing  the 
thickness  of  the  walls ;  or  this  abnormal  volume  may  be  owing,  in  certain  cases, 
to  the  presence  of  newly  formed  coagula.  Eut,  however  that  may  be,  I  felt 
bound  to  point  out  these  anomalies,  to  prevent  the  inexperienced  practitioner 
from  falling  into  an  error. 

The  condition  of  the  internal  surface  of  the  uterus  after  delivery,  has  of  late 
been  studied  attentively  by  M.  Colin ;  who,  although  deceived  as  to  the  nature 
of  the  lining  membrane,  has  at  least  given  a  much  better  description  of  it  than 
any  writer  who  has  preceded  him. 

He  states  that  a  few  hours  after  delivery,  the  internal  surface  of  the  womb  is 
covered  with  clots  of  blood,  which,  upon  being  removed,  discover  a  soft,  moist, 
reddish  surface,  occasionally  presenting  in  some  points  an  uneven  and  gashed 
appearance.  Very  soft,  filamentous  laminao  adhere  to  this  surface,  and  may  be 
pinched  up  by  the  fingers,  or  raised  by  immersing  the  organ  in  water.  If  the 
surface  be  scraped  with  the  blade  of  a  scalpel,  a  layer  varying  in  thickness  from 
the  one-eighth  to  the  one-sixteenth  of  an  inch  may  be  raised  from  it.  This 
layer,  which  increases  in  thickness  towards  the  middle  and  fundus  of  the  organ, 
is  of  a  reddish-gray  color  and  friable,  tearing  like  a  newly-formed  pseudo-mem- 
brane, and  even  giving  way  beneath  the  fingers.  Below  it  is  found  the  muscular 
tissue,  of  a  white  or  grayish  appearance,  entirely  distinct  from  this  layer,  and 
easily  recognized  by  its  clearer  hue,  the  appearance  of  fibres  and  their  transverse 
direction,  as  also  by  its  greater  consistency. 

The  point  of  attachment  of  the  placenta  is  marked  by  a  much  greater  thick- 
ness of  the  mucous  membrane.  There  the  surface  is  mammillated,  rounded, 
anfractuous,  and  projecting  to  the  extent  of  a  quarter  of  an  inch  above  the  level 
of  the  surrounding  surface.  The  anfractuosities  are  filled  up  with  coagulated 
blood,  which  is  removed  from  them  with  difficulty. 

These  inequalities,  which  have  been  regarded  by  some  anatomists  as  tufts  des- 
tined to  dip  down  between  the  cotyledons  of  the  placenta,  are  due,  according  to 
Desormcaux,  to  the  excessive  distension  which  the  arteries  and  veins,  the  last, 
especially,  have  undergone  during  pregnancy,  and  upon  the  slowness  of  their 
subsequent  retraction;  though,  according  to  Velpeau,  they  are  owing,  in  women 
that  die  shortly  after  delivery,  to  the  swelled  and  fungous  character  of  that  por- 
tion of  the  internal  uterine  surface  which  corresponded  to  the  placenta.  We 
prefer  the  following  explanation,  given  by  M.  Jacquemier,  viz.,  the  internal  mus- 
cular layer  of  the  womb  is  perforated  in  all  the  space  occupied  by  the  after-birth, 


ATTENTIONS    TO    THE    WOMAN.  489 

by  a  great  number  of  holes,  which  give  a  peculiar  aspect  to  this  portion  of  its 
inner  surface,  and  render  it  less  contractile  than  at  other  parts ;  and  conse- 
quently, as  the  organ  retracts,  it  has  a  tendency  to  project  into  its  cavity,  and 
when  it  arrives  at  the  final  state  of  repose,  a  tumor  is  formed,  which  is  ordinarily 
larger  than  the  palm  of  the  hand,  with  a  very  irregular  lacerated  surflice,  spongy, 
as  it  were,  in  character,  and  often  standing  out  in  considerable  relief;  the  torn 
utero-placental  vessels  are  comprised  in  this  mass,  which  renders  them  tortuous 
and  nearly  inextricable.  But  whatever  the  explanation  may  be,  it  is  highly  im- 
portant, adds  M.  Jacquemier,  to  bear  this  arrangement  constantly  in  mind,  for 
an  attentive  perusal  of  several  cases  of  artificial  delivery  of  the  after-birth,  has 
convinced  me  that,  in  those  instances  the  tumor  formed  by  the  most  internal 
layer  of  the  womb,  was  mistaken  for  debris  of  the  placenta,  which  the  medical 
attendants  endeavored  ineff"ectually,  though  not  without  danger,  to  extract. 

At  the  upper  boundary  of  the  cavity  of  the  neck,  this  membrane  is  terminated 
by  an  irregular  edge  projecting  above  the  latter,  and  from  which  are  put  forth 
small  shreds  or  lamina;,  from  one  to  three-sixteenths  of  an  inch  in  length,  of  the 
same  nature  as  the  layer  covering  the  wall  of  the  uterus. 

The  cavity  of  the  neck  contains  a  glutinous,  transparent,  and  slightly-reddish 
mucus.  The  color  of  its  internal  surface  varies  greatly  according  to  the  mode 
of  death,  from  a  reddish-gray  to  a  blackish-brown.  The  thickness  of  the  mucous 
membrane  lining  the  cavity  of  the  neck,  varies  from  the  one-thirty-second  to  the 
one-sixteenth  part  of  an  inch ;  it  is  very  moist  and  flexible,  although  firm  and 
torn  with  difficulty.  It  remains  intact,  and  does  not  participate  in  the  exfoliation 
which  that  of  the  body  undergoes. 

The  condition  of  the  mucous  membrane  at  a  period  still  more  remote  from 
delivery,  has  also  been  studied  by  M.  Colin.  Thus,  from  the  twenty-eighth  to 
the  thirtieth  day,  the  membrane  has  assumed  a  rose-red  or  grayish  color,  espe- 
cially in  the  vicinity  of  the  neck ;  it  is  smooth,  moist,  and  soft,  but  resists  the 
action  of  a  stream  of  water,  though  it  may  be  scraped  off  entirely  by  the  scalpel, 
so  as  to  expose  the  muscular  fibres.  Numerous  vessels,  whose  greatest  diameter 
docs  not  exceed  the  one-ninetieth  part  of  an  inch,  proceed  from  the  muscular 
tissue,  and  ramify  ad  infinitum  in  its  substance.  By  the  fortieth  day,  the  mem- 
brane is  of  a  rather  deep  red  color,  opaque,  and  of  about  the  one-thirty-second 
part  of  an  inch  in  thickness,  toward  the  fundus;  it  is  semi4ransparent  and 
thinner  in  the  lower  part  of  the  body,  where  it  is  continuous  with  the  mucous 
membrane  of  the  neck,  which  presents  no  peculiarities.  It  is  soft,  and  easily 
removed  by  the  back  of  a  scalpel.  It  is  traversed  by  a  very  close  network  of 
capillary  vessels.  By  the  sixtieth  day,  it  is  smooth,  gray,  and  traversed  by  small 
vessels;  it  has  the  true  consistency  of  a  mucous  membrane,  and  the  scalpel  re- 
moves from  it  but  a  slight  pellicle,  which  has  no  longer  the  pulpy  appearance  of 
the  substance  detached  from  it  at  an  earlier  period. 

This  new  mucous  membrane,  which,  according  to  M.  Robin,  begins  to  be 
formed  by  the  fourth  month  of  gestation,  is,  therefore,  after  delivery,  the  seat  of 
a  rcparatory  process,  which  ends  in  the  completion  of  a  new  mucous  membrane. 
The  mucous  membrane  of  the  neck  is  not  thrown  ofi";  it  is  simply  hypertrophied 


490  LABOR. 

during  pregnancy,  and  after  delivery  continues  to  exhibit  the  arbor  vitae,  though 
of  a  somewhat  modified  form. 

Professor  Stoltz  has  studied  the  modifications  that  occur  in  the  neck  of  the 
uterus,  after  the  delivery,  with  a  great  deal  of  care,  and  we  extract  the  following 
passage  from  his  excellent  thesis  on  this  subject:  "As  soon  as  the  child  is  born, 
the  cervix  is  partly  formed  anew,  but  it  is  soft,  short,  wide,  and  irregular,  and 
one  or  more  fingers  can  easily  be  made  to  penetrate  it ;  the  internal  orifice  offers 
the  greatest  resistance,  as  is  proved  when  an  attempt  is  made  to  introduce  the 
hand  into  the  womb,  for  it  enters  with  considerable  difficulty,  and  only  when  this 
orifice  has  been  progressively  dilated.  The  latter  is  sometimes  so  contracted  as 
to  induce  inexperienced  persons,  who  endeavor  for  the  first  time  to  carry  the 
hand  up  into  the  womb,  to  believe  they  have  succeeded,  when  in  fact  they  have 
only  reached  the  dilated  vagina,  where  they  find  a  large  cavity,  but  no  opening 
to  get  any  further,  and  the  clots  of  blood,  then  collected  at  the  upper  part  of  the 
vagina  and  around  the  cervix,  add  still  more  to  this  confusion." 

The  internal  orifice  formed  after  the  expulsion  of  the  child,  offers  but  little 
resistance;  and,  consequently,  it  has  scarcely  occasion  to  dilate  again  for  the 
passage  of  the  placenta,  as  it  yields  readily;  and  when  the  delivery  of  the  after- 
birth is  effected,  the  womb  contracts,  and  the  neck  becomes  longer,  and  more 
consistent ;  although  it  must  again  open  several  times  to  permit  the  numerous 
clots  of  blood  to  escape.  During  the  lying-in,  it  gradually  returns  to  its  natural 
size;  sometimes,  even,  it  is  longer;  but  it  acquires  the  ordinary  disposition  more 
or  less,  as  it  regains  its  proper  consistence,  and,  by  the  end  of  the  first  month,  it 
generally  exhibits  about  the  same  dimensions  as  it  had  prior  to  gestation ;  at 
times,  however,  it  is  a  little  shortened,  but  the  consistence  is  nearly  as  firm  as 
usual,  although  the  inferior  part  has  seemed  to  us  rather  more  softened.  It  no 
longer  presents  a  conical  shape,  but  is  more  cylindrical,  from  the  fact  of  the 
summit  having  become  larger.  As  a  general  rule,  the  sears  on  the  lips  are  pro- 
portionably  more  numerous,  as  the  patient  has  had  a  greater  number  of  children, 
and  her  labor  has  been  more  tedious.  The  transverse  fissure  is  deeper,  and  more 
angular;  and,  in  such  women,  the  upper  part  of  the  cervix  is  sometimes  larger 
than  the  base,  though  it  is  much  shorter  than  usual,  and  at  times  is  divided  into 
two  lips  that  are  more  or  less  flat,  broad,  and  unequal,  and  the  anterior  of  which 
is  longer  than  the  posterior ;  indeed,  in  some  cases,  the  latter  seems  to  have  been 
altogether  destroyed,  while,  in  others,  it  is  well  marked,  and  the  anterior  one  is 
scarcely  perceptible.  In  fact,  almost  as  many  varieties  exist  on  this  point  as 
there  are  different  subjects. 

The  vagina  becomes  shorter,  and  the  ridges  that  were  effaced  during  the  last 
stage  of  labor,  gradually  but  slowly  reappear,  and  the  orifice  of  this  canal,  and 
the  vulva,  also  regain  their  primitive  condition.  At  first,  the  labia  externa,  as 
well  as  the  perineum,  are  thin  and  distended,  and  the  po.sterior  part  of  the  con- 
tour of  the  vulva  is  flabby,  wrinkled,  and  projecting  outward.  Sometimes  the 
epidermis  is  fretted,  at  others,  actual  lacerations  are  found,  Avhich  produce  a 
smarting  sensation;  and  as  to  the  fourchette,  it  is  almost  inevitably  torn  in  the 
first  labor. 


ATTENTIONS    TO    THE    WOMAN.  491 

The  broad  ligaments  seem  to  re-form  by  the  approximation  of  their  two 
constituent  layers,  while  the  round  ligaments  gradually  become  shortened  and 
retracted. 

The  abdominal  muscles  and  integuments,  which  were  at  first  soft  and  flabby, 
and  exei'cised  but  a  very  imperfect  pressure  on  the  viscera  and  vessels  contained 
in  their  cavity,  again  retract ;  although  this  process  is  very  often  incomplete  in 
women  of  a  soft  fibre,  or  who  have  had  many  children. 

This  slow  and  gradual  retraction  of  the  uterus  takes  place,  in  some  instances, 
without  the  least  pain,  and  without  the  knowledge  of  the  patient ;  but  it  more 
generally  becomes  intermittent  and  distressing,  and,  as  the  suff"erings  the  women 
then  experience  have  a  great  analogy  to  those  of  childbirth,  they  are  called  the 
after-pains.  At  the  same  time,  a  more  or  less  abundant  discharge  takes  place 
from  the  vulva,  consisting  at  first  of  pure  blood,  then  of  blood  mixed  with  a  white 
fluid,  and,  lastly,  of  a  white  sero-purulent  liquid;  and  these  discharges  have 
received  the  name  of  the  lochia.  Finally,  a  function  altogether  new  sets  in,  in 
the  course  of  the  first  few  days,  which  may  be  considered  as  the  complement  of 
the  puerperal  functions ;  this  is  the  milk  secretion,  whose  onset  is  attended  by 
certain  general  phenomena,  which  are  ordinarily  described  under  the  term  of  the 
milk  fever ;  we  shall  therefore  have  to  examine,  in  turn,  these  three  principal 
phenomena  of  the  lying-in  state. 

§  1.  Of  the  After-Pains. 

The  after-pains  are  certainly  occasioned  by  the  contraction  of  the  womb ;  to  be 
satisfied  on  this  point,  it  is  only  necessary  to  place  the  hand  over  the  hypogastric 
region,  when  we  will  ascertain  that  the  uterus  becomes  harder  just  at  the  moment 
when  the  patient  complains  the  most.  These  pains  are  much  more  frequent  and 
intense  in  women  who  have  borne  many  children,  than  in  primiparae ;  as,  also, 
after  an  easy  than  after  a  long  and  painful  labor ;  and  when  the  womb  encloses 
some  foreign  body,  such  as  the  coagula,  or  a  portion  of  the  membranes  or  pla- 
centa, than  when  its  cavity  is  entirely  empty.  Now,  all  these  difiiirences  in 
character  will  be  readily  comprehended,  if  the  reader  will  only  bear  in  mind  that 
the  object  of  the  contractions  is  to  express  from  the  uterine  parietes  those  liquids 
with  which  the  walls  are  still  engorged  after  the  delivery,  and  to  expel  from  its 
cavity  all  the  foreign  substances  contained  therein;  that,  in  very  prompt  labors, 
the  organ,  from  being  evacuated  too  rapidly,  does  not  retract  so  perfectly  as  it 
ought,  and  allows  the  blood  to  coagulate  and  accumulate  in  its  interior,  and  that 
the  very  feeble  contractility  of  its  tissue  forces  out  but  very  imperfectly  the  fluids 
remaining  in  the  thickness  of  the  walls. 

The  pains  generally  commence  soon  after  the  delivery,  being  at  first  feeble  and 
distant,  then  more  frequent  and  painful;  and,  at  the  moment  of  their  occurrence, 
the  uterine  globe  retracts,  becomes  harder,  more  resistant,  and  sometimes  even 
seems  to  rise  up,  by  resting  on  the  posterior  plane  of  the  abdomen,  as  a  point 
d'appui,  and  projecting  in  the  form  of  a  globular  tumor,  through  the  walls  of 
the  abdomen.  The  escape  of  the  lochia  is  ordinarily  more  abundant  towards  the 
end  of,  or  just  after  each  pain,  and  not  unfrequently  a  few  small  coagula  come 


492  LABOR. 

away  from  the  vulva ;  but,  •where  the  uterus  contains  a  large  one,  the  pains  con- 
stantly increase  in  force  and  frequency,  until  it  is  expelled,  after  which  they 
again  diminish.  In  most  cases,  they  cease  during  the  milk  fever,  though  they 
may  continue  for  the  first  seven  or  eight  days.  Sometimes  they  return  after 
having  entirely  disappeared,  are  followed  by  the  discharge  of  a  little  blood  from 
the  vulva,  or  the  expulsion  of  a  clot,  or  of  a  portion  of  membrane  that  has 
remained  in  the  uterus,  and  then  everything  returns  to  its  natural  condition. 

As  regards  the  diagnosis,  it  is  highly  important  to  distinguish  the  after-pains 
from  those  caused  by  a  peritoneal  inflammation,  but  fortunately  this  is  not  very 
difiicult ;  for,  however  strong  the  after-pains  may  be,  they  are  generally  inter- 
mittent, and  are  separated  by  an  interval  of  variable  duration ;  besides,  the  dis- 
tress attendant  upon  them  is  rather  alleviated  than  augmented  by  pressure,  and 
a  rather  more  abundant  lochial  discharge  accompanies  or  follows  them.  While 
they  last,  there  is  an  absence  of  febrile  movement ;  finally,  when  the  child  seizes 
the  nipple,  especially  if  the  latter  is  the  seat  of  any  ulceration,  the  suffering 
thereby  caused  most  frequently  brings  on  an  after-pain,  and  this  circumstance 
alone  has  often  sufficed  to  make  them  reappear,  even  after  a  suspension  of  seve- 
ral hours.  When  existing,  these  differential  characters  are  quite  sufficient  to 
distinguish  them,  but  unhappily  they  are  not  always  so  well  marked ;  for,  where 
they  are  very  acute,  or  follow  each  other  in  rapid  succession,  they  are  accom- 
panied by  fever,  and  sharp  pains  in  the  hypogastrium.  But,  even  then,  there  is 
always  a  remission,  which,  conjoined  with  the  absence  of  the  other  signs  of  peri- 
toneal inflammation,  may  aid  in  determining  their  character. 

Dr.  Dewees  states  that  he  had  several  times  an  opportunity  of  observing  a  sin- 
gular pain  which  was  manifested  almost  immediately  after  the  delivery,  and  yet 
was  altogether  different  from  the  ordinary  after-pains.  It  is  a  very  acute  pain, 
referred  by  the  patients  to  the  lower  part  of  the  sacrum  and  coccyx.  It  com- 
mences as  soon  as  the  child  is  born,  and  continues  without  interruption,  and  of 
a  frightful  intensity.  It  is  declared  by  the  patient  to  be  vastly  more  insupport- 
able than  the  after-pains,  for  it  is  quite  as  violent,  besides  being  constant;  the 
latter  character  serving  as  a  ready  means  of  distinguishing  it.  Camphor  and 
opium  appeared  to  him  the  most  successful  means  of  relieving  it. 

The  after-pains,  of  which  we  have  just  spoken,  are  sometimes  so  severe  as  to 
claim  the  attention  of  the  physician,  and  although  they  may  be  useful  when 
caused  by  the  retention  of  a  foreign  body,  they  are  so  annoying,  that  it  is  cer- 
tainly advisable  to  endeavor  to  prevent  them.  Dewees  states  that  this  may  often 
be  effected  by  observing  the  following  precautions  :  1.  Do  not  rupture  the  mem- 
branes before  the  neck  is  completely  dilated ;  2,  after  the  head  is  born  make  no 
tractions,  but  allow  the  uterus  to  expel  the  shoulders  and  trunk;  3,  do  not  ex- 
tract the  placenta  until  the  womb  is  thoroughly  contracted;  4,  after  the  placenta 
is  delivered,  excite  the  womb  so  as  to  oblige  the  muscular  fibres  to  contract  as 
much  as  possible.  It  is  evident  that  all  these  measures  have  for  their  object  to 
insure  the  slow  and  complete  contraction  of  the  walls  of  the  uterus,  in  proportion 
as  its  contents  are  expelled. 

In  the  cases  of  women  who  have  suffered  much  from  after-pains  in  previous 


ATTENTIONS    TO    THE    WOMAN.  493 

confinements,  T  have  made  it  a  practice  to  administer  a  few  doses  of  ergot  imme- 
diately after  delivery,  with  the  effect,  I  have  thought,  of  preventing  their  occur- 
rence in  many  cases,  or  at  least  of  lessening  their  violence.  When  the  womb 
contracts  feebly,  it  has  seemed  to  me  of  advantage  to  add  pressure  upon  the 
uterus  to  the  use  of  the  ergot.  This  is  done  by  means  of  the  ordinary  bandage, 
and  made  more  effectual  by  placing  a  compress,  formed  of  one  or  two  folded 
towels,  upon  the  fundus  of  the  organ. 

If  the  after-pains  are  feeble,  nothing  need  be  done;  if,  however,  they  are  very 
violent,  the  physician  should  interpose.  Provided  the  patient  has  not  suffered 
from  hemorrhage,  or  been  threatened  with  it,  we  may  begin  by  placing  warm 
and  emollient  cataplasms  upon  the  abdomen.  Lotions  containing  laudanum  may 
be  used  upon  the  belly,  and  the  cataplasm  may  be  wet  with  the  same  substance. 
An  injection  may  also  be  given  of  from  twenty  to  forty  drops  of  Sydenham's  lau- 
danum, in  as  small  an  amount  of  vehicle  as  possible.  Dewees  professes  to  have 
derived  great  advantage  from  a  camphor  mixture,  consisting  of  a  drachm  of  cam- 
phor to  six  ounces  of  vehicle,  a  tablespoonful  to  be  taken  every  hour  or  two. 
When  the  mixture  disagrees  with  the  patient,  ten  grains  of  finely-powdered  cam- 
phor, every  hour  or  two,  mixed  in  a  little  syrup  of  any  kind,  may  be  substituted 
for  the  julep  just  mentioned.  When  the  after-pains  are  accompanied  by  signs 
of  general  plethora,  blood  may  be  taken  from  the  arm.  Finally,  should  there  be 
cause  to  suspect  the  presence  of  large  clots  or  portions  of  the  membranes  in  the 
cavity  of  the  uterus,  one  or  two  fingers  may  be  introduced  within  the  neck,  in 
order  to  seize  them,  or  at  least  to  bring  about  their  expulsion.  These  are, 
perhaps,  the  only  circumstances  under  which  the  use  of  ergot,  so  highly  vaunted 
by  Crozat  and  Velpeau  as  a  remedy  for  after-pains,  is  likely  to  be  successful. 

§  2.  Or  THE  Lochia. 

Of  all  the  various  excretions  that  take  place  after  the  delivery,  the  lochia  are 
certainly  the  most  interesting  to  us  as  practitioners.  This  name  is  applied  to 
the  matters  that  escape  from  the. vulva  during  all  the  period  from  the  delivery 
of  the  after-birth,  until  the  womb  has  regained  its  normal  size  and  consistence. 
The  order  in  which  these  discharges  appear,  has  been  very  accurately  described 
by  Desormeaux,  as  follows  :  Immediately  after  the  delivery  of  the  placenta,  and 
the  escape  of  the  accompanying  blood,  all  further  sanguineous  discharge  becomes 
temporarily  suspended,  probably  because  the  blood  that  transudes  from  the  sur- 
face of  the  womb  accumulates  in  the  cavity  of  that  organ ;  but  the  pure  fluid 
soon  begins  to  flow  again,  although,  in  the  course  of  twelve  or  fifteen  hours,  it 
loses  its  consistence,  and  its  color  becomes  lighter,  and,  after  a  short  time,  it  is 
changed  into  a  bloody  serosity.  When  the  milk  fever  comes  on,  which  is  usually 
in  about  forty-eight  hours  after  the  parturition,  the  flow  of  the  lochia  is  either 
diminished  or  entirely  suspended.  When  it  is  over,  the  bloody  discharges  reap- 
pear, and  continue  during  the  four  or  five  succeeding  days,  though  with  charac- 
ters varying  greatly  in  different  individuals  :  thus,  in  some  women,  those  especially 
who  menstruate  profusely,  they  appear  with  the  same  characters,  f|u:intity  ex- 
cepted, as  before  the  milk  fever.     They  are  still  composed  of  pure  blood,  which 


494  LABOR. 

sometimes  contains  numerous  small  clots;  with  the  majority,  however,  they 
become  more  and  more  serous,  though  still  exhibiting  here  and  there  some 
bloody  streaks,  or  perhaps  are  slightly  tinged  by  the  blood,  the  quantity  of  which 
diminishes  every  day.  It  usually  disappears  altogether  about  the  sixth  day;  the 
lochia  being  thenceforth  composed  of  a  more  or  less  consistent  yellowish-white 
liquid,  and  they  thus  continue  for  two  or  three  weeks  or  a  month;  though  in 
some  women,  who  do  not  nurse,  they  do  not  pass  off  until  the  menses  reappear, 
that  is,  in  about  six  weeks  or  two  months  after  the  delivery. 

These  discharges  have  been  divided,  according  to  their  color,  into  the  sangui- 
nolent,  the  serous,  and  the  milki/,  puri/orm,  or  purulent  lochia.  As  the  uterus 
retracts,  its  walls  gradually  disgorge  the  fluids  they  had  imbibed,  and  these 
naturally  run  towards  its  central  cavity.  So  long  as  the  large  venous  canals  in 
its  substance  arc  not  empty,  the  discharge  consists  of  pure  blood;  somewhat 
later^  it  is  composed  of  serum,  together  with  the  detritus  of  the  ovum  and  the 
mucosities  of  the  organ ;  and  still  later,  a  true  suppurative  irritation  is  established, 
the  products  of  which,  analogous  in  some  respects  to  the  non-contagious  dis- 
charges of  the  urethra,  constitute,  in  a  great  measure,  the  white  or  the  purulent 
issue. 

The  lochia  have  a  peculiar  odor,  called  (jravis  odor  jyuerperii,  which  varies  in 
strength  according  to  the  individual  and  her  habits  of  cleanliness ;  and  to  this  is 
also  added  the  scent  from  the  perspiration  and  the  milk,  which  latter,  distilling 
from  the  breast,  is  imbibed  by  her  garments  and  turns  sour.  Sometimes  the 
lochia  become  fetid,  and  where  this  circumstance  is  not  owing  to  slovenliness,  it 
is  alwaj'S  an  unfavorable  sign,  since  it  most  generally  announces  that  coagula  or 
some  other  foreign  substances  are  putrefying  in  the  uterus;  and  where  the 
lochial  fluid  has  the  color  of  coffee-grounds,  and  a  cadaverous  smell,  it  is  almost 
uniformly  an  evidence  of  the  existence  of  an  inflammation  of  the  womb  or  vagina, 
which  has  terminated  in  gangrene.  Again,  whenever  the  patient  is  afflicted  with 
carcinoma  uteri,  the  discharges  resemble  the  washings  of  flesh,  and  have  a  very 
nauseous  smell.  In  all  such  cases  the  aromatic.injections,  the  infusions  of  elder 
or  chamomile  flowers,  for  instance,  should  be  made  several  times  a  day. 

The  lochia  are  also  very  variable  in  quantity  and  duration,  though  we  may 
state,  as  a  general  rule,  that  the  patient  soils  ten  to  twelve  napkins  in  the  course 
of  the  first  twenty-four  hours;  but  after  the  milk  fever  is  over,  the  flow  dimi- 
nishes more  and  more,  its  amount  being  usually  proportionate  to  that  of  the  men- 
strual evacuation.  It  is  more  copious  in  women  who  have  borne  many  childi-en, 
or  who  make  use  of  an  over-nourishing  or  a  heating  regimen,  and  in  those  who 
do  not  nurse.  The  sanguineous  discharges  vary  much  in  amount  during  the 
first  days,  according  to  the  force  of  retraction  with  which  the  uterine  walls 
were  endowed  immediately  after  or  during  the  delivery  of  the  after-birth ;  thus, 
at  times,  tlicy  are  very  copious,  frequently  coinciding  with  a  considerable  develop- 
ment of  the  organ ;  and,  in  such  cases,  I  have  known  the  womb  to  continue  a 
high  up  as  the  umbilicus  for  several  days  after  the  delivery. 

This  condition,  which  Leroux  calls  humoral  engorgement,  depends,  in  his  esti- 
mation, on  the  fact  that  the  vessels  and  pores  of  the  womb,  from  being  distended 


ATTENTIONS     TO    THE    WOMAN.  495 

with  blood,  do  not  become  empty  as  soon  as  usual,  because  the  contractility  of 
tissue  is  not  then  active  enough  to  expel  it;  for  the  walls  of  the  uterus  con- 
stitute a  true  sponge,  whose  meshes  are  composed  of  muscular  fibres,  and  which 
must  retract  forcibly  so  as  to  express  all  the  liquids  contained  in  the  vessels 
and  vacuities  which  they  form ;  hence,  if  this  contraction  is  not  strong  enough, 
the  parietes  remain  engorged,  and  preserve  an  abnormal  thickness,  which  singu- 
larly augments  the  whole  volume  of  the  uterus,  although  its  cavity  may  be  en- 
tirely effaced.  Soon,  however,  the  contractile  action  of  the  tissue  is  aroused,  and 
the  muscular  fibres  forcibly  compress  and  flatten  the  vessels  that  ramify  between 
them,  and  thus  force  the  liquids  which  had  hitherto  remained  there  to  discharge 
into  the  cavity  of  the  organ,  whence  they  flow  towards  the  exterior  in  conside- 
rable quantities.  This  discharge  might  very  readily  be  mistaken  for  a  flooding, 
occasioned  by  a  retention  of  some  part  of  the  after-bivth,  or  of  voluminous  coagula, 
the  more  especially  as  it  is  accompanied  at  times  by  sharp  after-pains;  bvit  if  one 
finger  can  then  be  introduced  into  the  uterus,  the  accoucheur  will  ascertain  that 
it  contains  no  foreign  substance,  and  by  placing  the  other  hand  at  the  same  time 
on  the  hypogastric  region,  he  will  easily  satisfy  himself  that  the  unusual  size  of 
the  organ  depends  only  on  the  engorgement  of  its  walls.  In  these  cases,  there 
is  nothing  to  be  done,  as  the  sanguineous  discharge  is  itself  the  best  remedy; 
for  it  slowly  empties  the  uterine  texture,  diminishes  the  after-pains,  and  the  womb 
gradually  returns  to  its  normal  size. 

This  slowness  of  the  retraction  also  prolongs  the  flow  of  the  sanguineous  lochia, 
and  the  same  result  is  observed  whenever  one  of  the  layers  of  the  uterus  or  its 
enveloping  cellular  tissue  is  aff"ected  with  inflammation.  Indeed,  we  can  readily 
understand  that  from  this  sluggishness  of  the  uterine  fibres,  this  defect  of  re- 
action, as  Leroux  called  it,  to  a  more  or  less  perfect  inertia  of  the  womb,  there  is 
but  a  single  step,  and  that  a  secondary  hemorrhage  might  result  from  the  absence 
of  contractility,  if  it  were  carried  to  the  extent  of  relaxation. 

Lactation  lessens  the  duration  and  amount  of  the  lochia.  Some  women  have 
them  for  a  few  hours  only  (Van-Swieten),  and  others  have  none  at  all  (Millot). 
An  instance  of  the  latter  kind  came  under  my  notice  quite  recently  (1855),  in 
the  case  of  the  young  wife  of  a  medical  friend.  After  an  easy  and  happy  labor, 
the  lochia  were  almost  completely  suppressed.  She  hardly  lost  a  few  spoonsful 
of  blood  within  the  first  twenty-four  hours ;  after  the  second  day  there  was  no 
discharge  whatever,  and  the  husband,  who  examined  the  linen  daily  with  the 
greatest  care,  assured  me  that  he  was  unable  to  detect  the  slightest  evidence  of 
lochial  discharge.  Everything  went  on  well  during  the  lying-in,  with  the  excep- 
tion of  a  very  fetid  odor  from  the  genital  parts  during  the  first  seven  or  eight 
days.  After  satisfying  ourselves  that  there  was  no  foreign  substance  in  the 
uterus,  we  recommended  the  use  of  injections,  frequently  repeated,  and  all  passed 
ofi"  well.  This  young  lady  had  been  delivered  once  before,  on  which  occasion 
she  had  a  perfectly  regular  lochial  discharge. 

In  a  case  observed  by  Bruckmann,  and  quoted  by  Velpeau,  the  lochia  were 
substituted  by  a  hsematemesis. 

In  some  instances,  the  sanguineous  lochia  are  prolonged  far  beyond  the  usual 


496  LABOR. 

term ;  while,  in  others,  they  reappear  at  various  intervals,  though  this  latter  cir- 
cumstance, in  the  absence  of  inflammation  of  the  uterus  or  of  its  appendages,  is 
ordinarily  owing  to  some  eri'or  in  regimen,  more  especially  to  getting  up  too  soon ; 
and,  therefore,  the  best  plan  is  to  persuade  the  patient  to  remain  in  bed.  In 
the  course  of  a  short  time  the  lochia  cease  their  continual  flow,  and  intervals  of 
several  hours  in  duration  are  observed  at  first,  then  of  a  day,  and  sometimes  of 
two  days. 

"When,  in  spite  of  this  precaution,  the  bloody  discharge  continues  for  two  or 
three  weeks  after  labor,  its  cause  should  be  sought  for  in  a  local  alteration  of  the 
uterus  and  of  the  neighboring  parts,  or  else  in  the  general  condition  of  the  patient. 
Thus,  it  is  not  unusual  for  it  to  be  kept  up  by  a  circumscribed  peritoneal  inflam- 
mation, an  inflammation  of  the  uterine  mucous  membrane,  a  chronic  or  acute 
engorgement  of  one  or  both  ovaries,  or  a  phlegmon  of  the  broad  ligaments,  of  the 
iliac  fossa,  or  of  the  cellular  tissue  surrounding  the  uterus. 

It  is  important  to  diagnose  these  various  aff"ections  from  the  outset,  as  it  is 
they  which  should  be  attacked,  in  order  to  stop  the  discharge,  which  is  here  but 
a  symptom  of  the  disease. 

The  continuance  of  red  discharges  is  connected,  perhaps,  more  frequently  with 
ulcerations  of  the  neck  of  the  uterus,  having  their  origin  in  many  cases  in  the 
lacerations  which  occur  during  labor,  and  the  cicatrization  of  which  is  prevented 
by  circumstances  which  elude  our  detection.  When,  therefore,  it  is  certain  that 
no  symptom  of  engorgement  or  inflammation  in  the  pelvic  or  hypogastric  region 
is  present,  the  patient  should  be  examined  with  the  speculum,  taking  care  to 
separate  the  lips  of  the  neck  with  the  valves  of  the  instrument,  when  very  often 
a  fungous  and  bleeding  ulceration  will  be  discovered  either  within  the  cavity  of 
the  neck  or  upon  the  os  tincro.  The  only  means  of  arresting  the  discharge  con- 
sist in  cauterizations  with  nitrate  of  silver  or  acid  nitrate  of  mercury,  and  even, 
if  the  fungosities  are  very  projecting,  with  the  actual  cautery.  In  some  cases,  it 
is  necessary  to  repeat  the  cauterizations  several  times. 

Amoncrst  the  causes  of  these  anomalous  lochial  discharges,  should  be  reckoned 
a  local  irritation  sustained  by  obstinate  constipation.  Here  the  use  of  purgatives 
is  demanded. 

Sometimes  no  lesion  can  be  discovered,  but  the  discharge  seems  evidently  to 
be  connected  with  an  over-excited  condition  of  the  entire  organism.  This  con- 
dition is  indicated  by  heat  of  the  skin,  fulness  of  pulse,  some  febrile  movement 
towards  evening,  and  disturbed  sleep.  Notwithstanding  the  apparent  weakness 
of  the  patient,  great  care  should  be  taken  in  reference  to  the  use  of  tonics, 
which,  unfortunately,  are  too  often  employed ;  a  moderate  antiphlogistic  treat- 
ment, on  the  contrary,  is  the  one  indicated.  A  small  bleeding  from  the  arm, 
mild  laxatives,  and  a  restricted  vegetable  diet,  might  be  directed  with  advantage. 
Stimulating  or  even  tonic  drinks  should  be  proscribed,  and  only  after  the  general 
irritation  shall  have  been  quieted,  is  it  proper  to  endeavor  to  increase  the  strength 
of  the  patient  by  the  appropriate  means. 

In  some  rare  cases,  however,  the  abundance  and  persistence  of  the  bloody  dis- 
charge seem  to  be  sustained  by  the  general  debility.    The  absence  of  the  general 


ATTENTIONS    TO    THE     WOMAN.  497 

symptoms  just  now  mentioned,  allow  of  recourse  being  had  immediately  to  a 
tonic  treatment;  then  it  is  that  infusions  of  cinchona  and  sulphate  of  iron  are 
capable  of  rendering  effectual  services.  (See  in  Part  Fifth  the  article  devoted  to 
Secondary  Hemorrhage.) 

The  white  or  purulent  lochial  discharges  sometimes  become  very  profuse,  and 
have  at  the  same  time  an  exceedingly  disagreeable  odor.  The  discharge  is  no 
longer  colored  with  blood,  but  appeai-s  as  a  reddish  water  flowing  in  large  quaa- 
tity,  and  sometimes  even  escaping  in  gushes.  They  are  occasionally  so  acrid  as 
to  inflame  the  parts  over  which  they  flow.  The  patients  are  almost  always  much 
weakened  by  the  evacuation,  and  their  general  health  evidently  demands  the  use 
of  tonics.  The  irritated  parts  should  be  washed  frequently  with  warm  water,  and 
injections  of  infusion  of  chamomile  flowers,  afterwards  made  rather  more  astrin- 
gent, should  be  thrown  into  the  vagina  five  or  six  times  a  day.  A  few  spoonfuls 
of  chloride  of  soda  might  be  added  with  advantage.  My  friend,  Dr.  Casaubon, 
informs  me  that  he  has  met  with  several  cases  of  this  kind. 

These  purulent  lochia,  also  sometimes  continue  long  after  the  usual  period  of 
their  cessation.  This  circumstance  is  sometimes  connected  with  some  one  of  the 
causes  mentioned  as  productive  of  the  anomalous  persistence  of  the  bloody  dis- 
charge, though  it  has  oftener  seemed  to  me  to  be  the  i-esult  of  a  catarrhal  metritis 
or  peri-uterine  phlegmon.  Both  these  affections  may  hinder. the  gradual  retrac- 
tion of  the  uterus,  which  may  remain  of  considerable  size  for  a  month  or  six 
weeks  after  delivery.  Large  flying  blisters  upon  the  abdomen,  frequent  alkaline 
baths,  and  bleeding  from  the  arm,  when  there  is  fever  and  the  strength  permits 
it,  have  appeared  to  me  to  be  the  most  effectual  under  these  circumstances. 

The  suppression  of  the  lochia  long  before  the  time  at  which  they  usually  dis- 
appear, is  an  unfortunate  symptom  only  when  it  seems  to  be  connected  with  the 
development  of  a  serious  inflammatory  affection,  or  when  it  is  replaced  by  a  sup- 
plemental hemorrhage.  It  then  merits  the  closest  attention  of  the  physician ; 
but  when  the  contrary  is  the  case,  there  is  no  occasion  for  uneasiness,  since  it  is 
the  evidence  of  a  rapid  and  forcible  contraction  of  the  uterus,  which  is  a  favor- 
able circumstance. 

§  3.  Of  the  Milk  Fever. 

One  of  the  most  important  phenomena  appertaining  to  the  lying-in  state,  is 
that  usually  designated  under  the  name  of  the  milk  fever.  It  has  already  been 
seen,  when  studying  the  modifications  impressed  on  the  whole  organism  by  ges- 
tation, that  the  breasts  in  most  women,  even  in  the  very  commencement  of  their 
pregnancy,  are  apt  to  become  tumefied,  that  the  swelling  persists,  and  that  some- 
times they  become  the  seat  of  an  abundant  secretion  long  before  delivery. 
After  the  delivery,  they  yield  on  suction  a  liquid  of  a  yellowish  color,  and  some- 
what more  consistent  than  the  preceding,  which  in  some  women  escapes  during 
the  latter  months  of  gestation.  This  fluid  has  a  sweetish  taste,  and  is  called  the 
colostrum.  It  retains  these  qualities  for  twenty-four  hours ',  but  becomes  whiter 
after  that  period.  In  the  course  of  forty  to  sixty  hours,  the  breasts  enlarge 
greatly;  the  subcutaneous  veins,  seen  through  the  skin,  are  more  swollen  than 

32 


498  LABOR. 

during  the  pregnant  state,  and  the  former  become  manifestly  harder.  Headache 
very  often  accompanies  this  enlargement,  as  also,  at  times,  though  more  rarely, 
slight  shiverings,  or  heat  and  dryness  of  the  skin,  which  is  succeeded  in  a  few 
hours  by  a  copious  perspiration  j  there  are  thirst  and  loss  of  appetite ;  the  tongue 
is  slightly  furred ;  the  pulse,  at  first  small  and  contracted,  soon  becomes  full,  soft, 
and  accelerated;  and  the  face  is  flushed  and  animated.  During  this  febrile 
movement,  which  is  generally  slight,  though  in  certain  cases  the  symptoms  may 
acquire  a  great  degree  of  intensity,  the  enlargement  of  the  mammae  continually 
increases,  extends  as  f-AV  as  the  arm-pits,  and  involves  the  surrounding  cellular 
tissue,  whence  the  patient  can  no  longer  bring  the  arms  down  alongside  of  her 
body,  and  therefore  has  to  hold  them  off.  The  skin  is  sometimes  so  stretched  as 
to  become  painful  and  incommode  the  inspiratory  movements  of  the  chest;  and 
lastly,  as  elsewhere  stated,  the  discharge  of  the  lochia  either  disappears  altogether, 
or  else  is  greatly  diminished.  This  fever  lasts  for  twelve,  twenty-four,  thirty-six, 
or  possibly  forty-eight  hours ;  and  then  is  followed  by  a  calm ;  at  times,  however, 
it  is  continued  for  three  or  four  days ;  but,  in  such  cases,  it  is  often  due  to  a 
deep-seated  inflammation,  or  else  soon  exhibits  a  well-marked  intermittence,  and 
may  degenerate  into  a  true  intermittent  fever,  which  yields  readily  to  sulphate 
of  quinine.  The  pulse  is  ordinarily  not  very  rapid,  and  whenever  it  exceeds  100 
per  minute,  the  cause  should  be  sought  elsewhere  than  in  the  lacteal  secretion. 

Authors  have  stated  that  the  milk  fever  is  less  intense  with  primiparas  than 
with  others.  The  same  is  the  case  with  those  who  begin  to  suckle  their  children 
very  soon  after  delivery ;  indeed,  it  is  not  at  all  uncommon  for  the  latter  to  escape 
it  entirely.  Finally,  certain  females,  even  of  those  who  do  not  nurse  at  all,  have 
no  milk  fever  whatever,  and  this  notwithstanding  that  the  breasts  are  conside- 
rably swollen  and  the  secretion  of  milk  is  abundant.  This  is  a  much  more  com- 
mon occurrence  than  is  generally  supposed,  and  I  have  frequently  had  occasion 
to  point  it  out  to  students.  Still,  I  am  far  from  supposing,  as  some  do,  that  it 
forms  the  rule,  and  from  regarding  every  febrile  movement  occurring  in  a  lying- 
in  woman,  even  when  the  lacteal  secretion  is  commencing,  as  indicative  of  an 
apparent  or  concealed  inflammation.  Nothing,  indeed,  could  be  more  reasonable 
than  to  regard  the  swelling  and  painfulness  of  the  mammary  glands  as  the  cause 
of  the  general  reaction  which  usually  accompanies  them,  and  which  diminishes 
or  ceases,  as  soon  as  the  breasts  become  soft,  or  the  system  habituated  to  the  new 
condition  of  things. 

In  some  women  the  breasts  remain  inactive,  and  no  milk  is  secreted;  it  really 
would  seem,  as  Prof.  P.  Dubois  has  remarked,  that  nature  has  left  her  work  un- 
finished in  them ;  that,  being  capable  of  becoming  mothers,  and  able  during  the 
whole  term  of  gestation  to  furnish  the  necessary  materials  for  the  child's  nutri- 
tion, yet  their  organization  is  absolutely  inadequate  to  supply  its  wants  aftjcr  birth. 
I  have  at  this  moment  under  observation  a  young  primiparous  woman,  convales- 
cing, it  is  true,  from  an  attack  of  varioloid  which  camtf  on  immediately  after 
delivery,  who  has  not  had  a  single  drop  of  milk. 

The  milk  fever  generally  manifests  itself  about  forty-eight  hours  subsequent  to 
the  delivery;  at  times  a  little  sooner,  at  others  somewhat  later;  thus,  I  have  seen 


ATTENTIONS    TO    THE    WOMAN.  499 

two  patients  at  the  Clinique  (and  all  observers  record  similar  facts),  wlio  had  this 
fever,  the  one  on  the  fifth  and  the  other  on  the  sixth  day ;  and,  since  that  time, 
I  have  often  had  occasion  to  make  the  same  remark. 

Where  the  child's  death  takes  place  at  an  advanced  stage  of  gestation,  and  the 
dead  body  is  not  expelled  for  several  days  afterwards,  it  is  by  no  means  uncom- 
mon to  find  all  the  phenomena  of  milk  fever  manifesting  themselves. 

In  ordinary  cases,  by  the  time  the  fever  is  over,  the  breasts  have  acquired  their 
highest  degree  of  distension,  and  the  secretion  of  milk  is  very  abundant.  If  the 
child  draws  well,  they  are  emptied  and  the  patient  relieved ;  but,  should  the 
mother  not  suckle  her  infant,  the  engorgement  continues  for  a  longer  period, 
though  it  wears  away  the  more  promptly  as  it  was  less  considerable  in  the  first 
place,  or  as  the  milk  flows  more  easily  from  the  nipple,  and  as  the  perspiration  and 
lochia  are  the  more  abundant. 

The  question,  as  to  the  cause  of  milk  fever,  has  been  discussed  again  and 
again ;  but,  without  entering  into  all  the  arguments  which  this  point  of  doctrine 
has  given  rise  to,  we  will  merely  remark,  that  the  febrile  movement  (which,  how- 
ever, is  not  always  constant)  most  probably  is  a  consequence  of  the  greater  acti- 
vity the  mammae  then  assume,  and  that  it  is  nothing  more  than  what  takes 
place  whenever  any  organ  undergoes  a  very  considerable  and  rapid  development. 

To  women  who  do  not  nurse,  the  lacteal  secretion  may  be  the  cause  of  acci- 
dents which  are  to  be  prevented  or  opposed.  Everything  that  could  tend  to 
increase  the  secretion  of  milk,  such  as  succulent  food,  and  the  practice  of  drink- 
ing freely,  should  be  strictly  avoided.  Warm  and  soft  towels  should  be  applied 
to  the  breasts,  and  renewed  as  soon  as  they  become  moist.  A  still  better  appli- 
cation is  cotton  wadding.  By  these  means  perspiration  is  excited,  and  the  heat 
of  the  parts  maintained.  Should  the  secretion  diminish  gradually,  everything 
may  be  left  to  nature,  but  should  the  breasts  become  too  much  swollen,  the  dis- 
charge from  the  nipple  should  be  facilitated  by  the  use  of  emollient  cataplasms, 
or  efforts  be  made  to  empty  them  by  suction.  In  case  of  these  measures  proving 
ineffectual,  recourse  must  be  had  to  lotions  containing  laudanum  for  the  purpose 
of  relieving  the  pain,  and  to  sudorifics  and  purgatives  as  revulsives.  As  amongst 
the  most  commonly-employed  diaphoretics,  we  may  mention  weak  tea,  and  the 
infusions  of  Parietarla  and  Borage.  The  purgatives  are  those  which  have  been 
already  mentioned.  Of  all  the  preparations  which  have  been  extolled  as  lacti- 
fuge,  the  2^ei  it-la  It  of  Weiss'  is,  according  to  Desormeaux,  the  only  one  which  is 
still  employed.  The  same  author  states  that  he  knew  a  lady  to  apply  an  ammo- 
niacal  liniment  with  success.  Neuter  asserts,  as  proved  by  experiment,  that  the 
application  of  cups  to  the  back,  diminishes  the  flow  of  milk,  and  Van-Swieten 
knew  a  galactorrhoea  to  yield  to  a  strong  infusion  of  sage,  taken  in  doses  of  from 
one  to  two  ounces  every  three  hours. 

'  The  petit  lail  (whey)  gf  Weiss,  is  prepared  by  infusing  in  boiling  whey  a  species  of 
galiunn,  flowers  of  elder,  hypericum,  and  of  the  linden  tree,  together  with  senna  and  sulphate 
of  soda.     It  acts  as  a  purgative. — Translator. 


500  LABOR. 

ARTICLE  VI. 

OF   THE   NECESSARY   ATTENTIONS   TO   THE   LTINO-IN   WOMAN. 

Hygiene. — The  patient  should  be  placed  in  a  large,  well-aired  chamber,  which 
is  moderately  warm,  and  free  from  all  strong  odors.  In  summer,  the  doors  and 
windows  are  to  be  opened  every  day ;  though,  while  the  air  of  the  apartment  is 
being  changed,  she  ought  to  be  carefully  covered,  and  have  the  curtains  drawn, 
so  as  to  protect  her  from  any  draft ;  but,  at  other  times,  the  curtains  need  not 
be  closed.  The  room  ought  to  be  kept  scrupulously  neat,  and  the  urine,  excre- 
ments, and  soiled  linen  should  be  removed  at  once.  The  genital  parts  must  be 
often  bathed  with  lukewarm  water,  or  some  emollient  decoction.  These  frequent 
ablutions  have  the  further  advantage  of  calming  any  inflammation  in  the  parts 
that  have  been  contused  during  the  labor ;  they  should  be  made  morning  and 
evening,  and  without  uncovering  the  patient. 

The  woman  should  make  no  exertion  during  the  first  few  days,  and  if  the  labor 
has  been  long  and  painful,  or  attended  with  any  serious  accident,  it  is  best  that 
she  should  be  protected  from  violent  and  rude  motions,  and  that  the  bed  be  not 
made  up  until  after  the  milk  fever  has  subsided.  When,  however,  the  patients 
are  but  slightly  fatigued,  the  bed  may  be  made  on  the  evening  of  the  day  pre- 
ceding that  on  which  the  milk  fever  supervenes,  after  which,  it  should  be  left 
until  the  next  day  but  one ;  thereafter  it  may  be  made  every  day.  The  woman 
should  on  these  occasions  be  transferred  to  another  couch. 

It  is  very  important  that  the  patient  should  not  rise  before  the  ninth  day;  and, 
where  she  is  in  easy  circumstances,  and  can,  without  detriment  to  her  interests, 
abstain  for  a  longer  period  from  her  household  duties,  she  should  be  required  to 
remain  in  bed  for  at  least  two  weeks.  At  this  period,  she  may  be  carried  to  an 
easy-chair,  where  she  will  remain  seated  for  an  hour  or  two,  and  again,  on  the 
following  day,  for  two  or  three  hours.  On  the  third,  she  might  try  her  strength 
by  making  a  few  turns  around  the  chamber,  and  then  through  the  apartments ; 
but  it  would  be  imprudent  to  venture  out  of  doors,  especially  in  the  winter  sea- 
son, before  the  fifteenth  or  twentieth  day,  and  only  then  in  fine  weather,  and 
about  the  middle  of  the  day. 

Most  women,  actuated  by  a  religious  feeling,  go  to  church  on  the  occasion  of 
their  first  going  out;  and,  as  these  buildings  are  always  cold  and  damp,  they 
often  return  with  the  germs  of  an  inflammatory  disease,  which,  sooner  or  later, 
develops  itself;  and  hence,  the  physician  should  advise  the  deferring  of  this  re- 
ligious ceremony,  called  the  churching,  to  a  more  distant  period. 

As  regards  her  diet,  the  articles  ought  to  be  of  the  mildest  character,  and  of 
easy  digestion;  thus,  as  a  general  rule,  she  will  only  need,  during  the  first  day 
or  two,  a  little  porridge  two  or  three  times  in  the  course  of  the  day,  and  some 
broth  during  the  night;  and  she  should  observe  an  abiblute  diet  pending  the 
duration  of  the  milk  fever,  for  fear  of  adding  to  its  intensity;  though  even  here, 
if  the  general  reaction  is  moderate,  she  might  be  allowed  some  broth.  After  the 
fever  is  over,  the  quantity  of  nourishment  is  gradually  augmented;  so  that,  by 


ATTENTIONS    TO    THE    WOMAN.  501 

the  twelfth  or  the  fifteenth  day,  the  woman  has  resumed  her  ordinary  habits.  In 
those  who  do  not  nurse,  the  regimen  must  be  more  restricted,  especially  when 
the  breasts  still  remain  engorged  or  painful. 

Throughout  the  whole  lying-in  period,  the  patient  should  use  some  diluted 
ptisan,  moderately  sweetened  and  rendered  aromatic,  as  an  ordinary  drink ;  such 
as  a  solution  of  gum,  or  an  infusion  of  mallows,  of  violets  or  linden,  the  orange 
or  chamomile  flowers,  &c.  &c.;  but  the  acidulated  drinks  must  never  be  allowed 
to  those  who  nurse.  About  the  seventh  or  eighth  day,  most  patients  ask  their 
medical  attendant  for  something  to  drive  away,  the  milk,  which,  of  course,  is 
generally  a  useless  precaution ;  but,  perhaps,  it  would  be  better  to  yield  to  a  very 
popular  prejudice,  so  as  to  escape  all  subsequent  reproach.  The  Canne  de  Pro- 
vence, and  the  infusion  of  periwinkle,  &c.,  enjoy  a  high  reputation  for  this  pur- 
pose ;  and,  as  the  root  of  the  former  is  nearly  inert,  it  will,  on  that  account,  be 
preferably  employed. 

The  excitability  of  the  nervous  system  is  such,  in  lying-in  women,  that  the 
greatest  care  should  be  exercised  in  keeping  away  everything  that  might  excite 
them,  and  in  avoiding  all  acute  moral  emotions. 

A  temporary  constipation,  prior  to  the  invasion  of  the  milk  fever,  is  a  matter 
of  no  consequence ;  but,  should  it  persist  for  several  days  afterwards,  injections 
may  be  administered,  either  simple,  or  else  rendered  slightly  kxative  by  the  addi- 
tion of  an  ounce,  or  an  ounce  and  a  half  of  the  miel  mercitriale,  or  a  decoction 
of  senna  leaves ;  and,  where  these  measures  do  not  answer,  a  mild  purgative,  such 
as  the  following,  is  exhibited  by  the  mouth,  viz.,  from  half  an  ounce  to  an  ounce 
OT  castor  oil,  rubbed  up  with  an  ounce  of  almond  emulsion  and  a  little  lemon 
syrup ;  or  the  sal  de  duohus  (sulphate  of  potash)  might  be  employed,  in  the  dose 
of  fifteen  or  thirty  grains,  dissolved  in  her  usual  drinks.  The  castor  oil  can  be 
swallowed  without  much  difficulty  when  it  is  diffused  in  a  cup  of  rich  broth, 
made  as  hot  as  the  patient  can  bear  it.  I  have  observed  that  it  is  much  oftener 
retained  when  given  in  broth  than  when  mixed  with  almond  emulsion. 

Most  women  think  it  necessary  to  be  purged  towards  the  end  of  their  lying-in; 
and  though,  when  the  physician  discovers  any  positive  counter  indication  to  the 
administration  of  even  a  mild  purgative,  he  doubtless  should  not  yield  to  their 
desires ;  yet,  under  ordinary  circumstances,  he  ought  to  purge  them  slightly,  both 
on  account  of  his  own  reputation  and  to  avoid  subsequent  unjust  reproaches; 
indeed,  this  will  become  necessary,  if  the  tongue  is  broad,  furred,  and  yellowish, 
or  greenish,  the  mouth  bitter  and  clammy,  and  there  is  loss  of  appetite.  The 
Seidlitz  waters  and  castor  oil  are  perhaps  preferable,  from  their  mildness  and 
certainty  of  operation. 


502  LABOR. 

CHAPTER  V. 

OF   THE   ATTENTIONS    TO   THE   CHILD  IMMEDIATELY   AFTER   ITS    BIRTH. 

The  nianageuient  of  the  new-born  infant  necessarily  varies  according  to  whether 
it  is  strong,  vigorous,  and  healthy;  or  whether,  on  the  other  hand,  it  is  born  in 
a  state  of  debility  or  disease. 

ARTICLE   I. 

OF   THE    CHILD   IX   A   HEALTHY    STATE. 

When  the  child  escapes  from  its  mother's  womb  living,  and  in  a  healthy  state, 
the  circulation  existing  between  it  and  the  placenta  is  observed  to  continue  for 
some  time,  where  the  delivery  is  abandoned  entirely  to  the  powers  of  nature ;  the 
after-birth  is  soon  detached  and  expelled,  and  then  it  as  well  as  the  cord  loses  its 
vitality,  the  circulation  becomes  weaker  and  weaker,  and  the  pulsations  in  the 
arteries  gradually  cease,  commencing  at  their  placental  extremity;  and  some 
authors  have  advised  this  event  to  be  waited  for  before  cutting  the  cord;  but  as 
this  spontaneous  delivery  most  generally  requires  a  long  time,  it  is  customary  to 
make  the  section  immediately  after  its  birth,  and  then  the  following  attentions 
to  the  new  being  become  necessary,  namely:  where  the  infant  is  entirely  clear  of 
the  mother's  parts,  the  cord  is  disengaged  if  it  had  been  twisted  around  its  neck 
or  body,  and  the  child  is  placed  on  the  side,  having  its  face  turned  away  from 
the  vulva,  so  that  it  may  breathe  freely  without  running  the  risk  of  being  suflFo- 
cated  by  the  liquids  that  escape  from  the  vagina.  The  umbilical  cord  is  next 
cut  at  about  five  or  six  fingers'  breadth  from  the  abdomen,  generally  using  the 
scissors  for  this  operation,  though  it  may  be  done  with  any  cutting  instrument 
whatever.  As  soon  as  the  section  is  effected,  the  cut  extremity  is  slightly 
pinched  between  the  thumb  and  forefinger,  while  the  remaining  three  fingers 
crasp  the  breech,  and  the  other  hand  is  placed  under  the  shoulders  and  neck  of 
the  child,  which  is  thus  lifted  out  of  the  bed,  and  placed  on  the  nurse's  knees 
prepared  for  its  reception.  It  may  then  be  examined  more  at  leisure,  to  ascer- 
tain that  no  loop  of  intestine  exists  at  the  base  of  the  cord,  and  to  permit  the 
latter  to  bleed  if  judged  advisable,  before  applying  the  ligature.  A  ribbon,  eight 
or  ten  inches  long,  may  be  used  for  this  latter  purpose,  or  a  cord  consisting  of  a 
skein  of  coarse  thread ;  but,  before  applying  it,  the  gut  is  to  be  reduced  if  there 
is  an  umbilical  hernia,  and  then  it  ought  to  be  tied  at  about  two,  three,  or  four 
inches  from  the  surface  of  the  abdomen;  the  only  precaution  requisite  is  to  avoid 
placing  it  around  the  skin,  which  is  prolonged  more  or  less  upon  the  cord;  for 
pain,  inflammation,  and  ulceration  would  thereby  result,  the  subsequent  cure  of 
which  might  be  attended  with  .some  difficulty.  As  a  general  rule,  it  is  best  to 
leave  sufficient  space  between  the  ligature  and  the  fold  of  the  skin,  to  allow  of 


ATTENTIONS    TO    THE     CHILD.  503 

the  application  of  a  second,  should  the  first  prove  insufficient.  The  ligatui'e 
must  be  drawn  tight  enough  to  obliterate  the  arteries  completely  and  permanently, 
without  cutting  their  coats.  If  the  cord  happens  to  be  thick  and  infiltrated,  the 
ligature  will  strangle  its  vessels  but  very  imperfectly ;  and  when  it  afterwards 
becomes  diminished  by  the  escape  or  evaporation  of  the  fluid  parts,  the  vessels 
being  no  longer  compressed,  will  obviously  permit  a  free  discharge  of  blood  from 
the  cut  end.  Besides,  the  putrefying  of  the  lymph  will  soon  produce  a  very  fetid 
smell,  and  irritate  the  skin  wherever  it  comes  in  contact;  and  it  is  therefore,  to 
prevent  such  accidents,  that  authors  very  properly  recommend  the  expression  of 
this  viscid  fluid  by  pressing  and  slipping  the  cord  between  the  fingers,  and  even 
by  pricking  its  enveloping  membrane,  taking  care,  however,  to  avoid  wounding 
its  vessels ;  and  lastly,  if  the  cord  were  unusually  large,  it  might,  for  greater 
security,  be  bent  backward  after  the  first  knot  was  tied,  and  be  included  in  a 
second  one.  Where  there  is  reason  to  suspect  a  twin  pregnancy,  it  is  necessary, 
after  cutting  the  cord  of  the  first-born,  to  apply  a  ligature  around  its  placental 
extremity  also.  Though  the  application  of  the  second  ligature  is,  in  most  cases, 
a  useless  precaution,  yet  the  fact  that  in  some  very  exceptional  cases  in  which  a 
communication  exists  between  the  vascular  ramifications  of  the  two  placentas,  it 
might  prevent  a  hemorrhage  which  would  quickly  prove  fatal  to  the  second  childj 
is  sufficient  reason  for  never  dispensing  with  it. 

Numerous  discussions  have  sprung  up  as  to  whether  the  ligature  of  the  umbi- 
lical cord  was  absolutely  indispensable,  and,  if  so,  whether  it  should  be  applied 
prior  to  the  section,  or  whether  the  cord  might  be  cut  before  it  is  tied.  Now, 
although  it  is  highly  probable  that  the  circulation  in  the  umbilical  vessels  would 
be  arrested  spontaneously,  after  the  regular  establishment  of  the  respiration ;  as, 
also,  that  the  ligature  is  almost  or  entirely  useless  in  the  great  majority  of  cases ; 
yet,  if  it  is  certain  that  a  hemorrhage  has  taken  place  in  some  few,  even  though 
they  be  exceptionable  instances,  from  the  cord  having  been  imperfectly  tied,  or 
else  not  ligated  at  all;  this,  of  itself,  is  a  sufficient  reason  for  not  neglecting  so 
simple  a  precaution ;  and  as  to  the  second  question,  the  course  just  pointed 
out,  is,  in  our  opinion,  decidedly  preferable. 

The  surface  of  the  chili's  body  is  next  to  be  cleansed  of  the  ceruminous 
(^ubstance  that  covers  it,  and  from  the  blood  and  other  matters  which  become 
attached  at  the  moment  of  delivery ;  but,  as  this  can  scarcely  be  removed  by  a 
simple  rubbing  with  dry  towels,  it  should  first  be  diluted  with  a  little  oil,  or  fresh 
butter,  and  then  be  gently  wiped  off;  the  yolk  of  an  egg  would  produce  the  same 
effect,  and,  besides,  would  render  this  matter  more  miscible  with  water.  To  get 
rid  of  the  blood,  and  other  impurities,  water  mingled  with  wine,  or  else  a  simple 
bath,  into  which  the  child  is  plunged,  is  most  generally  employed ;  the  tempera- 
ture of  the  bath  .should  be  about  twenty-five  degrees  (77°  Fahr.). 

The  infant  being  well  washed,  sponged,  and  wiped,  is  next  to  be  dressed;  but, 
before  doing  so,  the  physician  himself  should  first  envelope  the  cord  in  a  com- 
press intended  for  that  purpose ;  which  compress  is  merely  a  piece  of  fine  linen, 
of  a  square  shape,  and  having  an  opening  at  its  centre  large  enough  to  allow  the 
cord  to  pass  through  it  easily,  and  then,  after  having  ripped  one  of  its  sides  from 


504  LABOR. 

the  free  margin  down  to  this  hole,  the  root  cf  the  cord  is  lodged  at  the  bottom  of 
the  resulting  fissure ;  then  the  uncut  part  of  this  little  compress  remains  below, 
and  the  two  halves  of  the  divided  portion  are  turned  over  and  crossed  in  front  of 
the  cord,  the  whole  being  placed  at  the  upper  and  left  side  of  the  abdomen.  A 
second  soft  and  square  compress  covers  the  first,  and  a  band  three  or  four  fingers' 
breadth  wide,  and  long  enough  to  go  twice  round  the  body,  supports  the  whole  of 
the  little  apparatus  in  this  position. 

Before  enveloping  the  cord,  the  dressing  of  the  child  had  already  commenced, 
its  head,  arms,  and  chest,  being  then  covered.  The  rest  of  its  clothing  should 
be  warm,  soft,  and  moderately  tight.  In  France,  it  consists  of  a  camisole,  or 
little  woollen  jacket,  furnished  with  a  soft  chemisette  that  is  fastened  behind  by 
pins,  then  one  of  linen,  and  another  of  wool  or  cotton.  The  English  envelope 
their  children  in  a  long,  loose  robe,  or  something  like  a  flannel  sack. 

Before  dressing  the  child,  the  physician  should  ascertain  whether  it  is  affected 
with  any  malformation ;  and  during  the  three  or  four  days  following  its  birth,  he 
ought  carefully  to  watch  over  the  excretion  of  urine  and  of  meconium  (for  the 
expulsion  of  the  latter  is  sometimes  delayed  for  that  length  of  time),  and  to  faci- 
litate it  by  plunging  it  into  a  tepid  bath,  when  he  is  certain  the  infant  is  well 
formed.  The  prolonged  retention  of  the  meconium  is  also  an  indication  for  the 
employment  of  some  mild  laxative,  such  as  whey,  the  syrup  of  violets,  the  oil  of 
sweet  almonds,  or  manna;  the  compound  syrup  of  succory  is  also  very  gene- 
rally used,  or  the  compound  syrup  of  rhubarb,  either  alone,  or  mixed  with  sweet 
almond  oil,  in  the  quantity  of  two  drachms  or  half  an  oAnce  in  the  course  of  the 
day.  Some  persons  administer  these  gentle  remedies  to  all  children  without  dis- 
tinction, more  especially  to  those  that  are  wet-nursed,  for  the  purpose  of  supply- 
ing, they  say,  the  place  of  the  colostrum,  or  first  maternal  milk,  whose  slightly 
purgative  action  clears  out  the  intestinal  canal ;  but  the  warm  water  and  sugar 
ordinarily  given  to  the  child  as  nourishment  on  the  first  day,  is  usually  quite 
sufficient  to  facilitate  the  expulsion  of  the  meconium,  and  the  viscid  fluids  that 
sometimes  obstruct  the  fauces  and  stomach. 

All  questions  having  reference  to  the  hygiene  and  nursing  of  infants  will  be 
treated  of  in  a  special  chapter. 

ARTICLE  II. 

OP   THE    CHILD   IX   A   FEEBLE   OR   DISEASED   STATE. 

The  ordinary  attentions  to  the  child,  when  born  in  a  healthy  condition,  have 
just  been  described;  but  it  not  unfrequently  happens  that  the  infant,  at  the  mo- 
ment of  its  birth,  is  in  a  state  of  great  debility,  or  even  of  apparent  death,  which 
would  soon  be  followed  by  a  real  one,  if  adequate  measures  were  not  resorted  to 
at  once  to  prevent  it.  This  apparent  death  shows  itself  under  two  widely  dif- 
ferent aspects,  which  have  been  described  by  most  authors  as  the  apoplexy  and 
the  asphyxia  of  new-born  children.  Many  English  and  German  accoucheurs 
have  for  a  long  time  rejected  these  denominations,  as  characterizing  but  iniper- 


ATTENTIONS    TO    THE    CHILD.'  505 

feetly  the  pathological  conditions  to  which  they  were  applied;  and  M.  P.  Dubois, 
in  a  more  recent  article,  after  having  remarked  that  the  most  constant  anatomical 
character  of  apoplexy  in  the  adult  is  wanting  in  what  has  been  called  the  apo- 
plexy of  the  child,  and  that  wide  differences  also  exist  between  the  symptoms  of 
asphyxia  in  grown  persons,  and  those  of  the  asphyxiated  state  of  the  new-born 
infant,  likewise  concludes  that  the  same  name  has  been  improperly  applied  to 
such  dissimilar  conditions;  and  consequently  he,  like  M.  Ntegele,  designates  that 
state  of  the  child  in  which  no  sign  of  life  is  observed,  and  none  of  those  of  death 
is  recognized,  under  the  title  of  apparent  death. 

Both  terms  of  this  definition  are  evidently  contradictory,  since  death  is  charac- 
terized by  an  entire  absence  of  the  signs  of  life.  For  our  own  part,  we  regard 
apparent  death  as  a  state  in  which,  notwithstanding  the  abolition  of  the  actions 
of  animal  life,  some  at  least  of  the  functions  of  organic  life  continue,  and,  of 
necessity,  the  pulsations  of  the  heart. 

Now,  in  carefully  examining  the  symptoms  of  the  child's  apparent  death,  it  is 
found  that  it  is  sometimes  characterized  by  a  vivid  redness  of  the  fliee  and  upper 
part  of  the  body,  by  a  prominence  and  injection  of  the  eyeball,  and  a  swelling  of 
the  countenance,  the  skin  of  which  is  dotted  here  and  there  with  bluish  spots; 
while  at  others,  we  are  struck  with  the  discoloration  in  the  skin,  and  the  flabbi- 
ness  of  the  flesh.  In  the  former  case,  the  head  is  swollen  and  very  warm,  the 
lips  also  swelled  and  of  a  deep  blue  color;  the  eyes  start  from  the  head,  and  the 
tongue  adheres  to  the  roof  of  the  mouth ;  the  head  is  often  elongated,  hard,  and 
the  features  slightly  swollen;  the  pulsations  of  the  heart,  though  sometimes  quite 
strong  and  distinct,  are  at  others  obscure  and  feeble ;  occasionally  the  umbilical 
cord  is  distended  with  blood. 

In  the  second,  the  child  exhibits  a  mortal  pallor;  its  limbs  are  pendent  and 
flabby ;  the  skin  is  discolored,  and  is  often  soiled  by  the  meconium ;  the  lips  are 
pale;  the  lower  jaw  hangs  down,  and  the  umbilical  cord  and  heart  either  do  not 
jjalpitate  at  all,  or  but  very  feebly.  An  infont,  in  this  condition,  often  moves  at 
the  moment  of  birth  and  cries,  but  soon  falls  back  again  in  a  state  of  apparent 
death. 

These  diversities  in  the  physical  characters  of  children  born  in  a  state  of  ap- 
parent death,  may  be  occasioned,  doubtless,  by  various  causes,  though  they  are 
also  often  due,  simply,  to  a  greater  or  less  advanced  condition  of  the  same  patho- 
logical state  ;  hence  it  is  wrong  to  regard  them  as  the  characteristic  signs  of  quite 
dissimilar  lesions.  Therefore,  although  I  am  convinced  that  they  sometimes 
furnish  indications  for  very  different  kinds  of  treatment,  and  that  under  this 
point  of  view  it  is  important  to  observe  them  carefully,  I  cannot  regard  them  as 
affording  a  basis  for  nosological  distinctions  which  it  is  impossible  to  justify.  As 
the  expression,  ajjjjarent  death,  presupposes  nothing  in  regard  to  the  nature  and 
cause  of  that  state,  it  deserves  on  that  very  account  to  be  retained. 

That  what  we  are  about  to  state  respecting  the  apparent  death  of  new-born 
children  may  be  the  better  understood,  we  shall  give,  first,  a  brief  exposition  of 
the  mechanism  by  which  respiration  is  established  immediately  after  birth. 

All  physiologists  admit,  that  the  medulla  oblongata  is  the  centre  and  regulator 


506  LABOR. 

of  the  respiratory  movements  of  the  adult.  From  it  also  is  sent  forth  the  motor 
impulse  which  gives  rise  to  the  first  act  of  inspiration. 

Marshall  Hall  has  endeavored  to  prove,  experimentally,  that  the  first  inspira- 
tion is  the  result  of  a  reflex  action/  produced  by  the  excitement  of  the  nerves  of 
the  surface  of  the  body,  especially  of  the  tiifacial,  by  the  contact  of  the  external 
air,  and  that  the  respiration,  when  once  established,  is  sustained  through  the 
influence  of  the  reflex  action  due  to  the  irritation  of  the  pneumogastric  nerve  by 
the  contact  of  the  air  introduced  into  the  lungs. 

The  same  physiologist  also  holds  that  the  respiratory  movements  may  take  place 
under  the  influence  of  other  causes;  such,  for  example,  as  the  impression  pro- 
duced upon  the  medulla  oblongata  by  a  great  loss  of  blood,  as  also  the  excite- 
ment which  it  undergoes  from  the  contact  of  venous  blood.  Into  the  latter 
category  enter  all  the  respiratory  movements  of  incomplete  asphyxia. 

In  normal  cases,  the  foetus  having  in  no  wise  sufi"ered  during  the  labor,  retains 
its  cutaneous  sensibility  intact,  and  the  irritation  produced  by  the  contact  of  the 
air  with  the  cutaneous  nerves  is  transmitted  to  the  medulla  oblongata,  which, 
acting  in  its  turn  upon  the  inspiratory  nerves,  produces  the  movements  of  respi- 
ration. 

But  should  it  happen  that  the  foetus  from  the  moment  of  birth  has  been 
deprived  for  a  certain  time  of  those  means  of  respiration  which  it  finds  in  the 
placenta,  or  that  the  latter  being  separated  immediately  after  the  child  is  ex- 
pelled, any  obstacle  should  arise  to  the  introduction  of  air  into  the  bronchia,  there 
would  be,  in  both  cases,  a  commencement  of  asphyxia.  The  contact  of  the  non- 
oxj^genated  blood  would  irritate  the  medulla  oblongata,  and  this  irritation  being 
transmitted  to  the  inspiratory  nerves,  may  also  give  rise  to  respiratory  move- 
ments of  the  muscles  of  the  face,  breast,  and  abdomen,  and  produce,  in  short,  the 
first  inspiration.^     The  central  motor  impulse  would  soon  be  substituted  by  the 

'  An  impression  made  upon  our  organs  may  £[ive  rise  to  movements  of  different  charac- 
ters, by  pursuing  different  routes  to  the  cerebro-spinal  axis.  Thus,  sometimes,  wlien  trans- 
mitted directly  to  the  encephalon  by  the  sensitive  nerves  of  the  cranium,  or  indirectly 
through  the  nerves  of  the  spinal  marrow,  it  is  transformed  into  a  sensation  in  that  part  of 
the  encephalon  in  wliich  the  sensornim  commune  is  situated,  and  consequently  reaches  the 
consciousness  of  the  animal,  who  is  then  capable  of  reacting  by  voluntary  movements.  Some- 
times, also,  it  is  transmitted  by  the  nerves  of  sensation  either  to  the  encephalon  or  to  the 
spinal  marrow,  which  impression,  without  necessarily  being  transformed  into  a  sensation, 
may  produce  an  excitement  which  is  immediately  reflected  upon  the  motor  nerves,  and  gives 
rise  to  the  so-called  reflex  movements,  in  the  production  of  which  the  will  has  no  part  what- 
ever. 

The  power  which  thus  gives  rise  to  movements  without  the  participation  of  the  will,  has 
been  regarded  as  a  special  endowment  of  the  cerebro-spinal  axis,  and  has  been  designated 
as  the  reflex  power,  faculty,  or  properly. 

*  Marshall  Hall  removed  the  brain  of  a  kitten,  cut  the  pneumogastric  nerves,  and  opened 
the  trachea.  He  found  the  respiration  to  become  slower,  though  it  continued  with  regularity. 
When  he  stopped  the  opening  in  the  trachea,  the  scene  changed  immediately;  the  animal 
opened  its  mouth  widely,  made  violent  inspiratory  efforts,  and  was  affected  with  some  move- 
ments of  a  convulsive  character.  When  the  trachea  was  re-opened,  the  respiration  became 
as  regular  as  before,  and  when  closed  again,  the  symptoms  of  asphyxia  reappeared;  in  both 


ATTENTIONS    TO    THE    CHILD.  507 

reflex  action  of  the  ramifications  of  the  pneumogastric  nerves,  which  are  irritated 
by  the  air  introduced  into  the  lungs,  and  the  respiration  would  continue  under 
its  influence. 

When  the  foetus  is  threatened  with  asphyxia  in  the  latter  stages  of  pregnancy 
or  during  labor,  in  consequence  of  compression  of  the  cord  or  separation  of  the 
placenta,  its  death  is  preceded  by  convulsive  movements  and  efforts  to  breathe; 
then  the  mothers  tell  us,  that  the  child,  after  having  moved  actively,  suddenly 
became  quiet ;  and  Beclard  saw  a  foetus  enclosed  in  the  unruptured  membranes 
make  inspiratory  movements,  and  breathe  water  instead  of  air.  It  is  for  this 
reason,  also,  that  in  certain  positions  of  the  face,  the  child  has  been  enabled  to 
respire,  although  still  enclosed  in  its  mother's  womb;  and  the  uterine  vagitus, 
which  always  supposes  a  previous  inspiration,  can  be  explained  in  no  other  man- 
ner. In  all  these  cases,  in  fact,  the  non-oxygenated  blood  acts  as  an  irritant  to 
the  medulla  oblongata,  which  transmits  the  irritation  in  its  turn  to  the  nerves  of 
inspiration.     Nothing  can  be  claimed  here  for  reflex  action. 

We  must  be  careful,  however,  not  to  confound  these  two  exciters  of  the  inspi- 
ratory act.  The  first  is  the  natural  excitant,  whilst  the  other  is  always  patholo- 
gical, and  only  intended  to  replace  the  normal  stimulus.  Now,  every  pathological 
act  is  but  an  effort  to  accomplish  some  physiological  process,  which  has  become 
difficult  or  impossible ;  and  though  it  may  in  some  cases  restore  life  to  a  child,  it 
is  likely,  in  many  others,  to  prove  insufficient. 

It  very  often  happens  that  a  child  born  in  a  semi-asphyxiated  condition,  in 
consequence  of  a  difficult  labor,  makes  a  few  sudden  and  violent  inspiratory  move- 
ments, but  would  nevertheless  succumb  rapidly,  were  not  the  reSex  action  called 
into  play,  and  did  it  not  soon  replace  completely  the  pathological  excitant,  which, 
just  before,  had  acted  alone  upon  the  spinal  marrow.  As  the  skin,  in  this  state 
of  diminished  sensibility,  is  no  longer  stimulated  sufficiently  by  the  external  air, 
special  means  should  be  resorted  to  whilst  there  is  yet  time  to  arouse  the  excito- 
motor  action  of  the  cutaneous  nerves,  and  provided  the  asphyxia  has  not  gone  too 
far,  they  will  often  be  crowned  with  success.  But  if  the  child  is  small  and 
feeble,  or  if  the  causes  of  the  asphyxia  have  acted  for  too  long  a  time,  the  con- 
tractions of  the  inspiratory  muscles  are  feeble  and  distant,  and  soon  cease  en- 
tirely; the  heart,  too,  ceases  to  beat,  and  the  child  dies.  Though,  whilst  the 
heart  is  still  beating,  we  may  succeed  in  exciting  the  reflex  action  of  the  muscles 
of  inspiration,  to  the  extent  of  producing  a  sudden  inspiratory  movement  after 
every  excitation,  the  symptoms  of  asphyxia  remaining,  however,  unchanged,  the 
child  will  die  in  spite  of  all  that  can  be  done. 

If  it  be  true  that  the  impression  produced  by  the  external  cold  upon  the  skin 
of  the  body  and  face,  is  the  first  and  only  cause  of  the  reflex  action  of  the  medulla 
oblongata  upon  the  nerves  of  inspiration,  and  thus  produces  the  first  inspiratory 
act,  we  can  readily  understand  that  everything  calculated  to  diminish  notably  or 
to  destroy  the  cutaneous  sensibility,  will  retard,  or  even  render  impossible,  the 

these  cases,  the  central  organ,  or  the  medulla  oblongata,  was  evidently  the  source  of  the  re- 
spiratory impulse ;  since  the  destruction  of  the  brain  and  the  section  of  the  pneumogastric 
nerves  rendered  all  reflex  action  impossible. 


508  LABOR. 

first  inspiratory  effort,  and  reduce  the  foetus  to  a  state  of  apparent  death.  The 
causes  of  the  latter  are,  therefore,  such  as  paralyze  to  a  greater  or  less  extent  the 
nervous  centres,  whose  influence,  though  completely  foreign  to  the  maintenance 
of  foetal  life,  becomes  indispensable  to  the  establishment  and  continuance  of 
extra-uterine  existence. 

Now,  these  causes  are  quite  numerous ;  and,  with  the  exception  of  a  few,  exert 
their  destructive  influence  during  the  latter  periods  of  labor.  They  may  be 
divided  into:  1,  lesions  of  respiration;  2,  lesions  of  circulation;  3,  lesions  of 
the  nervous  centres.  The  first  are  capable  of  producing  various  degrees  of 
asphyxia ;  the  second  may  give  rise  to  a  fatal  hemorrhage  as  regards  the  child ; 
the  third  aifcct  the  nervous  centres  directly,  and  render  them  incapable  of  per- 
forming the  functions  to  which  they  arc  destined  immediately  after  birth. 

1.  Lesions  of  the  Respiration. — These  are  occasioned  by  everything  which 
obstructs  the  respiration.  Thus,  there  have  been  pointed  out  as  occurring  during 
labor,  the  compression  of  the  umbilical  cord  between  the  sides  of  the  pelvis  and 
the  head  or  body  of  the  child;  the  winding  of  the  cord  so  tightly  around  the 
neck  or  some  other  part,  as  to  obstruct  simultaneously  the  venous  circulation  ia 
the  brain,  and  that  of  the  blood  in  the  umbilical  vessels ;  the  premature  separa- 
tion of  the  placenta,  whether  it  be  inserted  upon  the  neck  or  not,  for  sin<Je  the 
separation  necessarily  produces  the  rupture  of  the  utero-pJacental  vessels,  it  ren- 
ders the  foetal  haematosis  as  impossible  as  does  the  compression  of  the  cord ;  the 
great  retraction  of  the  uterus,  when  in  delivery  by  the  breech  the  head  only 
remains  in  the  excavation,  and  the  child  is  unable  to  respire ;  for  this  retraction 
renders  the  vessels  of  the  uterus  almost  impermeable  to  blood.  In  all  these 
cases,  the  asphyxia  results,  evidently,  from  a  suspension  of  the  placental  respira- 
tion, and  it  is  the  contact  of  black  blood  with  the  brain,  which  paralj-zes  its  action 
in  the  foetus  as  well  as  in  the  adult. 

Finally,  it  is  plain  that  after  the  child  is  born,  the  accumulation  of  mucus  in 
the  nose,  mouth,  and  air-passages,  may  also  produce  asphyxia  by  preventing  the 
introduction  of  air  into  the  bronchiae ;  here,  however,  the  mode  of  operation  is 
precisely  the  same  as  in  the  adult,  since  it  results  from  a  mechanical  obstacle  to 
the  introduction  of  the  external  air  into  the  pulmonary  vesicles. 

In  consequence  of  the  action  of  some  one  of  these  causes,  the  foetus  may  be 
born  in  a  state  of  apparent  death,  and  exhibit  the  very  diff"erent  symptoms  which 
we  have  already  mentioned ;  thus,  in  most  cases,  the  surface  of  the  body  has  a 
swollen  appearance,  and  is  of  a  violet,  or  rather  of  a  blackish-blue  color,  the  dis- 
coloration being  more  marked  at  the  upper  parts  of  the  trunk,  and  more  particu- 
larly on  the  face  than  elsewhere.  The  muscles  do  not  exhibit  any  motion ;  the 
limbs  preserve  their  flexibility,  and  the  body  its  heat ;  the  pulsations  of  the  cord, 
of  the  radial  artery,  and  even  those  of  the  heart,  are  obscure  or  insensible. 

Where  a  j)ost-viortem  examination  is  made,  the  vessels  of  the  encephalon  are 
found  engorged  with  blood ;  at  times,  this  fluid  is  even  efl"used  on  the  surface  of 
the  membranes,  or  into  the  substance  of  the  brain  itself,  though  most  generally, 
saj's  M.  Cruveilhier,  the  efi'usion  is  limited  to  the  surface  of  the  cerebellum ; 
sometimes  it  covers  the  posterior  lobes  of  the  cerebrum,  but  it  is  rarely  found  in 


ATTENTIONS    TO    THE     CHILD.  509 

the  ventricles  of  the  brain ;  and,  in  all  the  cases  examined  by  him,  there  was 
blood  enough  in  the  cavity  of  the  vertebral  arachnoid  membrane  to  distend  the 
dura  mater.  Again,  those  congestions  of  the  liver,  that  are  so  common  in  infants, 
are  then  particularly  apt  to  be  met  with  ;  but,  says  ]5illard,  they  vary  considerably 
as  regards  the  quantity  of  blood  accumulated  in  the  tissue  of  the  organ ;  for,  in 
some  instances,  it  is  found  there  in  such  great  abundance  as  to  give  rise  to  a  san- 
guineous exudation  on  the  exterior  of  the  organ,  the  convex  surface  of  which  is 
discolored  and  moistened  by  a  layer  of  effused  blood,  and  I  have  even  known  an 
extravasation  of  this  fluid  into  the  abdomen  to  result  from  this  turgescence. 
The  lungs  are  also  gorged  with  blood. 

The  external  condition  of  the  asphyxiated  fcetus  is  not  always  such  as  we  have 
just  described,  for,  as  M.  Jacquemier  has  observed,  nothing  is  more  common 
to  find  the  foetus  born  without  any  anomalous  coloration  of  the  skin,  and  even 
with  a  remarkable  degree  of  pallor  and  flaccidity  of  the  limbs  ;  and  this,  notwith- 
standing the  apparent  death  has  been  produced  by  compression  of  the  cord.  Can 
this  difference  be  due,  as  M.  Jacquemier  supposes  in  the  latter  case,  to  a  sudden 
suspension  of  the  placental  respiration,  whilst  in  the  former  the  cessation  was 
slow  and  gradual  ?  This  explanation  is  probable,  inasmuch  as  the  same  differ- 
ences are  observed  in  the  asphyxia  of  adults,  and  as,  according  to  M.  Devergie, 
those  persons  who  are  killed  by  the  falling  in  upon  them  of  earth,  present  the 
same  discoloration  of  the  integuments.  The  suddenness  of  the  real  death,  may 
explain  the  peculiarity  under  these  circumstances ;  but  it  must  not  be  forgotten 
that  this  external  pallor  is  also  the  consequence  of  a  slow  but  prolonged  asphyxia, 
and  that  it  often  succeeds  to  the  violet  hue  of  the  tissues ;  that  we  every  day 
witness  this  succession  going  on  before  our  eyes  when  the  asphyxia  has  lasted 
too  long,  and  that  a  child  born  with  a  very  deep  color,  becomes  rapidly  pale  and 
flaccid,  if  the  means  employed  fail  to  excite  respiration. 

In  the  latter  case,  the  discoloration  of  the  tissues  is  the  symptomatic  expres- 
sion of  a  more  advanced  stage :  the  pulsations  of  the  heart,  which  before  were 
sufficiently  strong  and  rapid,  become  less  frequent  and  feebler,  return  only  at  long 
intervals,  and  real  death  soon  succeeds  to  the  apparent  one.  Now,  these  pheno- 
mena, which  we  observe  occasionally,  take  place  in  the  same  manner  whilst  the 
foetus  is  still  contained  in  the  womb,  but  is  deprived  of  the  placental  respiration. 

When,  at  the  moment  of  birth,  the  asphyxia  has  lasted  but  a  short  time,  the 
child  will  exhibit  turgescence  of  the  fixce,  the  violet  hue  of  the  skin,  firmness 
of  flesh,  and  frequent  and  regular  pulsations  of  the  heart;  if  a  longer  period  has 
elapsed  since  the  interruption  of  the  foe  to-maternal  cii'culation,  the  child  will  be 
pale  and  discolored,  and  the  pulsations  of  the  heart  and  cord  feeble  and  intermit- 
ting; finally,  if  the  asphyxia  has  lasted  longer  than  is  compatible  with  the  life  of 
the  heart,  the  child  will  be  really  dead  at  the  time  of  its  expulsion. 

These  two  conditions,  which  are  apparently  so  different,  are  due  to  the  same 
cause,  and  are  simply  two  degrees  of  asphyxia.  Though,  in  an  etiological  sense, 
no  distinction  can  be  made  between  them,  they  are  important  as  regards  the 
prognosis,  for  one  is  much  more  serious  than  the  other,  and,  as  regards  treatment, 
the  same  means  are  not  applicable  to  both. 


510  LABOR. 

M.  Pajot  informs  me  that  he  has  found  these  observations  to  hold  true  as 
regards  the  adult. 

2.  Lesions  of  the  Foetal  Circulation. — Ruptures  of  the  cord  or  of  the  placenta, 
may,  of  themselves,  give  rise  to  such  a  degree  of  hemorrhage  as  to  endanger  the 
life  of  the  foetus;  fortunately,  however,  they  are  quite  rare.  When  the  hemor- 
rhage is  profuse,  the  child  dies  before  the  labor  is  over;  but  should  anything 
happen  to  arrest  the  discharge  of  blood,  the  child  may  be  born  alive,  but  in  a 
state  of  apparent  death  resembling  syncope.  The  deficiency  of  nervous  influ- 
ence is  here  manifestly  due  to  the  fact  that  the  medulla  oblongata  and  the  brain 
no  longer  receive  a  sufficient  amount  of  blood  to  enable  them  to  react  upon  the 
nerves  of  inspiration.  The  condition  is  a  most  dangerous  one.  The  child  is 
pallid,  and  its  muscles  completely  relaxed ;  sometimes,  however,  it  makes  a  few 
short  inspirations,  and  utters  some  very  feeble  cries ;  but  if  the  hemorrhage  has 
been  at  all  profuse,  it  succumbs  in  a  very  short  time. 

3.  Lesions  of  the  jVervous  Centres. — The  cerebro-spinal  system  presides  over 
none  of  those  functions  whose  integrity  is  necessary  to  the  maintenance  of  foetal 
life;  the  respiration,  circulation,  and  nutrition,  being  subject  exclusively  to  the 
nerves  of  organic  life.  These  ganglions  and  their  nerves  derive  from  the  arte- 
rial blood  that  principle  of  organic  sensibility  and  motility  which  is  necessary  to 
the  production  of  involuntary  or  automatic  movements,  as  also  to  the  maintenance 
of  the  irritability  and  vitality  of  the  organs.  Although  the  foetus  possesses 
organs  of  animal  life,  its  vitality  is  purely  vegetative  or  organic.  This  fact 
serves  to  explain  the  life  and  development  of  acephalae,  for  where  the  organs  are 
absent,  the  functions  are  also  wanting;  yet  these  monsters  are  endowed  with 
irritability,  are  capable  of  motion,  and  their  life  is  preserved  intact,  until  the  ter- 
mination of  pregnancy. 

Since  the  brain  and  spinal  marrow  have  nothing  to  do  with  the  performance 
of  the  foetal  functions,  we  readily  foresee  that  any  lesions  which  may  affect  them 
during  pregnancy  or  labor,  cannot  disturb  the  harmony  of  those  functions,  or 
have  any  influence  whatever  upon  the  intra-uterine  vitality.  Therefore,  it  is  only 
after  birth  that  the  cerebro-spinal  alteration  or  paralysis  prevents  the  establish- 
ment of  animal  life,  even  though  the  organic  life  is  still  manifested  by  the  inte- 
grity of  the  circulation,  and  even  of  the  placental  respiration.  The  first  respira- 
tory act  is,  as  we  have  said  before,  the  consequence  of  an  excitement  of  the 
medulla  oblongata,  produced  by  the  impression  of  the  temperature  of  the  sur- 
rounding air  upon  the  skin  of  the  new-born  child.  For  this  impression  to  be 
effectual,  however,  it  is  necessary  that  the  sensation  should  be  perceived  by  the 
central  organ,  which  is  rendered  incapable  of  perceiving  it  by  serious  lesions 
of  the  cerebro-spinal  axis.  This  important  distinction  should  therefore  be  made 
between  the  various  circumstances  capable  of  reducing  the  foetus  to  the  state  of 
apparent  death,  namely,  that  the  foetus  may  be  destroyed  in  the  womb  by  as- 
phyxia and  hemorrhage,  whilst  lesions  of  the  nervous  centres  always  cause  it  to 
be  born  in  a  state  of  apparent  death. 

We  should  also  interpret  in  this  way  the  effect  which  may  be  produced  by  the 


ATTENTIONS    TO     THE     CHILD.  511 

violent  compression  whicli  the  brain  undergoes  in  certain  cases  of  contracted 
pelvis: ;  that  which  may  result  from  the  application  of  the  forceps  or  lever  under 
circumstances  of  difficulty;  that  which  results  from  vascular  congestion  due  to 
an  obstruction  to  the  return  of  venous  blood  in  certain  deliveries  by  the  face ;  in 
cases  where  the  cord  is  wound  tightly  several  times  around  the  neck,  as  also 
where  it  is  strongly  grasped  by  a  spasmodic  contraction  of  the  neck  of  the  uterus ; 
and  finally,  to  the  compression  sometimes  produced  by  effusions  of  blood,  either 
upon  the  surface,  or  into  the  substance  of  the  brain  itself. 

So,  also,  is  to  be  explained  the  mode  of  action  of  lesions  of  the  medulla  oblon- 
gata, such  lesions  as  we  know  are  easily  produced  by  extreme  rotation  of  the 
head,  by  tractions  upon  the  head,  or  the  pelvis  when  the  head  is  arrested  in  an 
elevated  position,  and  finally,  by  effusions  at  the  base  of  the  brain  and  upper  part 
of  the  vertebral  canal. 

As  lesions  of  the  brain  are  not  absolutely  incompatible  with  the  establishment 
of  respiration,  they  are  not  so  dangerous  as  those  of  the  medulla  oblongata.  The 
destruction  of  a  large  portion  of  the  encephalon  has  not  always  prevented  the 
child  from  breathing  and  crying  after  its  birth,  and  even  from  living  for  several 
days.  A  smilar  fact  is  presented  by  anencephalous  foetuses.  By  this  we  are 
advised  that  in  difficult  labors,  the  temporary  compression  of  the  head  may 
also  suspend  momentarily  the  action  of  the  brain,  but  that  .as  this  suspension 
does  not  absolutely  preclude  respiration,  the  species  of  shock  or  concussion  which 
the  brain  experiences  may  pass  away  so  soon  as  not  to  interfere  with  the  continu- 
ance of  life. 

It  is  different,  however,  with  lesions  of  the  medulla  oblongata,  which  is  the 
only  motor  of  the  respiratory  movements  :  it  cannot  be  seriously  affected  without 
rendering  extra-uterine  life  impossible.  This  explains  the  frequent  death  of 
children  in  pelvic  presentations,  when  tractions  have  been  made  upon  the  trunk 
with  the  object  of  disengaging  the  head. 

Treatment. — Since  apparent  death,  however  produced,  may  present  the  very 
different  symptoms  already  mentioned,  it  is  evident  that  mere  inspection  of  the 
child  can  afford  no  information  as  to  the  cause  of  its  condition.  Although  we 
regard  the  discoloration  of  the  skin  and  relaxation  of  the  extremities  as  signs  of 
very  grave  import,  it  is  impossible  to  determine  the  extent  of  the  cerebral  disor- 
ders, and  consequently  to  foresee  the  result  of  measures  calculated  to  restore  the 
child.  In  this  state  of  uncertainty,  all  cases  should  be  treated  as  though  they 
afforded  a  chance  of  success.  The  lapse  of  half  an  hour,  an  hour,  or  even  more, 
from  the  time  of  delivery,  is  not  sufficient  cause  for  despair,  since  a  number  of 
facts  may  be  mentioned  going  to  prove  that  children  have  been  in  an  asphyxi- 
ated condition  for  an  hour,  and  were  afterwards  restored  to  life.  Long-continued 
silence  of  the  heart,  the  entire  absence  of  pulsations  at  the  prcecordial  region, 
frequently  determined  at  intervals,  is  the  only  sign  which  can  be  regarded  as 
destructive  of  all  hope.  The  heart  is  the  ultimum  moriens,  and  I  do  not  believe 
that  efforts  to  restore  its  pulsations,  when  once  completely  extinguished,  have 
ever  been  crowned  with  success.     But  the  softness  and  flaccidity  of  the  tissues. 


512  LABOR. 

and  coldness  of  the  body  and  ftice/  are  no  reason  for  abandoning  the  child,  pro- 
vided the  heart  still  beats,  however  feebly,  slowly,  or  irregularly. 

When  the  child  is  born  with  a  general  injection  of  the  capillaries  of  the  face 
and  trunk,  when,  in  short,  it  presents  the  characters  of  the  state  formerly  termed 
apoplexi/,  it  is  evident  that  the  first  indication  is  to  relieve  the  engorgement  of 
the  head  and  lungs,  which  is  done  by  promptly  cutting  the  umbilical  cord,  and 
allowing  a  few  spoonfuls  of  blood  to  escape;  when  the  respiration  is  most  usually 
established  soon  after,  if  there  are  no  mechanical  obstacles,  such  as  mucus  in  the 
fauces,  to  the  introduction  of  air  into  the  lungs;  and,  where  these  do  exist, 
they  may  be  removed  by  the  extremity  of  the  little  finger,  or  with  the  feathered 
end  of  a  quill ;  the  blue  and  violet  color  of  the  surface  will  then  be  found  to  gra- 
dually disappear,  and  give  place  to  a  rosy  hue,  at  first  on  the  lips,  then  on  the 
cheeks,  and  afterwards  over  the  rest  of  the  body.  However,  in  practice,  we  some- 
times find  the  circulation  so  enfeebled  or  benumbed,  as  it  were,  that  the  blood 
will  not  run  from  the  umbilical  arteries ;  its  effusion  may  then  be  encouraged  by 
plunging  the  child  into  a  warm  bath,  or  by  squeezing  the  cord  several  times  from 
its  insertion  towards  the  cut  extremity;  and  where  this  does  not  prove  successful 
in  obtaining  blood,  some  advise  the  application  of  a  leech  behind  each  ear.  But 
as  this  application  would  occasion  the  loss  of  precious  time,  it  is  better  to  have 
recourse  at  once  to  the  following  measures  : 

The  small  bleeding  being  practised  or  not,  every  effort  should  be  made,  by  the 
use  of  various  stimulants,  to  excite  the  sensibility  of  the  skin,  and  the  reflex 
action  of  the  cutaneous  nerves. 

According  to  Marshall  Hall,  the  best  plan  is  to  sprinkle  the  face  and  body  of 
the  child  vigorously  with  cold  water;  immediately  after  which,  it  should  be  ini- 
mersed  in  a  warm  bath,  and  then  wrapped  in  warm  flannels.  The  efliciency  of 
this  plan  of  treatment,  which  may  be  repeated  several  times,  depends,  espe- 
cially, upon  the  rapidity  with  which  it  is  executed.  The  impression  of  both  the 
cold  and  heat  should  be  sudden.  Afterwards,  the  skin  may  be  stimulated  by 
frictions  with  the  hand,  or  a  brush,  by  dry  flannel,  or  with  any  irritating  liquors, 
such  as  vinegar  or  brandy;  M.  Moreau  strongly  recommends,  and  with  reason, 
slight  blows  to  be  made  with  the  palmar  surface  of  the  fingers  upon  the  shoulders 
and  thighs.  In  grave  cases,  I  prefer  flagellating  the  thorax  and  loins  vigorously 
with  a  piece  of  wet  linen.  It  is  also  often  very  useful  to  irritate  the  mucous 
surfaces.  A  little  brandy  or  vinegar  may  be  placed  in  the  mouth,  or  the  fumes 
of  burnt  paper  blown  into  the  anus.  A  feather  may  be  dipped  into  vinegar  and 
then  introduced  into  the  nose  or  fauces ;  this  may  be  used  at  the  same  time  to 
clear  away  the  mucous  secretions  of  the  latter,  which  prevent  the  inhalation  of 
air ;  and,  where  there  is  reason  to  suppose  that  such  secretions  have  accumulated 
to  a  considerable  extent  in  the  air-passages,  the  advice  of  Dewees  should  be  fol- 
lowed, by  placing  the  child  on  its  belly,  taking  care  to  elevate  the  feet  higher 
than  the  head,  and  at  the  same  time  gently  shaking  it,  so  as  to  clear  out  the 

•  Tlie  experiments  of  M.  Brown-Sequard  on  warmblooded  animals,  prove  that  the  time 
for  which  they  are  capable  of  resisting  asphyxia  is  greater  in  proportion  as  they  are  sub- 
jected to  a  lower  temperature. 


ATTENTIONS    TO    THE     CHILD.  513 

trachea,  and  thus  facilitate  the  introduction  of  air;  ''for,"  says  the  American 
author,  "  this  is  a  measure  of  great  utility,  by  which  I  am  every  way  persuaded 
that  I  have  preserved  the  lives  of  many  children."  After  a  few  moments,  the 
child  should  be  again  plunged  into  a  warm  bath,  rubbed  with  warm  flannels,  and 
then  immediately  subjected  to  cold  aspersions. 

The  child's  body  may  be  exposed  with  advantage  to  a  current  of  cold  air, 
giving  it  at  the  same  time  a  swinging  motion,  and  even  after  it  has  been  restored 
and  dressed,  its  face  may  be  exposed  to  the  fresh  air,  or,  what  is  better,  fanned, 
for  a  short  time. 

It  has  been  advised  to  make  use  of  strong  suction  on  the  breasts,  for  the  pur- 
pose of  dilating  the  thorax  mechanically,  "which,"  says  Desormeaux,  ''although 
without  effect  for  the  proposed  object,  appears  to  me  admirably  calculated  to  sti- 
mulate the  muscles  that  move  the  ribs."  But  a  more  powerful  remedy,  highly 
extolled  by  the  same  author,  is  a  sort  of  douche  made  by  the  mouth  directly  on 
the  parietes  of  the  thorax ;  this  douche  is  performed  by  taking  a  mouthful  of 
brandy  and  blowing  it  forcibly  against  the  breast;  and  it  is  rarely  necessary,  he 
remarks,  to  repeat  it  many  times,  for  it  is  found  to  produce  a  convulsive  contrac- 
tion of  the  inspiratory  muscles  almost  immediately;  the  blood  and  air  penetrate 
the  lungs,  and  the  respiration  is  irregularly  established,  being  at  first  feeble  and 
spasmodic,  but  soon  becoming  stronger  and  more  regular.  I  have  often  used 
successfully  with  the  same  object,  a  cold  douche,  produced  by  pouring  a  stream 
of  cold  water  upon  the  prsecordial  region,  from  an  elevation  of  about  a  yard. 

If  the  excitation  of  the  spinal  and  facial  nerves  is  insufficient,  the  branches  of 
the  pneumogastric  nerve  should  be  acted  on  by  insufflation. 

This  measure  can  now  boast  of  such  a  degree  of  success,  as  to  make  it  proper 
to  have  recourse  to  it  whenever  the  means  just  mentioned  have  failed.  M.  De- 
paul,  has,  in  an  excellent  memoir  upon  the  subject,  completely  refuted  the  objec- 
tions urged  against  it,  and  confirmed  by  his  experiments  the  previous  results  of 
Dumeril  and  Magendie.  Like  them,  he  found  that  a  false  idea  has  been  enter- 
tained of  the  powers  of  resistance  of  the  pulmonary  vesicles,  and  that  it  is  neces- 
sary to  blow  much  more  strongly  than  is  required  to  produce  a  simple  dilatation, 
in  order  to  effect  their  rupture.  He  has  proved  by  instances,  that  children  have 
been  restored  to  life,  whom  the  failure  of  the  means  commonly  advised  seemed 
to  devote  to  certain  death ;  also,  that  in  cases  where  it  was  unsuccessful,  because 
the  lesions  occasioning  the  apparent  death  were  beyond  the  resources  of  art,  it 
had  the  effect,  when  the  pulsations  of  the  heart  had  not  ceased  entirely,  to  render 
them  stronger  and  more  frequent,  and  sometimes  even  to  determine  a  sponta- 
neous though  imperfect  inspiration. 

M.  Depaul,  who  has  rendered  a  real  service  in  calling  attention  to  a  measure 
generally  abandoned  by  some  as  dangerous,  and  by  others  as  useless,  also  pro- 
poses some  rules  of  conduct,  which  I  think  it  right  to  mention  briefly. 

He  uses  Chaussier's  canula,  dispensing,  however,  with  the  lateral  openings,  and 
substituting  for  them  a  terminal  one. 

The  child,  whose  temperature  is  to  be  maintained  by  warm  coverings,  should 
be  placed  with  the  breast  higher  than  the  pelvis,  and  the  head  thrown  a  little 

33 


514  LABOR. 

back,  so  as  to  render  the  front  of  the  neck  rather  more  projecting.  Having 
cleansed  the  tongue  and  pharynx  from  mucus,  the  forefinger  of  the  left  hand 
should  be  conducted  along  the  median  line  of  the  tongue  to  the  epiglottis.  The 
right  hand  holds  the  tube  like  a  pen,  and  directs  its  small  extremity  along  the 
finger  to  the  opening  of  the  larynx,  inclines  it  towards  the  left  commissure  of 
the  lips,  and  by  gentle  movements  endeavors  to  raise  the  epiglottis ;  it  is  then 
only  necessary  to  elevate  the  instrument,  carrying  it  at  the  same  time  toward  the 
median  line,  when  its  extremity  will  pass  through  the  glottis.  This  is  the  only 
part  of  the  operation  which  presents  any  difficulty,  for  it  is  not  uncommon  for 
the  tube  to  enter  the  oesophagus.  Before  resorting  to  insufflation,  we  should 
make  sure  of  its  situation  by  passing  the  finger  upon  the  larynx  and  trachea,  and 
observing  whether  the  larynx  follows  the  instrument  when  the  latter  is  moved 
from  side  to  side.  However,  the  first  insufflation  reveals  the  error  immediately, 
for  when  the  instrument  has  passed  into  the  oesophagus,  a  considerable  elevation 
of  the  epigastrium  precedes  that  of  the  base  of  the  chest ;  if,  on  the  contrary,  it 
is  in  the  larynx,  the  chest  is  dilated  uniformly,  and  the  epigastric  projection  is 
produced  exclusively  by  the  depression  of  the  diaphragm. 

To  prevent  the  reflux  of  the  air,  and  to  oblige  it  to  enter  the  air-passages, 
every  point  of  exit  by  the  oesophagus,  mouth,  and  nostrils  should  be  closed.  The 
anterior  wall  of  the  oesophagus  is  applied  against  the  posterior,  by  a  moderate 
pressure  with  the  instrument.  The  lips  are  pressed  closely  to  the  sides  of  the 
canula  by  means  of  the  thumb  and  forefinger,  whilst  the  nostrils  are  stopped  by 
pinching  the  nose  between  the  two  middle  fingers. 

The  insufflations  should  be  quite  near  to  each  other.  M.  Depaul  thinks  that 
from  ten  to  twelve  should  be  made  in  a  minute.  The  greater  part  of  the  air  is 
expelled  after  each  by  the  elasticity  of  the  pulmonary  vesicles ;  it  may  be  useful, 
however,  especially  at  the  commencement,  to  render  the  expiration  more  com- 
plete, by  pressure  properly  applied  with  the  whole  hand  on  the  front  of  the  chest. 

The  length  of  time  for  which  it  is  necessary  to  continue  the  insufflations  varies 
much.  Thus,  there  are  facts  showing  that  sometimes  a  quarter  of  an  hour  has 
been  sufficient,  whilst  at  others,  it  was  necessary  to  continue  them  for  three- 
quarters  of  an  hour,  an  hour,  or  even  an  hour  and  a  half. 

When,  under  their  influence,  the  action  of  the  heart  has  been  so  far  restored 
as  to  beat  from  a  hundred  to  a  hundred  and  thirty  times  a  minute.  I  think,  says 
M.  Depaul,  that  the  physician  should  continue  until  spontaneous  inspirations 
appear,  and  are  repeated  at  the  rate  of  at  least  five  or  six  per  minute ;  since  to 
stop  after  the  first  one,  would  in  many  cases  endanger  the  life  of  the  child. 
When,  however,  after  having  awakened  the  pulsations  of  the  heart,  and  even 
obtained  some  efforts  at  inspiration,  all  become  more  feeble  and  disappear,  the 
insufflation  may  be  dispensed  with  after  the  lapse  of  from  ten  to  twelve  minutes, 
for,  under  these  circumstances,  I  have  never  known  a  child  to  be  saved. 

It  is  necessary  to  withdraw  the  canula  from  time  to  time,  in  order  to  clear  it 
of  mucus.  When  the  trachea  contains  much  mucus,  which  is  manifested  by 
gurgling,  it  may  be  drawn  into  the  tube  by  suction,  and  the  future  insufflations 
be  thus  rendered  more  useful. 


ATTENTIONS    TO    THE    CHILD.  515 

When  spontaneous  aspirations  occur,  the  insufflations  may  be  suspended  for 
the  moment. 

Finally,  all  these  means  having  failed,  should  a  galvanic  battery  be  at  hand, 
currents  of  electricity  might  be  passed  through  the  muscles  of  inspiration ;  it  is, 
however,  an  auxiliary  upon  which  but  little  reliance  can  be  placed. 

Electricity  has,  in  fact,  much  less  action  upon  the  foetus  than  upon  the  adult. 
It  has,  for  example,  been  proved  by  experiment,  that  well-developed  fa3tal  ser- 
pents were  but  slightly  sensitive  to  the  action  of  galvanism  before  having  breathed, 
whilst  shortly  afterward,  they  were  endowed  with  a  very  delicate  sensibility. 

Some  persons  have  recommended  that  the  umbilical  cord  be  not  cut  in  cases 
of  asphyxia,  until  after  the  pulmonary  respiration  has  been  fully  established, 
hoping  that  the  continuance  of  the  fceto-placental  circulation  might  replace  the 
extra-uterine  one  that  is  wanting.  Without  admitting,  with  Dr.  King,  that  this 
practice,  by  allowing  the  contractions  of  the  heart  to  drive  all  the  blood  into  the 
placenta,  would  expose  the  foetus  to  death  from  loss  of  the  circulating  fluid,  I 
think  that  in  the  majority  of  cases  the  precaution  is,  to  say  the  least,  useless, 
and  even  hurtful,  by  occasioning  the  loss  of  precious  time.  In  fact,  the  placenta 
is  almost  always  partly,  or  even  entirely  detached,  shortly  after  the  child  is  ex- 
pelled ;  and  even  were  this  not  the  case,  the  retraction  of  the  uterus  following  its 
expulsion,  has  so  modified  the  circulation  in  the  walls  of  the  uterus  and  that  of 
the  utero-placental  vessels,  that  the  newly-born  infant  would  certainly  find  its 
resources  in  that  direction  exhausted. 

However,  if  the  touch  does  not  discover  the  placenta  situated  upon  the  neck, 
and  consequently,  there  is  reason  to  suppose  that  it  retains  its  normal  relations 
with  the  womb,  we  may,  when  the  foetus  is  pale  and  discolored,  defer  cutting  the 
cord,  especially  should  it  still  exhibit  pulsations.  As  soon,  however,  as  the  pul- 
sations have  ceased,  or  it  is  ascertained  that  the  placenta  is  detached,  its  section 
should  be  practised  immediately. 

Some  children,  after  having  cried  and  breathed  quite  freely,  fall,  after  the  lapse 
of  several  hours,  and  sometimes  even  days,  into  a  state  of  apparent  death,  which 
soon  terminates  in  real  death  unless  assistance  is  promptly  rendered.  Therefore, 
it  is  prudent  to  be  carefully  on  the  watch  for  the  first  few  days.  This  secondary 
apparent  death  may  be  due,  like  that  just  described,  to  a  true  asphyxia,  or  to  a 
deficiency  of  nervous  influence,  for  which  the  stimulants  employed  immediately 
after  birth  have  proved  but  a  momentary  remedy.  Asphyxia  may  be  produced 
either  by  a  foreign  body  placed  over  the  mouth  and  nostrils,  or  by  an  accumula- 
tion of  mucus  in  the  fauces.  To  remove  the  foreign  bodies,  and  clear  out  the 
fauces  with  the  aid  of  a  feather,  and  the  bronchia  by  exciting  vomiting  by  tick- 
ling the  palate,  are  the  first  measures  to  be  used.  If  the  face  is  of  a  violet  color, 
a  leech  may  be  placed  with  advantage  behind  each  ear,  or,  as  recommended  by 
Kennedy,  upon  the  fontanelles.  When  the  accidents  are  attributable  to  deficient 
cerebral  action,  the  excitants  already  mentioned  must  again  be  had  recourse  to. 


516  LABOR. 

ARTICLE    III. 

DEBILITY    OF    THE   FCETUS. 

As  tlie  excessive  debility  of  the  child  may  generally  be  referred  to  some  of  the 
circumstances  already  pointed  out,  it  should  be  combated  by  the  same  meanS' 
In  those  cases  where  the  infant  is  only  very  feeble,  because  it  is  born  before  term, 
or  in  consequence  of  a  prolonged  sickness  on  the  part  of  the  mother,  very  great 
care  is  requisite  to  maintain  a  high  degree  of  temperature  by  surrounding  it  with 
cotton  wadding,  and  bottles  containing  hot  water,  since  heat  is  then  the  best 
stimulant. 

For  the  first  few  days,  and  sometimes  even  weeks,  its  alimentation  demands 
some  precaution.  It  is  very  important  that  a  nurse  should  be  procured  for  it  as 
soon  as  possible,  whose  milk  flows  so  easily  that  she  can  herself  project  a  few 
spoonfuls  into  the  mouth  of  the  child ;  for  its  feebleness  is  often  so  great  as  to 
render  the  necessary  effort  at  suction  impossible. 

It  is  equally  important  to  give  it  only  the  first  milk,  which  being  lighter  is  of 
easier  digestion. 

Whenever  a  child  is  born  in  a  state  of  apparent  death  or  of  extreme  weakness, 
the  accoucheur  should,  in  Catholic  families,  cause  the  rite  of  baptism  to  be  ad- 
ministered immediately.  For,  whatever  the  religious  opinions  of  the  physician 
may  be,  it  is  his  duty  to  respect  the  feeling  of  families,  and  he  would  be  truly 
blamable,  were  he  not  to  yield  in  this  respect  to  the  wishes  of  the  parents. 


PAET    IV. 


OF  DYSTOCIA,  OR  PRETERNATURAL  AND  PAINFUL 

LABORS. 


Although  labor  Is  a  natural  function,  and  the  resources  of  the  organism  are 
usually  sufficient  for  its  accomplishment,  yet  there  are  a  number  of  circumstances 
which  may  interfere  with  the  work  of  nature,  and  render  the  process  difficult, 
dangerous,  or  even  wholly  impossible.  It  is  to  the  exposition  of  those  difficulties 
and  dangers,  and  more  particularly  to  the  indication  of  the  appropriate  measures 
for  preventing  or  for  remedying  them,  that  the  fourth  part  of  this  work,  which 
we  shall  arrange  in  two  principal  divisions,  is  devoted.  In  the  first,  we  shall 
point  out  the  accidents  that  may  complicate  the  labor,  and  thereby  render  the 
intervention  of  art  imperative ;  and  we  shall  further  study  such  accidents  in  their 
causes,  symptoms,  prognosis,  and  therapeutical  indications.  In  the  second,  we 
shall  carefully  describe  the  various  operative  processes,  by  the  aid  of  which  all 
those  indications  may  be  met;  in  fact,  this  last  might  be  designated,  without  any 
impropriety,  as  the  surgery  0/ labor. 


FIRST  DIVISION. 

OF   THE   CAUSES   OF   DYSTOCIA,    OR   THE    CIRCUMSTANCES    THAT    REQUIRE 
THE   INTERVENTION    OF   ART. 

The  causes  that  render  a  labor  either  difficult,  impossible,  or  dangerous,  and 
which  therefore  require  the  more  or  less  active  interposition  of  the  accoucheur, 
are  numerous,  varied,  and  far  from  always  having  the  same  mode  of  action ;  some, 
indeed,  operate  only  by  enfeebling  or  reducing  the  forces  necessary  for  the  expul- 
sion of  the  child,  while  others  constitute  an  obstacle  to  its  delivery  by  occasion- 
ing a  disproportion  between  the  dimensions  of  the  pelvic  canal  and  those  of  the 
body  that  must  traverse  it,  thus  rendering  the  most  powerful  contractions  of  the 
womb  entirely  nugatory.  On  the  other  hand,  when  all  the  conditions  are  appa- 
rently most  favorable  to  a  natural  labor,  we  may  find  a  number  of  accidents 


618  DYSTOCIA 

suddenly  manifesting  themselves,  of  a  character  dangerous  to  the  lives  of  both 
mother  and  child. 

Consequently,  as  regards  the  causes  that  may  thus  interfere  with  the  regular 
process  of  nature,  we  may  distinguish  three  different  groups  of  difficult  labors, 
namely:  1.  Those  rendered  difficult,  impossible,  or  dangerous,  by  a  deficient  or 
excessive  action  of  the  expulsive  forces;  2.  Those  rendered  difficult,  impossible, 
or  dangerous,  by  obstacles  to  the  expulsion  of  the  foetus;  3.  Those  complicated 
by  accidents  liable  to  endanger  the  life  or  health  of  the  mother  and  child. 


BOOK  I. 

OF  LABORS  RENDERED  DIFFICULT,  IMPOSSIBLE,  OR  DANGEROUS,  BY 
A  DEFICIENCY  OR  AN  EXCESS  OF  ACTION  IN  THE  EXPULSIVE 
FORCES. 

In  practice,  we  meet  with  numerous  cases  in  which  the  position  is  favorable, 
the  organs  of  the  mother  and  child  well  formed,  and  in  which  none  of  those 
grave  complications,  hereafter  spoken  of,  that  have  given  rise  to  the  title  of  ^:)re^e?*- 
naturallahor,  are  met  with;  but  in  which,  notwithstanding,  the  different  stages  of 
the  labor  are  not  accomplished  with  the  customary  ease  or  regularity.  Now,  every- 
thing seems  so  admirably  arranged  in  the  works  of  nature,  that  the  least  deviation 
is  sufficient  to  interfere  with  their  accomplishment ;  and  whether  this  deviation 
be  dependent  on  an  unusual  slowness  or  an  excessive  rapidity  in  the  course  of 
the  phenomena  of  parturition,  it  may  prove  detrimental,  in  either  case,  to  the 
mother  or  her  child,  and  require  the  intervention  of  art  just  as  imperiously  as 
would  a  hemorrhage  or  a  contraction  of  the  pelvis.  We  therefore  believe  it  will 
prove  serviceable  to  treat,  with  a  little  more  detail  than  has  hitherto  been  done, 
of  the  causes  and  proper  measures  for  preventing  the  disastrous  consequences  of 
extreme  slowness  or  a  too  rapid  progress  of  the  labor. 


CHAPTER  I. 

OF  EXTREME   SLOWNESS   OF   THE   LABOR. 

Whilst  stating,  page  397,  the  usual  duration  of  labor,  we  were  careful  to 
remark  that  it  was  often  prolonged  beyond  the  fixed  period,  and  that  a  duration 
of  eighteen  or  twenty  hours,  in  primipara;  especially,  could  not  be  regarded  as 
an  alarming  circumstance;  but  that,  in  all  cases  where  more  than  twenty-four 
hours  have  elapsed  from  the  time  of  its  commencement,  serious  accidents  might 


EXTREME    SLOWNESS    OF    THE    LABOR.  519 

result  therefrom,  either  to  the  mother  or  the  child,  which  should  always  be  pre- 
vented by  removing  immediately  the  cause  of  this  excessive  slowness. 

In  natural  labor,  the  phenomena  occur  with  such  a  marked  degree  of  regularity 
that,  as  regards  the  duration,  the  period  of  dilatation  of  the  cervix  is  to  that  of 
the  expulsion  as  two  or  three  to  one ;  though  it  is  proper  to  state  that  the  delay 
may  be  manifested  during  either  the  first  or  the  second  stage,  and  then,  of  course, 
this  proportion  no  longer  exists.  This  distinction,  which  might  serve  to  establish 
a  classification  of  the  causes  that  retard  the  labor,  if,  indeed,  they  do  not  make 
their  influence  felt  in  all  stages,  merits  a  particular  attention  with  regard  to  the 
prognosis ;  for,  although  the  first  stage  may  be  prolonged  without  danger,  the 
second,  on  the  contrary,  cannot  pass  beyond  certain  limits  without  greatly  endan- 
gering the  health  of  the  patient,  and  oftentimes  the  life  of  her  child.  It  is  found 
that  the  latter  is  lost  at  least  one  time  in  four,  when  the  head  remains  in  the 
excavation  longer  than  seven  or  eight  hours  after  the  complete  dilatation  of  the 
OS  uteri,  and  the  rupture  of  the  bag  of  waters ;  whilst  it  nearly  always  survives 
when  the  first  period  is  prolonged  even  to  forty,  fifty,  or  sixty  hours  and  more.^ 
Besides,  in  the  latter  case,  there  are  scarcely  any  symptoms  worth  mentioning 
presented  by  the  mother,  for  the  great  fatigue  caused  particularly  by  the  loss  of 
sleep,  and,  in  nervous  women,  a  considerable  irritation,  depression  of  spirits,  and 
alarm,  are  about  the  only  inconveniences  that  result  from  it;,  since  the  contrac- 
tion, although  feeble,  returns  at  regular  intervals,  and  the  labor  makes  some  pro- 
gress, notwithstanding  it  is  slow.  But,  when  the  period  of  expulsion  is  extended 
beyond  ten  or  twelve  hours,  the  pain,  as  a  general  rule,  is  found  to  become  irre- 
gular, both  in  its  returns  and  intensity ;  and,  although  it  be  sometimes  more 
severe  and  frequent,  it  is  in  reality  less  efficacious,  to  such  an  extent,  indeed, 
that  the  foetus  really  seems  to  be  retrograding  instead  of  advancing;  in  a  word, 
there  are  uterine  pains,  but  no  expulsive  contraction. 

The  local  disorder  is  accompanied,  or  at  least  is  soon  followed,  by  a  violent 
trembling ;  the  patient  has  an  inclination  to  vomit,  and  even  throws  up  bilious 
matters ;  she  is  uneasy,  excited,  and  changes  her  position  every  moment ;  the 
skin  is  hot  and  dry;  the  pulse  runs  up  to  a  hundred  or  a  hundred  and  fifty  per 
minute ;  the  tongue  is  dry,  and  both  it  and  the  teeth  are  covered  with  a  dark 
coating.  The  vagina  and  cervix  are  hot,  and  sensitive  to  the  touch,  an.d  a  yel- 
lowish liquid  escapes  from  them,  which  occasionally  has  a  fetid  odor;  the  pres- 
sure of  the  child's  head  on  the  cervix  vesicas  prevents  the  emission  of  urine ;  and 
the  parts  that  line  the  superior  strait  and  the  pelvic  excavation,  being  com- 
pressed for  a  long  time  by  the  head,  may  become  inflamed  or  even  gangrenous ; 
which  complications  may  subsequently  prove  a  source  of  the  most  serious  acci- 
dents. 

If  the  woman  still  remains  undelivered,  these  symptoms  augment  in  intensity 

'  The  following  summary,  which  I  take  from  Churchill,  is  calculated  to  confirm  the  above  : 
in  one  hundred  and  thirty-three  cases,  where  the  first  stage  was  prolonged  from  twenty-four 
to  sixty  hours,  only  eight  children  were  lost ;  in  eight  that  lasted  from  sixty  to  a  hundred 
hours,  but  one  died ;  and  in  three  cases  ranging  from  a  hundred  to  a  hundred  and  seventy- 
seven  hours,  not  a  single  death  occurred. — Churchill,  192. 


520  DYSTOCIA. 

in  a  friji^litfal  manner;  the  vomitings  become  more  frequent,  and  the  abdomen 
more  distended ;  the  excitability  of  the  patient  knows  no  bounds;  the  pulse  is 
more  and  more  feeble  and  frequent,  and  she  ftxlls  into  a  half  stupid,  or  a  semi- 
delirious  condition,  which  is  soon  terminated  by  death.  It  is  scarcely  necessary 
to  remark  that,  in  the  latter  case,  the  life  of  the  child  is  also  most  seriously  com- 
promised. 

We  have  felt  bound  to  point  out  these  differences  in  the  danger  of  the  symp- 
toms, in  order  to  prove  the  necessity  of  the  distinction  we  have  made ;  and  we 
may  now  proceed  to  study  the  divers  causes  which,  at  times,  retard  the  course  of 
labor,  and  also  to  indicate  the  means  calculated  to  remedy  them,  without  the 
necessity  of  repeating,  in  each,  that  the  dangers  to  which  they  expose  the  mother 
and  child  are  much  more  grave  in  the  second  than  the  first  stage  of  the  labor; 
and  that,  although  in  the  latter,  we  may  trust  longer  to  the  resources  of  the 
organism;  in  the  former,  the  intervention  of  art  is  demanded  at  an  earlier 
period. 

The  causes  that  may  retard  the  delivery  depend  either  on  the  patient's  general 
condition,  or  on  a  special  modification  of  the  genital  organs;  and,  in  both  cases, 
their  influence  may  be  exerted  at  the  commencement,  or  only  at  a  subsequent 
period  of  the  labor;  consequently,  we  have  to  consider  the  three  following  con- 
ditions :  1,  where  the  pains  or  contractions  are  slow  or  feeble  in  the  commence- 
ment; 2,  where,  after  having  set  in  with  considerable  energy,  they  afterwards 
relax,  diminish,  or  even  cease  altogether;  and  3,  where  they  exhibit  great  irregu- 
larity in  their  duration,  intensity,  and  returns;  an  irregularity  that  almost  wholly 
destroys  their  expulsive  action.  The  English  writers  have  applied  the  term 
tedious  lahor  to  all  these  varieties,  and  this  appellation  merits  our  adoption, 
for  it  is  perfectly  adapted  to  the  cases  we  are  about  to  describe. 

§  1.  Of  Slowness  or  Feebleness  or  the  Contractions. 

A  slowness  or  feebleness  of  the  contractions  may  occur  at  the  very  commence- 
ment of  the  labor,  and  persist  throughout  its  whole  duration ;  the  pains  are  quite 
feeble,  the  dilatation  of  the  os  uteri  is  efi"ected  very  slowly,  and  at  a  rather  later 
period  they  seem  unable  to  efi'ect  the  expulsion  of  the  head.  This  slowness  of 
labor  may  be  dependent  either  on  the  woman's  general  condition,  or  on  a  local 
disposition  of  the  womb.  In  the  former  case,  it  occurs  in  women  endowed  with 
a  delicate  or  debilitated  constitution,  or  in  those  accidentally  enfeebled  by  chronic 
diseases. 

It  should,  however,  be  borne  in  mind  that,  as  was  stated,  page  122,  general 
debility  of  the  muscular  system  has  but  little  influence  upon  the  contractile 
power  of  the  uterus,  the  latter  being  often  very  strong,  as  in  consumptive  pa- 
tients for  example.  The  labor  sometimes  progresses  even  more  rapidly  than 
usual  in  such  individuals,  for  when  the  uterine  fibre  preserves  its  contractile 
powers,  the  slight  resistance  of  the  floor  of  the  pelvis  seems  to  expedite  the  de- 
livery. 

Generally  speaking,  there  is  nothing  to  be  done  but  to  encourage  the  woman 
to  have  patience,  and  to  make  use  of  some  light  stimulus,  such  as  broth,  claret, 


EXTREME     SLOWNESS     OF     THE     LABOR.  521 

or  a  few  spoonfuls  of  sherry  wine;  in  a  word,  to  sustain  her  strength  as  much  as 
possible,  resorting  to  the  ergot  as  soon  as  the  cervix  is  sufficiently  dilated,  if  the 
uterine  contraction  is  too  feeble  to  effect  the  engagement  and  subsequent  expul- 
sion of  the  head. 

But  where  the  slowness  of  the  labor  is  to  be  wholly  attributed  to  a  local  con- 
dition of  the  womb,  the  determining  causes  ought  to  be  carefully  sought  after,  as 
they  are  variable,  and  require  the  employment  of  different  means,  and  hence  we 
learn  the  importance  of  a  correct  diagnosis. 

A.  An  excessive  distension  of  the  uterine  walls,  whether  dependent  on  a  dropsy 
of  the  amnios  or  on  the  presence  of  several  children  in  the  womb,  should  be 
placed  in  the  first  rank  of  these  causes.  In  fact,  this  over-distension  renders  the 
uterine  walls  much  thinner  than  usual,  benumbs  thera  in  some  measure,  and 
diminishes  their  force  of  contraction.  Independently  of  a  considerable  enlarge- 
ment of  the  belly,  and  the  unusual  elevation  of  the  head,  towards  the  end  of 
gestation,  or  beginning  of  labor,  which  is  worthy  of  attention,  there  is  something 
then  altogether  peculiar  in  the  character  of  the  pains.  The  contractions,  though 
feeble  and  only  returning  at  distant  and  irregular  intervals,  reduce  the  patient  to 
a  state  of  anxiety  and  continual  suffering;  and,  if  we  may  judge  from  her  ex- 
pression, seem  to  implicate  the  fundus  alone,  without  extending  lower  down,  for 
the  amniotic  pouch,  if  still  unruptured,  scarcely  bulges  out  during  their  continu- 
ance. Under  such  circumstances,  we  should  carefully  avoid  resorting  to  stimu- 
lants, which  would  have  no  other  effect  than  to  augment  her  sufferings,  with- 
out rendering  the  contractions  any  more  energetic.  The  rupture  of  the 
membranes  is  here  the  only  remedy,  because,  by  facilitating  the  discharge  of  the 
waters,  we  relieve  the  excessive  distension  of  the  organ,  as  well  as  the  continual 
distress  thereby  occasioned,  and  then  the  genuine  pains  become  more  frequent 
and  more  effectual. 

B.  The  slowness  and  feebleness  of  the  contractions  may  likewise  depend  on  a 
sanguineous  engorgement,  or  plethora,  of  the  uterine  tissue.  This  condition, 
when  it  exists,  can  be  recognized  by  the  following  signs :  the  pains  are  at  first 
quite  energetic,  but  soon  diminish,  both  in  frequency  and  intensity ;  the  cervix 
uteri  is  soft,  supple,  and  non-resistant,  but  the  presenting  part  does  not  engage 
during  the  pain,  which  latter  is  equally  diffused  over  the  whole  abdomen ;  the 
phenomena  of  general  plethora  nearly  always  manifest  themselves  at  the  same 
time ;  thus,  the  respiration  is  laborious,  the  pulse  hard  and  full,  and  the  pains 
are  very  irregular,  both  in  force  and  frequency.  Bleeding  in  the  arm,  propor- 
tioned to  the  general  condition  of  the  patient,  is  then  the  best  remedy. 

c.  Or  it  may  be  owing  to  a  debility,  or  an  imperfect  organization  of  the  uterus 
itself,  though  the  patient  may  otherwise  be  perfectly  healthy,  that  is,  the  mus- 
cular apparatus  of  the  womb  may  be  deficient  in  contractile  force,  while  the  other 
muscles  of  the  organism  are  endowed  with  their  usual  energy.  The  dilatation 
of  the  OS  uteri  is  effected  slowly,  for,  notwithstanding  the  cervix  no  longer  offers 
any  resistance,  the  organ  appears  incapable  of  determining  the  expulsion  of  the 
foreign  body  it  encloses.  In  such  cases,  the  ergoted  rye  is  the  only  article  capable 
of  stimulatiu";  the  enfeebled  contractions. 


522  DYSTOCIA. 

Dr.  Franck,  of  "Wolfenbutten,  has  recently  recommended  the  employment  of 
electro-magnetism  in  cases  marked  by  weakness  or  absence  of  the  contractions, 
giving  four  observations,  in  •which,  he  states,  it  was  used  with  advantage.  The 
perusal  of  these  cases  fails  to  convince  me  of  its  utility.  Besides,  the  difficulty 
of  obtaining  a  proper  apparatus  when  wanted,  will  render  its  employment  a  thing 
of  rare  occurrence.' 

D.  According  to  Baudelocque,  the  death  of  the  child  would  have  the  unfavor- 
able effect  of  diminishing  and  enfeebling  the  uterine  contractions ;  but  M.  P. 
Dubois  remarks,  and  very  justly,  in  our  opinion,  that,  if  the  woman  is  otherwise 
healthy,  this  event  has  no  influence  over  the  progress  of  her  labor ;  and  that,  if 
it  sometimes  happens  that  the  delivery  is  more  painfully  accomplished  where  the 
infant  has  been  dead  for  some  time,  it  is  only  because  the  diseases  of  the  mother 
have  been  the  occasion  of  its  death,  and  that  her  forces  are  weakened  by  the  an- 
tecedent malady. 

E.  Finally,  a  premature  rupture  of  the  membranes  may  have  the  same  effect, 
in  relaxing  and  weakening  the  pains,  as  their  more  retarded  rupture ;  and  the 
following  phenomena  may  then  take  place  :  if  the  head  happens  to  be  very  large, 
and  is  low  down  when  this  occurs,  it  becomes  applied  directly  to  the  orifice,  and 
retains  a  great  part  of  the  waters  behind  it,  and  if  the  os  uteri  is  sufficiently 
dilated  to  permit  the  head  to  engage  freely,  no  water  escapes,  even  during  the 
contraction ;  but,  if  the  dilatation  is  still  imperfect,  the  waters  leak  away  drop 
by  drop,  it  is  said,  at  the  commencement  and  termination  of  each  pain,  which 
latter  is  wholly  employed  in  thus  gradually  expelling  the  amniotic  liquid,  with- 
out contributing  in  anywise  to  the  enlargement  of  the  cervix.  The  same  pheno- 
menon is  observed  when  the  membranes  yield  at  a  higher  point  of  the  pouch, 
one  not  corresponding  at  all  to  the  neck  of  the  utenis,  for  in  such  cases  but  little 
water  escapes  at  the  moment  of  the  rupture,  and  each  pain  is  likewise  accompa- 
nied or  followed  by  a  greater  discharge  without  accelerating  the  dilatation  in  the 
least.  However,  this  circumstance,  according  to  M.  P.  Dubois,  does  not  merit 
all  the  importance  usually  ascribed  to  it,  since,  properly  speaking,  the  expulsive 
process  has  not  commenced,  and  the  foetus,  protected  by  the  surrounding  liquid, 
cannot  suffer  in  anywise  from  the  slowness  of  the  labor,  and  therefore,  in  most 
cases  of  this  kind,  there  is  nothing  to  be  done.  If,  however,  the  labor  lingers 
too  long,  we  might  follow  the  plan  generally  advised,  and  introduce  two  fingers 
into  the  cervix  uteri,  and  push  up  the  child's  head,  for  the  purpose  of  promoting 
a  more  ready  escape  of  the  waters,  or,  indeed,  of  lacerating  the  inferior  segment 
of  the  membranes,  if  the  original  rupture  had  occurred  at  a  much  higher  point. 
Nevertheless,  this  manoeuvre  is  only  to  be  resorted  to  when  the  dilatation  is 
already  well  advanced,  for  it  is  evident  that,  if  all  the  water  should  escape  a  long 

'  The  author's  apparatus  is  composed  of  a  concave  metalHc  plate,  moistened  with  salt 
water,  applied  upon  the  lumbar  region,  and  connected  with  the  positive  pole  of  a  rotating 
electro-magnetic  machine.  The  negative  conductor  is  attached  to  a  hollow  cylinder  filled 
with  salt  water,  and  passed  into  the  vagina  to  the  neck  of  the  womb.  The  electro-magnetic 
current  is  applied  for  five  or  six  minutes  between  the  contractions,  and  suspended  during 
their  continuance. 


EXTREME    SLOWNESS    OF    THE    LABOR.  523 

time  before  the  enlargement  of  the  neck,  the  infant  might  suffer  from  the  pro- 
longed and  direct  compression  of  its  body. 

§  2.  Eelaxatiox  or  Suspension  of  the  Pains. 

It  is  not  at  all  unusual  to  find  a  labor  which  has  heretofore  been  progressing 
favorably  to  become  at  once  arrested,  and  the  pains,  which  up  to  that  time  were 
strong  and  frequent,  to  relax  or  even  disappear  altogether.  Of  course,  the  indi- 
cations which  these  phenomena  present  will  necessarily  vary  with  the  causes  that 
have  given  rise  to  them,  and  therefore  the  physician  ought  to  search  them  out 
with  the  greatest  possible  care.  Among  those  which  may  thus  diminish  or  sus- 
pend the  pains,  the  following  are  usually  enumerated,  namely : — 

A.  Any  vivid  moral  impressions  operating  during  the  labor,  any  unexpected 
news  or  sharp  discussions,  the  announcement  of  a  child  of  an  unwished-for  sex, 
and  the  arrival  or  presence  of  persons  disagreeable  to  the  lying-in  woman,  may 
determine  a  cessation  of  the  pains ;  and  in  these  cases  the  removal  of  the  cause 
is  the  only  remedy.  But,  unfortunately,  it  is  not  always  an  easy  matter  to  ascer- 
tain what  that  cause  may  be,  and  it  is  left  to  the  prudence  and  sagacity  of  the 
medical  attendant  to  penetrate  the  mystery  and  remove  the  trouble. 

B.  A  pain  caused  by  the  coincidence  of  some  malady,  either  existing  antece- 
dent to,  or  appearing  during  the  labor,  such  as  distressing  and  repeated  vomit- 
ings, sharp  pains  in  the  muscles  of  the  back  and  abdomen,  gripings  in  the  intes- 
tines, etc.  &e.  In  all  such  instances,  the  woman,  experiencing  an  intense  pain, 
which  is  further  heightened  by  the  uterine  contraction,  endeavors  to  suspend  the 
latter  as  much  as  possible,  and  hence  the  accoucheur  should  try  to  remove  the 
cause  which  thus  interferes  with  the  labor.  For  instance,  where  the  emesis  ob- 
stinately persists,  he  ought,  if  the  patient  bears  opiates  well,  to  administer  a  few 
drops  of  laudanum,  and,  if  not,  some  aromatic  drinks  or  antispasmodics,  accom- 
panied by  narcotic  lotions  over  the  epigastrium.  In  case  of  acute  muscular 
pains,  embrocations  with  an  opiated  liniment  might  be  practised  over  the  affected 
part,  or  a  change  of  position  is  sometimes  all  that  is  requisite  to  calm  them.  If, 
however,  as  often  happens,  this  pain,  which  is  wholly  foreign  to  the  uterine  con- 
traction, cannot  be  relieved,  then  the  powers  of  nature  must  be  assisted  by  an 
artificial  termination  of  the  labor. 

Those  violent  cramps,  which  are  occasionally  produced  by  the  pressure  of  the 
child's  head  on  the  sacral  nerves,  should  certainly  be  classed  among  the  circum- 
stances that  may  relax  or  even  suspend  the  uterine  contraction  altogether;  as 
occurred  in  three  cases  of  the  kind  observed  by  Professor  Meigs,  of  Philadelphia, 
where  the  pain  was  so  violent  that  it  caused  the  patient  the  most  inexpressible 
anguish.  The  women  describe  this  pain  as  similar  to  what  would  be  produced 
by  the  pinching  or  twisting  of  a  large  nervous  trunk;  they  incessantly  demand  a 
prompt  deliverance,  and  the  physician  is  often  obliged  to  yield  to  their  entrea- 
ties ;  besides,  his  intervention  may  be  further  necessitated  by  the  more  or  less 
perfect  suspension  of  the  contractions  of  the  womb ;  for  the  organ  seems  para- 
lyzed by  the  violence  of  these  nervous  pains,  and  we  are  often  constrained  to 
apply  the  forceps  for  the  double  purpose  of  relieving  the  patient  from  the  fright- 


524  DYSTOCIA. 

fill  sufferings  that  torment  her,  and  of  supplying  the  want  of  power  in  the  uterine 
eiForts. 

C.  We  have  already  alluded  (page  469)  to  the  unflivorable  influence  that  an 
extreme  distension  of  the  bladder  might  have  over  the  progress  of  parturition ; 
and,  therefore,  if  the  suspension  of  the  pains  could  be  justly  attributed  to  this 
circumstance,  the  catheter  should  evidently  be  resorted  to  at  once ;  but  if  this 
operation  is  rendered  impossible  by  the  engagement  of  the  head  in  the  excava- 
tion, recourse  should  be  had  to  the  application  of  the  forceps;  for  the  adminis- 
tration of  ergot  here  would  appear  to  be  very  imprudent,  to  say  the  least. 

D.  If  caused  by  general  plethora,  which  is  characterized  and  is  easily  recog- 
nizable by  the  redness  of  the  fice,  by  headache,  throbbings  in  the  head,  vertigo, 
dimness  of  vision,  tinnitus  aurium,  agitation,  unusual  force  and  fulness  of  the 
pulse,  and  by  weariness  of  the  limbs,  it  must  be  relieved  by  general  venesection. 

E.  Debility  of  the  uterus  itself  is  also  mentioned  as  a  cause,  since  there  are 
some  women  in  whom  the  contractile  force  of  this  organ  is  so  easily  exhausted 
that  the  contractions,  after  having  proved  quite  sufficient  for  the  earlier  steps  of 
the  labor,  diminish,  or  disappear  all  at  once,  without  any  other  appreciable  cause 
than  this  feebleness  of  the  organ.  In  such  cases,  the  patient  should  be  advised 
to  rise  up  and  walk  about  the  chamber  for  some  time,  and  it  is  also  necessary  to 
rub  her  abdomen,  to  titillate  the  cervix  uteri,  and  to  make  pressure  on  the  peri- 
neum ;  and  then,  if  all  these  means  fail,  to  administer  the  ergot,  or  apply  the* 
forceps. 

r.  The  second  stage  of  labor  is  sometimes  exceedingly  slow  in  very  fat  women; 
in  whom  the  contractions  do  not  cease  altogether,  but  appear  to  be  ineffectual, 
and  do  not  force  the  child's  head  to  advance ;  this  impotence  of  the  uterine 
efforts  has  appeared  to  me  to  be  much  less  dependent  on  resistances  from  the 
lower  part  of  the  pelvic  canal,  than  on  a  default  of  action  in  the  abdominal 
muscles ;  because  the  thick  layer  of  fiit,  which  lines  the  anterior  walls  of  the  belly, 
must  paralyze,  to  a  certain  extent,  the  synergic  action  of  those  muscles,  and  thus 
deprive  the  uterus  of  the  aid  which  they  habitually  render.  The  abdominal 
compression,  which  is  so  much  extolled  as  a  remedy,  would  then  appear  pecu- 
liarly applicable ;  for  a  circular  bandage,  applied  around  the  body,  would  effec- 
tually replace  the  point  d'appui,  which  the  contracted  muscles  usually  furnish 
to  the  womb;  besides,  as  Velpeau  observes,  this  is  too  innocent  a  remedy  not  to 
be  employed  before  having  recourse  to  ergot,  or  to  an  artificial  termination  of  the 
labor. 

§  3.  Irregularity  of  the  Pains. 

The  contractions  may  be  irregular  in  their  progress,  or  they  may  be  partial  in 
their  operation ;  that  is,  only  one  portion  of  the  uterine  walls  contracts,  the  rest 
of  the  organ  remaining  in  a  state  of  inaction ;  which  irregularity  is  sufficiently 
explained  by  the  muscular  structure  of  the  womb.  In  the  first  variety,  the  pains 
are  recognized  by  the  following  signs :  there  is  not  a  complete  and  perfect  inter- 
val between  them,  they  are  continuous,  and  only  interrupted  by  the  paroxysms, 
during  which  the  intensity  of  suffering  is  horrible.     In  the  second  variety,  the 


EXTREME    SLOWNESS    OF    THE    LABOR.  525 

pain  returns,  it  is  true,  at  intervals,  but  sometimes  it  is  only  tlie  fundus,  again 
one  of  the  angles,  and  at  others,  some  part  of  the  body,  which  contracts  spasmo- 
dically, whilst  the  remainder  scarcely  does  so  at  all.  The  pains  are,  however,  no 
less  acute  than  if  the  whole  organ  were  involved ;  often,  indeed,  they  are  more 
so,  though  even  then  they  are  easily  recognized  by  the  fact  of  occurring  almost 
without  effect,  or  at  least  without  having  a  decided  influence  upon  the  progress 
of  the  labor.  For  during  the  pain,  and  even  at  the  very  moment  when  the 
woman  suffers  the  most,  we  may  ascertain,  by  applying  the  hand  on  the  hypo- 
gastrium,  in  the  case  of  partial  contraction,  that  the  uterine  ovoid  does  not  pre- 
sent its  normal  regularity,  and  that  it  exhibits  instead  various  bosses  and 
inequalities;  besides,  we  can  readily  assure  ourselves,  in  all  cases,  that  no  impul- 
sion is  given  to  the  foetus,  and  that  the  presenting  part  does  not  advance ;  as, 
also,  that  where  the  membranes  are  still  unruptured  they  do  not  bulge  out,  nor 
indeed  scarcely  become  tense  during  the  pain.  At  the  height  of  the  latter,  just 
at  the  moment  of  the  paroxysm,  the  presenting  part  seems,  at  times,  to  advance 
a  little ;  but  this  progression  does  not  correspond,  on  the  one  hand,  with  the 
violence  of  the  pains,  and,  on  the  other,  it  is  not  kept  up,  though  the  pains  con- 
tinue. The  patient  is  then  suffering  from  an  extreme  agitation,  she  weeps  and 
becomes  despondent,  and  very  often  her  pulse  is  frequent,  developed,  and  febrile; 
the  face  red  and  flushed;  the  skin  hot;  the  mind  confused,  and  the  limbs  con- 
•vulsively  contracted.  These  irregular  contractions,  which  have  been  designated 
under  the  title  of  uterine  tetanus,  sometimes  disappear  of  their  own  accord, 
though  they  may  be  prolonged  for  an  indefinite  length  of  time.  It  is  then  highly 
important  to  remedy  them  as  soon  as  possible,  which  is  best  done  by  a  general 
bleeding  where  the  woman  is  pletlioric,  the  pulse  full  and  well  developed,  and 
the  face  red  and  flushed ;  but,  as  this  is  not  practicable  in  nervous  and  very  irri- 
table women,  we  should  then  resort  to  tepid  baths,  emollient  injections,  and 
opiated  lotions  over  the  abdomen,  and  more  especially,  to  laudanum,  given  once 
or  twice  as  an  injection,  in  the  dose  of  twenty  to  forty  drops,  diffused  in  three  or 
four  ounces  of  some  mild  vehicle. 

Under  the  influence  of  these  measures,  the  last  particularly,  the  pains  almost 
entirely  disappear  in  the  course  of  half  an  hour  or  an  hour;  during  which  period 
the  patient  generally  slumbers,  and  then  the  good  pains,  that  is  the  natural  and 
regular  ones,  come  on,  and  the  labor  terminates  happily. 

The  action  of  opiates  is  occasionally  much  more  prompt,  being  felt  in  the 
course  of  ten  minutes  or  a  quarter  of  an  hour  after  their  administration.  I  wit- 
nessed this  fact  in  a  young  primiparous  lady,  whose  labor  commenced  at  ten 
o'clock  in  the  morning,  and  the  pains  progressed  slowly  but  regularly  until  four 
the  next  morning,  when  they  assumed  the  peculiar  character  under  considera- 
tion; and,  from  that  moment,  notwithstanding  the  almost  continuous  suffering 
and  permanent  contraction  of  the  womb,  the  head  did  not  descend.  At  six,  I 
administered  opiates;  and,  in  the  course  of  ten  minutes,  the  excessive  agitation 
was  calmed,  the  pains  disappeared  entirely,  then  returned  again  a  few  minutes 
after,  at  first  slow  and  feeble,  but  soon  regular  and  energetic  enough  to  effect  the 
delivery  in  a  short  time.     When  the  cervix  participates  in  this  state  of  spasm, 


526  DYSTOCIA. 

the  employment  of  the  ointment  and  extract  of  belladonna,  as  we  shall  have  occa- 
sion hereafter  to  point  out,  will  be  found  decidedly  useful ;  though  we  ought  to 
mention  that  the  employment  of  belladonnna  has  been  objected  to  on  the  ground 
that  it  suspends  the  pains,  and  paralyzes  the  exercise  of  the  contractility  of  tissue 
after  the  labor  is  over;  but  this  is  an  error,  for  its  action  is  always  limited  to  the 
neck,  and  the  latter,  at  most,  may  be  paralyzed  for  some  time. 

In  the  case  before  us,  M.  Velpeau  says  he  has  used  the  following  potion  with 
advantage:  R. — Lettuce,  or  wild  poppy  water,  fsiv;  orange-flower,  or  mint 
water,  f5J ;  syrup  of  white  poppies,  f^j ;  extract  of  opium,  gr.  j. 

§  Ergot. 

Of  all  the  various  means  just  alluded  to  as  capable  of  stimulating  the  weak, 
enfeebled,  or  suspended  contractions  of  the  womb,  there  are  but  few  we  have  so 
often  recommended  as  the  spurred  rye ;  and  the  importance  of  this  medicine 
induces  us  to  devote  a  special  article  to  its  consideration,  in  which  we  shall  first 
study  the  nature  and  physical  characters  of  the  ergot,  and  afterwards  its  thera- 
peutical action. 

1.  The  Natural  History  op  Ergot.  (Spurred  Rye.  Secale  Cornu- 
turn.) 

The  spurred  I'ye,  which  is  now  used  so  extensively  in  medicine,  has  at  all 
times  been  considered  as  an  alteration  of  that  grain,  the  writers  on  the  subject 
only  differing  in  opinion  with  respect  to  the  causes  which  produce  it.  Some 
think  it  depends  on  atmospherical  or  local  influences,  such  as  long-continued 
rains,  fogs,  and  noxious  dews,  or  on  too  poor  or  too  humid  a  soil ;  while  others 
have  regarded  it  as  being  produced  by  the  puncture  of  certain  insects  ;  this  latter 
opinion  has  even  yet  a  great  number  of  advocates,  although  at  the  present  day  it 
is  most  generally  considered  as  a  fungus.  Paulet  has  classified  it  among  the 
clavaria,  and  De  Candolle  among  the  parasitic  fungi,  under  the  name  of  sdero- 
tium  clavns,  from  its  form;  and  this  was  the  generally-received  opinion  until 
Dr.  Leveille,  in  a  memoir  published  in  1826,  in  the  Annals  of  the  Linnean 
Society  of  Paris,  announced  that  the  ergot  was  in  reality  an  alteration  of  the 
grain ;  and  that  it  was  produced  by  the  presence  of  a  parasitic  fungus,  which  he 
named  the  sphacelia  seyetuni,  intending  to  satisfy  by  this  title  both  the  color  of 
the  diseased  grain,  and  the  sad  consequences  which  result  from  its  use  when 
mixed  with  bread.  The  extended  observations  of  the  author  have  satisfied  him 
that  this  fungus  appears  chiefly  in  the  summer  season,  after  the  heavy  rains,  and 
that  it  is  developed  in  the  grain  itself  between  the  integuments  and  the  peri- 
sperm.  At  first,  it  is  invisible,  but  soon  increases  in  size,  and  breaks  through 
the  envelopes  of  the  grain,  while  the  perisperm,  which  was  very  small  and  white, 
assumes  a  violet  hue,  then  elongates,  or  grows,  and  becomes  hard  and  brittle, 
escaping  from  between  the  palero  (the  husk  or  chaff"),  and  pushing  before  it  the 
fungus  (.sphacelia)  found  at  its  free  extremity.  This  fungus  is  soft  and  yellow, 
of  a  disagreeable  odor  and  a  sweetish  taste ;  being  formed  of  several  lobes  joined 
at  their  centre,  its  surflice  exhibits  some  small  undulations,  similar  to  the  convo- 
lutions of  the  brain.     If  a  particle  of  it  be  placed  in  water,  under  the  microscope 


EXTREME     SLOWNESS    OF    THE    LABOR.  527 

it  is  found  to  become  partially  liquefied,  and  the  water  holds  in  suspension  an 
immense  number  of  little  grains,  or  spores,  which  are  oval,  transparent,  and 
exceedingly  minute  in  size.  These  facts,  which  my  learned  friend,  Dr.  Leveille, 
has  kindly  made  me  witness,  leave  no  doubt  on  my  mind  as  to  the  nature  of  this 
affection ;  and  I  am  satisfied  that  it  is  a  true  fungus,  and  a  perfectly  distinct  part 
of  the  sclerotium  clavus.  This  fungus  is  rarely  met  with  on  the  spurred  rye 
found  in  the  shops,  as  it  has  probably  been  detached  either  by  the  threshing,  or 
by  the  friction  of  the  heads  against  each  other.  As  this  product  is  soft  and  dif- 
fluent, it  spreads  over  the  teguments  and  the  spur,  where  it  becomes  dried  and 
cracked,  and  forms  a  thin  layer  of  a  dirty  white  or  yellowish  color,  which  dis- 
solves when  thrown  into  water.  Now,  does  the  ergot  owe  its  properties  to  this 
fungoid  portion,  or  to  its  own  proper  substance  ?  Experience  has  not  yet  settled 
the  doubts  of  M.  Leveille  on  this  subject;  but  as,  by  the  aid  of  this  theory,  we  can 
readily  explain  why  the  ergoted  rye  so  often  proves  worthless  when  administered, 
we  believe  the  choice  of  this  substance  is  not  an  indifferent  matter ;  therefore, 
such  grains  as  have  a  smooth  and  brilliant  surface,  as  well  as  those  that  exhibit 
numerous  deep  fissures,  should  be  rejected,  for  the  one  has  been  deprived  of  the 
sphacelated  portion  by  friction,  and  the  other  altered  by  successive  rains  and 
heats.  The  preference  should  be  given  to  those  which  still  have  the  fungus  on 
their  summits,  and  the  surfaces  of  which  are  entire,  of  a  violet  color  and  dirty 
aspect,  and  covered,  as  it  were,  with  a  powder. 

2.  Therapeutical  Action. 

The  action  of  this  medicine  is  too  well  ascertained  at  the  present  time  to  per- 
mit it  to  be  any  longer  called  in  question ;  though  we  have  only  to  speak  of  it 
here  in  its  obstetrical  relations. 

Ergot  is  now  recommended  by  accoucheurs  for  arousing  or  accelerating  the 
uterine  contractions  during  the  labor,  and  for  preventing  or  remedying  the  inertia 
of  the  womb  and  the  hemorrhage  which  so  often  accompanies  it,  after  the  deli- 
very. This  action  is  prompt,  and  is  recognizable  by  the  following  signs :  the 
uterine  contractions  are  observed  to  become  more  active  in  the  course  of  ten  to 
fifteen  minutes  after  its  administration,  more  frequent  and  energetic  if  they  were 
previously  slow  or  feeble,  and  reappearing,  if  before  suspended.  Now,  we  cannot 
believe,  like  the  authors  who  proscribed  this  medicine  as  useless,  that  this  is 
merely  a  simple  coincidence,  and  that  the  labor  would  have  been  restored  with- 
out its  use,  for  the  thousands  of  instances  in  which  its  administration  has  always 
been  followed  by  the  same  uniform  result,  will  not  permit  us  to  consider  the 
latter  as  the  mere  effect  of  chance ;  and,  besides,  all  those  who  make  use  of  this 
article,  know  full  well  that  the  contractions  which  attend  the  exhibition  of  ergot 
have  a  peculiar  character,  that  cannot  be  mistaken ;  for,  as  soon  as  its  action  is 
felt,  they  become  permanent  instead  of  intermittent ;  the  uterine  globe  remains 
hard  and  contracted,  and  the  pains  are  continual,  though  they  are  marked,  it  is 
true,  by  exacerbations,  or  paroxysms,  and  there  are  moments,  as  in  ordinary 
labor,  when  the  patient  does  not  appear  to  suffer  at  all,  and  others  where  she 
makes  loud  cries  or  bearing-down  efforts.     The  periods  of  repose  are,  however; 


628  DYSTOCIA. 

only  apparent,  for  the  womb  is  constantly  contracted  on  tlie  pi'oduct  of  concep- 
tion, and  the  hand,  if  applied  over  the  belly,  always  finds  this  organ  in  a  remark- 
able state  of  hardness ;  there  is  not  that  regular  succession  of  repose  and  con- 
traction which  is  constantly  observed  when  the  labor  is  spontaneous;  and  we 
may  further  add,  that  the  patients  themselves  detect  a  great  difference  between 
the  pains  excited  by  the  medicine  and  those  previously  felt  in  the  same  or  former 
labors,  and  they  bear  them,  as  a  general  rule,  more  impatiently  than  the  latter, 
complaining  particularly  of  the  want  of  relaxation.  The  labor  is  ordinarily  ter- 
minated in  an  hour  or  an  hour  and  a  half  after  the  exhibition  of  the  ergot;  but 
the  action  of  the  latter  wears  away  and  soon  disappears  after  this  period,  and 
therefore,  if  there  is  any  necessity,  it  must  be  again  renewed,  or  recourse  be  had 
to  artificial  means  for  terminating  the  labor. 

The  permanent  character  of  the  contractions  produced  by  ergot,  makes  them 
very  dangerous  to  the  child  when  they  are  long  continued.  The  violent  retrac- 
tion of  the  muscular  fibres  then  renders  the  circulation  diflfieult,  and  sometimes 
even  impossible,  in  those  vessels  which  are  distributed  between  their  various 
layers,  and  we  may  readily  understand  that  the  foeto-placental  functions  must  be 
remarkably  obstructed.  Therefore,  it  can  be  prudently  administered  only  when 
a  prompt  termination  of  the  labor  can  be  predicted. 

This  remedy  is  only  to  be  given  during  parturition,  where  the  pelvis  is  well 
formed,  the  infant  presenting  by  its  cephalic  or  pelvic  extremity,  and  of  course 
when  the  position  is  well  ascertained ;  where  no  serious  obstacle  exists  at  the 
uterine  orifice,  in  the  vagina,  or  at  the  external  parts,  that  is  to  say,  when  the 
cervix  uteri  is  sufliciently  dilated,  or  at  least  soft,  supple,  and  patulous  enough  to 
admit  of  dilatation,  and  where  the  membranes  are  ruptured.  On  the  other  hand, 
its  administration  ought  to  be  avoided  as  much  as  possible  in  primipara),  and,  if 
it  should  become  necessary  in  them,  the  perineum  must  be  supported  with  the 
greatest  care,  lest  it  be  exposed  to  a  considerable  rupture  should  the  delivery 
prove  rapid ;  in  very  irritable  women,  who  may  have  had  convulsions  either  during 
gestation,  or  in  their  previous  labors ;  because  the  ergot  often  produces  a  state  of 
nervous  excitement  in  such  persons,  which  occasionally  amounts  almost  to  mania ; 
in  plethoric  patients,  suffering  from  a  congestion  about  the  head,  which  is  cha- 
racterized by  flushing  and  turgesccnce  of  the  face,  by  injection  of  the  eyes,  head- 
ache, &c.  &c.,  in  a  word,  in  all  those  cases  where  venesection  is  obviously  indi- 
cated ;  and  lastly,  in  all  those  women,  where  the  womb,  from  being  endowed  with 
an  acute  degree  of  sensibility,  is  in  a  state  of  irritation,  and  is  habitually  the  seat 
of  pains,  or  who,  in  a  former  labor,  might  have  been  affected  with  an  inflamma- 
tion of  this  organ. 

The  spurred  rye  has  likewise  been  employed  successfully  in  the  profuse  hemor- 
rhages that  follow  abortion,  which  are  caused  by  the  retention  or  tardy  separation 
of  the  placenta;  as  also  for  the  floodings  that  take  place  after  the  expulsion  of 
the  foetus,  whether  before,  during,  or  subsequent  to  the  delivery  of  the  after- 
birth. We  shall  take  occasion  hereafter,  in  the  article  on  Hemorrhage,  to  refer 
to  its  use  under  such  circumstances.  The  question  now  arises,  can  the  ergot, 
which  possesses  in  so  high  a  degree  the  property  of  stimulating  the  enfeebled 


EXTREME    SLOWNESS     OF    THE    LABOR.  529 

contractions,  and  of  arousing  them  when  suspended,  can  it  develope  them  where 
they  have  not  yet  existed  ?  If  we  might  judge  from  certain  experiments  made 
for  this  purpose,  by  Professor  Dubois,  in  our  presence,  at  the  Clinique,  in  1837, 
•we  should  answer  this  question  in  the  negative  ;*  but  it  must  be  confessed  that 
those  trials  were  not  sufficiently  numerous  to  enable  us  to  decide  it  positively; 
and  although  this  article  has  seemed  to  possess  the  abortive  property  in  some  in- 
stances, yet  in  many  others  it  has  proved  wholly  inefficacious. 

Again,  it  has  not  been  observed  that  abortions  are  of  more  frequent  occurrence 
in  those  countries  where  the  bread  of  the  inhabitants  contains  a  certain  quantity 
of  ergot  J  but  habit,  perhaps,  might  explain  its  want  of  action  here. 

This  medicine  is  employed  under  divers  forms ;  and  the  powder,  the  infusion, 
the  decoction,  the  aqueous  extract,  or  alcoholic  extract,  ethereal  tincture,  or  the 
syrup,  may  be  used,  almost  indifferently;  although  in  France  scarcely  any  other 
preparation  than  the  powder,  the  infusion,  or  decoction,  is  ever  employed.  Thus, 
it  is  customary  to  administer  two  or  three  doses  of  the  powder,  consisting  of  eight 
or  ten  grains  each,  diffused,  at  the  time  it  is  given,  in  two  ounces  of  pure  or 
sugared  water,  or  a  little  wine  and  water,  or  some  slightly  aromatic  infusion ;  and 
these  doses  are  repeated  at  intervals  of  ten  minutes.  If  the  contraction  is  mani- 
fested after  the  second  dose,  as  most  usually  happens,  the  third  need  not  be 
given.  Some  accoucheurs  administer  it  in  a  small  quantity  of  white  wine  or 
tincture  of  canella,  and  other  excitants;  and  it  has  been  advised  to  add  a  small 
quantity  of  opium  to  prevent  the  medicine  from  being  rejected,  though  where 
the  patient  either  vomits  or  seems  disposed  to  vomit  during  the  labor,  it  is  better 
to  administer  it,  as  M.  Dubois  recommends,  by  injection,  and  the  dose  might  then 
be  increased  a  little. 

The  infusion  is  prepared  by  diffusing  two  scruples  of  the  powdered  ergot  in  a 
glass  of  water  for  ten  minutes  ;  or,  if  the  article  is  merely  bruised  without  being 
powdered,  three  or  four  scruples  may  be  infused  in  the  same  quantity  of  men- 
struum. In  conclusion,  we  shall  not  again  repeat  what  was  said  in  the  com- 
mencement of  this  article  concerning  the  physical  characters  that  distinguish 
good  and  genuine  ergot,  but  we  will  only  add  that  the  apothecaries  ought  to  be 
cautioned  to  have  the  drug  freshly  pulverized;  and  as,  notwithstanding  our  ear- 
nest recommendations,  they  will  not  all  take  the  proper  precautions,  the  accou- 
cheur would  do  well  to  always  carry  a  few  grains  with  him,  so  as  to  have  it  at 
hand  in  case  of  necessity. 

'  Such  also  was  the  opinion,  at  the  time,  of  the  honorable  professor  alluded  to;  but,  since 
then,  new  experiments  have  somewhat  modified  his  views;  for  we  have  heard  him  affirm, 
at  the  Academy  of  Medicine  (in  March,  1S40),  that,  in  certain  cases,  the  ergoted  rye  might 
bring  on  the  regular  pains,  and,  in  consequence,  he  classified  this  medicine  among  the  mea- 
sures calculated  to  produce  a  premature  artificial  delivery.  But  this  opinion  does  not  appear 
to  us  to  be  based  on  a  sufficient  number  of  facts  to  warrant  its  general  adoption. 

34 


530  DYSTOCIA. 


CHAPTER   II. 

OF   TOO    RAPID    LABORS. 

Although  these  are  mueli  more  rare  than  the  preceding  class,  yet  the  acci- 
dents that  may  result  in  consequence  of  too  prompt  a  delivery,  are  quite  as 
serious  as  those  produced  by  its  excessive  slowness ;  and,  therefore,  we  must 
endeavor  to  supply  an  important  omission  made  by  most  author^  and  ourselves 
likewise  in  the  first  edition  of  this  work,  by  devoting  a  few  lines  to  the  conside- 
ration of  the  attendant  circumstances. 

Some  women  have  the  unfortunate  privilege,  if  it  can  be  called  such,  of  being 
delivered  with  only  a  few  pains ;  and  this  extreme  rapidity  is  apt  to  characterize 
every  subsequent  labor.  What  is  still  more  singular,  this  peculiarity  even  seems 
to  be  hereditary  in  certain  families,  in  which  it  is  perpetuated  for  three  or  four 
generations. 

In  such  eases,  the  rapid  termination  is  always  to  be  attributed  either  to  an 
excess  of  energy  and  frequency  in  the  uterine  contractions,  or  to  a  want  of  re- 
sistance in  the  walls  of  the  canal  which  the  foetus  has  to  traverse. 

Certain  writers  have  attempted  to  establish  a  relation  between  the  phenomena 
that  precede  or  accompany  the  menstrual  discharge  in  the  non-gravid  state,  and 
the  activity  or  slowness  of  the  contractions  of  the  womb  during  the  labor;  for, 
they  say,  should  the  periodical  flow  be  difficult,  laborious,  and  painful,  and  the 
patient  be  tormented  every  month  with  violent  colicky  pains,  either  before  or 
during  her  terms,  the  irritability  of  the  uterus,  and  the  energy  of  the  contrac- 
tions, will  almost  invariably  be  excessive  in  the  hour  of  childbirth ;  but,  on  the 
contrary,  there  is  reason  to  anticipate  the  occurrence  of  slow  and  feeble  pains, 
where  the  woman  is  advised  of  the  return  of  her  menses  only  by  the  appearance 
of  blood,  and  when  they  pass  oif  without  suffering.     We  do  not  know  exactly  to 
what  extent  this  approximation  is  true ;  yet  we  believe  that  it  is  far  from  being 
without  exceptions.     But,  however  this  may  be,  it  is  generally  found  that  these 
very  powerful  contractions  are  most  likely  to  be  observed  in  nervous  and  excitable 
persons;  appearing  to  depend,  says  Wigand,  upon  a  high  grade  of  irritability, 
the  source  of  which,  especially  in  hysterical  patients,  seems  to  be  centred  in  the 
uterus.     The  moral  affections  are  often  found  to  have  a  great  influence  over  the 
progress  of  labor;  and  everybody  knows  that  where  an  application  of  the  forceps 
has  been  seriously  proposed  to  the  woman,  this  of  itself  has  often  proved  quite 
sufficient  to  bring  on  strong  and  powerful  contractions  of  the  womb,  by  the  fears 
which  the  instrument  gives  rise  to,  even  though  they  had  been  languishing  before. 
In  certain  eruptive  fevers,  scarlatina  especially,  the  pains  very  frequently  ex- 
hibit this  character,  and  the  child  is  then  expelled  with  an  unusual  rapidity ;  but 
it  is  difficult  to  decide  whether  this  circumstance  is  not  rather  owing  to  a  want 
uf  resistance  from  the  soft  parts,  which,  like  all  the  muscular  apparatus,  have 
been  enfeebled  by  the  disease. 


TOO    RAPID     LABOR.  531 

The  same  thing  also  occurs  iq  certain  strong,  robust,  and  plethoric  women  ; 
here,  however,  the  contractions  are  very  strong  from  the  commencement  of  labor ; 
they  are  very  painful,  last  for  a  long  time,  and  are  separated  by  short  intervals. 
While  the  pain  lasts,  the  patient  cannot  resist  the  urgent  desire  to  bear  down, 
and  forcibly  contract  all  the  muscles  of  her  body ;  she  is  much  more  irritable 
than  usual,  and  there  is  something  peculiar  in  her  attitude ;  the  head  is  hot ;  the 
face  red  and  puffed  up;  and  the  pulse  full  and  accelerated.  In  some  instances, 
the  intervals  are  scarcely  perceptible,  for  one  pain  has  hardly  terminated  before 
another  begins ;  sometimes,  indeed,  the  womb  seems  in  a  state  of  permanent 
contraction,  which  only  passes  off  after  the  expulsion  of  the  foetus.  The  belly  is 
then  very  hard;  the  whole  body  rigid  and  contracted;  the  woman  holds  her 
breath,  seizes  hold  of  some  neighboring  object,  and,  making  a  loud  cry  or  grind- 
ing her  teeth,  bears  down  with  incredible  force,  and  suddenly  expels  the  child 
together  with  the  contents  of  the  bladder  and  rectum. 

J3ut,  after  all,  however  forcible  we  may  suppose  the  uterine  contractions  to  be, 
they  will  hardly  explain  the  rapidity  of  the  delivery,  unless  we  admit  that  a 
want  of  resistance  in  the  walls  of  the  pelvic  canal  exists  at  the  same  time ;  but 
may  not  a  very  large  pelvis,  a  premature  child,  or  a  marked  diminution  of  the 
normal  resistance  of  the  soft  parts,  so  often  met  with  in  persons  worn  out  by 
lingering  diseases,'  may  they  not,  we  repeat,  be  considered  as  singularly  favoring 
a  too  early  expulsion  of  the  child  ? 

Where  the  phenomena  of  parturition  take  place  with  due  regularity,  the  infant 
rarely  comes  into  the  world  under  seven  or  eight  hours  after  the  first  pain,  and 
this  beneficent  delay  enables  the  parts  which  the  child  has  to  traverse  to  become 
prepared  for_  the  dilatation  they  must  shortly  undergo ;  the  uterine  orifice  gra- 
dually enlarges ;  the  soft  parts,  that  line  the  excavation  and  the  pelvic  floor,  being 
lubricated  for  a  long  time  by  the  liquids  exhaled  from  the  womb,  or  secreted  by 
the  upper  part  of  the  vagina,  become  more  soft  and  supple  and  better  prepared 
for  the  distension  they  will  be  subjected  to,  at  the  moment  when  the  head  is 
born ;  besides,  their  dilatation  being  effected  under  the  influence  of  intermittent 
contractions,  alternated  by  an  interval  of  rest,  is  slow  and  gradual,  and  takes 
place  without  causing  the  patient  any  very  acute  suffering  and  without  compro- 
mising the  life  of  the  child;  but  it  is  far  different  in  the  case  before  us,  where 
the  over-hasty  expulsion  of  the  infant  exposes  it  as  well  as  the  mother  to  grave 
accidents.  Thus,  not  to  speak  of  inertia  of  the  organ,  which  will  be  treated  of 
hereafter  as  one  of  the  circumstances  that  may  complicate  the  delivery,  we  must 
note  .as  of  possible  occurrence  the  laceration  of  the  perineum,  vagina,  and  vaginal 
portion  of  the  cervix,  so  often  produced  by  the  rapid  passage  of  the  foetus  through 
the  pelvic  canal ;  the  prolapsus  of  the  womb,  which,  not  being  yet  sufficiently 
dilated  to  allow  the  child  to  clear  its  orifice,  is  forced  down  beyond  the  vulvar 
ring;  the  serious  and  sometimes  fatal  syncopes  to  which  the  too  rapid  depletion 

'  This  want  of  resistance  from  the  soft  parts  may  be  met  with  in  women  who  are  other- 
wise healthy,  as  occurred  in  a  case  reported  by  Dr.  Rigby,  where  a  patient,  in  the  enjoyment 
of  good  health,  was  delivered  by  two  pains;  the  first  of  which  aroused  her  from  a  sound 
sleep,  and  the  second  expelled  the  foetus  into  her  bed. 


532  DYSTOCIA. 

of  the  womb  exposes  the  patient  ;^  and,  lastly,  death  itself,  produced  solely  from 
the  violence  of  the  nervous  shock  caused  by  such  pains. 

The  child  is  likewise  exposed  to  real  danger;  for  if  the  membranes  are  rup- 
tured and  the  waters  entirely  discharged  early  in  the  labor,  it  must  be  apparent 
that,  when  the  pains  become  permanent,  the  umbilical  cord  might  be  compressed 
between  the  foetal  surface  and  the  uterine  wall,  or  that  the  infont  itself  might 
suffer  from  the  direct  pressure  it  then  undergoes.  On  the  other  hand,  if  the 
woman,  supposing  herself  only  at  the  commencement  of  her  labor,  should  happen 
to  be  still  standing  or  walking  when  surprised  by  these  violent  pains,  the  child 
may  be  forcibly  expelled,  and,  striking  against  the  floor,  be  killed,  perhaps,  by 
the  severity  of  the  fall ;  besides  which,  the  umbilical  cord  is  stretched  from  its 
placental  insertion  to  the  navel,  and,  if  its  rupture  does  not  result  in  consequence, 
the  traction  made  upon  the  still  adherent  after-birth  may  be  sufficiently  great  to 
depress,  or  even  to  invert  the  womb  completely ;  though  this  latter  circumstance 
is  an  exceedingly  rare  one.  A  rupture  of  the  cord  has  been  observed  much 
oftener;  but  this  is  seldom  attended  with  much  danger,  so  far  as  the  child  is 
concerned,  because  the  laceration  usually  occurs  at  two  or  three  inches  from  the 
navel,  and  because,  by  tearing  the  umbilical  vessels,  is  likely  to  prevent  a  mortal 
hemorrhage,  even  should  the  pulmonary  respiration  not  be  established  imme- 
diately. 

Treatment. — Where  there  is  reason  to  believe  that  the  child  is  very  small,  as 
it  would  be  in  a  case  of  premature  labor,  or  if  previous  have  led  us  to  suppose 
that  the  pelvis  is  larger  than  usual,  the  woman  ought  to  lie  down  on  the 
occurrence  of  the  very  first  pain,  and  she  should  avoid  bearing  down  or  contract- 
ing the  muscles  subjected  to  the  influence  of  her  will,  as  much  as  possible, 
during  the  pain  ;  the  same  object  would  be  materially  aided  by  applying  a  mode- 
rately drawn  bandage  around  the  abdomen  (Rigby).  Finally,  every  precaution 
is  to  be  taken  to  retard  the  rupture  of  the  membranes  as  long  as  possible. 

If,  notwithstanding  these  precautions,  it  is  found  that  the  inferior  part  of  the 
uterus  is  strongly  pressed  downward  towards  the  floor  of  the  pelvis,  or  even 
through  the  vulvar  orifice,  it  must  be  carefully  sustained  until  the  cervix  is  suffi- 
ciently dilated  to  permit  the  free  passage  of  the  head.  We  might,  like  M. 
Naegole,  apply  a  large  T  bandage  in  front  of  the  vulva,  extending  up  over  the 
prominent  part  of  the  womb,  and  having  an  opening  at  its  centre  corresponding 
to  the  orifice  of  the  vagina. 

If  the  patient  had  been  delivered  too  rapidly  in  her  previous  pregnancies, 
opiates  might  be  administered,  either  by  the  mouth,  or  by  injection,  for  the  pur- 

■•  There  is  no  difFieiilty  in  explaining  the  production  of  syncope  in  this  case,  for  the  womb, 
being  distended  by  the  product  of  conception,  necessarily  exercises  a  greater  or  less  degree 
of  compression  on  the  large  abdominal  vessels;  and  when  the  foetus  is  slowly  delivered,  as 
in  a  natural  labor,  this  compression  diminishes  in  the  same  proportion,  and  the  blood  returns 
in  a  very  gradual  manner  into  the  great  trunks,  in  which  its  course  was  before  impeded  ; 
but  in  the  case  before  us  the  depletion  of  the  uterus  is  sudden,  and  the  vessels  are  relieved 
all  at  once  from  the  strong  pressure  they  previously  experienced,  the  blood  flows  into  them 
in  abundance,  and  goes  in  but  small  quantities  to  the  brain  ;  whence  the  latter,  deprived 
of  its  natural  stimulus,  no  longer  acts  on  the  heart,  &c.  &c. 


TOO     RAPID    LABOR.  533 

pose  of  calming  the  excessive  irritability  of  the  uterus.  Wigand  has  recom- 
mended venesection,  which,  perhaps,  might  be  employed  with  advantage  in 
strong  and  plethoric  women,  but  experience  has  not  yet  determined  the  efl&cacy 
of  the  measure  as  a  general  remedy. 


BOOK  II. 

OF  LABORS  RENDERED  DIFFICULT,  IMPOSSIBLE,  OR  DANGEROUS,  BY 
OBSTACLES  THAT  OPPOSE  THE  READY  EXPULSION  OF  THE  FCETUS. 

The  material  obstacles  which  too  often  render  spontaneous  labor  difficult  or 
impossible,  are  exceedingly  numerous,  and  depend  either  on  the  mother  or  child. 
The  diseases  and  vices  of  conformation,  or  of  direction,  of  the  canal  which  the 
foetus  has  to  traverse,  are  naturally  included  among  the  fii'st ;  and  to  the  second 
we  must  refer  the  diseases  and  malformations  of  the  infant  itself,  as  also  the 
unfavorable  positions  in  which  it  may  present  at  the  superior  opening  of  the 
pelvis.  We  shall  commence  our  description  with  the  obstacles  appertaining  to 
the  mother's  organs,  and  will  first  treat  of  malformations  of  the  pelvis. 


CHAPTER    I. 

OF   MALFORMATIONS    OF   THE    PELVIS. 

Whenever  the  pelvis  departs  from  the  dimensions  heretofore  described  as 
the  normal  ones,  there  is  said  to  be  a  vice  or  malformation  of  it ;  which,  as  the 
reader  will  readily  understand,  may  either  be  an  enlargement  or  a  diminution  of 
the  average  size;  and  this  explains  the  division  admitted  by  accoucheurs,  into 
pelves  deformed  by  excess  of  amplitude,  and  those  deformed  by  excess  of  retrac- 
tion. I  say  by  excess  of  amplitude  or  of  retraction,  for  it  must  not  be  supposed 
that  a  pelvis  is  reputed  to  be  malformed,  whenever  it  does  not  exactly  present 
the  dimensions  before  given  as  the  ordinary  standard  ;  because,  its  development 
is  subjected  to  the  influence  of  the  same  laws  that  regulate  the  whole  organism, 
and  we  all  know  what  great  varieties  those  laws  exhibit  in  their  accomplishment. 
Therefore,  as  a  few  lines,  more  or  less,  do  not  constitute  a  vice  of  conformation, 
we  shall  only  include  under  the  title  of  malformed  pelves  those  which,  from  their 
excessive  size  or  narrowness,  are  capable  of  producing  notable  difficulties  in  the 
exercise  of  the  puerperal  functions. 

§  1.  Of  the  Pelvis,  Deformed  by  Excess  of  Amplitude. 

A  large  pelvis  is  not  always  a  favorable  circumstance,  as  might  at  first  sight 


DYSTOCIA. 

be  supposed ;  because,  if  the  amplitude  is  too  great,  it  exposes  the  woman  to 
serious  accidents,  both  in  the  non  uravid,  the  pregnant,  and  the  parturient  state. 
Thus,  in  the  unimpregnated  condition,  the  uterus,  not  deriving  an  adequate  sup- 
port from  the  walls  of  the  excavation,  and  being  free  and  movable  in  an  over- 
spacious  cavity,  is  much  more  liable  to  the  various  displacements  known  as 
descent,  anteversion,  and  retroversion  of  the  womb;  which  accidents  are  then 
the  more  unfortunate,  as  they  are  the  more  difl&cult  to  remedy. 

During  gestation,  the  womb,  finding  more  space  than  usual  in  the  pelvic  cavity, 
remains  there  until  a  much  more  advanced  period  of  pregnancy,  and  the  volume 
of  the  organ,  by  compressing  the  rectum  and  the  bladder,  often  occasions  an 
excessive  tenesmus  in  these  parts,  which  proves  very  distressing  to  the  patient; 
sometimes,  even  the  discharge  of  the  urine  and  fecal  matters  is  impeded,  besides 
which,  varices,  hemorrhoidal  tumors,  or  a  considerable  infiltration  of  the  lower 
parts  are  found  to  be  developed,  in  consequence  of  the  mechanical  obstacle  to  the 
circulation  in  the  inferior  extremities.  If  this  excess  of  amplitude  is  restricted 
to  the  excavation,  while  the  straits  vary  but  little,  if  any,  from  their  normal 
dimensions,  the  fundus  of  the  womb  is  often  turned  back  into  the  hollow  of  the 
sacrum ;  and,  somewhat  later,  when  its  volume  is  too  great  to  permit  a  longer 
sojourn  in  the  lesser  pelvis,  it  meets  with  difiiculties  at  the  superior  strait  which 
it  cannot  surmount ;  and  the  impediment  then  offered,  in  either  case,  to  the  ulte- 
rior development  of  the  organ,  frequently  brings  on  an  abortion.  At  the  end  of 
gestation,  the  head  engaging  early  at  the  superior  strait,  gets  low  down  into  the 
excavation,  and  presses  on  the  neighboring  parts;  whence  all  the  unpleasant 
symptoms  that  had  accompanied  the  outset  of  pregnancy  are  found  to  be  renewed 
in  its  latter  months. 

Durinf  labor,  the  excess  of  amplitude  of  the  pelvis  exposes  the  woman  to  all 
the  dangers  that  may  result  from  a  too  rapid  delivery ;  for,  if  she  brings  into 
play  the  voluntary  muscles,  long  before  the  proper  dilatation  of  the  os  uteri,  or 
bears  down  too  strongly  during  the  pain,  the  organ,  being  imperfectly  sustained 
by  the  osseous  walls  of  the  canal,  may  be  forced  down  as  far  as  the  vulva ;  and, 
indeed,  be  driven  completely  beyond  the  parts  of  generation;  or,  possibly,  the 
circumference  of  the  cervix  uteri  may  yield,  and  thus  give  rise  to  a  laceration. 
Supposing  the  dilatation  is  already  perfected,  then  the  child,  being  urged  along 
by  the  energetic  and  repeated  contractions  of  the  womb,  and  not  encountering  a 
due  degree  of  resistance  on  the  part  of  the  straits,  speedily  reaches  the  perineum, 
and  tears  its  way  through,  because  the  latter  has  not  yet  had  time  to  become  dis- 
tended. The  expulsion  of  the  foetus  may  thus  take  place  at  a  moment  when  the 
patient  and  her  attendants  believed  it  still  distant;  and  hence,  the  absence  of 
the  ordinary  precautions,  and  the  erect  position  in  which  she  may  happen  to  be, 
will  expose  the  child  to  a  fall  on  the  floor,  or  produce  a  premature  separation  of 
the  placenta,  a  rupture  of  the  umbilical  cord,  or  an  inversion  of  the  womb;  and, 
last  of  all,  the  womb,  from  being  suddenly  emptied,  is  sometimes  affected  with 
inertia,  and  becomes  the  source  of  a  profuse  flooding. 

After  delivery,  a  very  large  pelvis  permits  the  uterus,  notwithstanding  its 
volume,  to  sink  down  into  the  excavation,  and  the  compression  thereby  produced 


MALFORMATIONS     OF     THE     PELVIS.  535 

on  the  adjacent  organs  may  become  the  cause  of  an  inflammation  that  is  always 
to  be  dreaded.  It  is  further  evident  that  an  excess  of  amplitude  must  favor  the 
displacements  of  the  organ ;  and  it  is  highly  probable  that  the  cases  of  retro- 
version reported  by  Martin,  of  Lyons,  and  Vermandois,  as  having  occurred  in 
the  first  few  days  immediately  following  the  delivery  were  owing  to  this  circum- 
stance.     (^Martin,  158.) 

The  indications  for  treatment,  which  malformation  of  the  pelvis,  from  excess 
of  amplitude,  present,  are  exceedingly  simple ;  for  all  that  we  have  to  do  is  to 
keep  the  patient  recumbent  throughout  the  labor,  and  recommend  her  not  to  aid 
the  pains  in  anywise,  and  particularly  not  to  bear  down  until  the  os  uteri  is  fully 
dilated.  Where  this  process  is  not  yet  completed,  and  the  cervix,  pressed  down 
by  the  head,  appears  at  the  vulva,  we  must  endeavor  to  push  it  back  during  the 
interval,  and  then,  by  supporting  it  with  the  hand,  oppose  its  escape  during  the 
contraction  J  though,  on  the  contrary,  if  the  neck  is  sufficiently  dilated,  the  labor 
is  to  be  terminated  by  the  application  of  the  forceps. 

For  the  indications  to  be  fulfilled  during  the  progress  of  gestation,  we  refer  to 
page  565,  et  seq. ;  as  also,  for  those  presented  by  the  displacements  of  the  uterus 
in  the  course  of  the  labor  itself,  to  the  following  chapter. 

§  2.  Or  THE  Pelvis  Deformed  by  Excess  op  Retraction, 

Among  the  various  conditions  necessary  to  a  spontaneous  labor,  there  is  one 
whose  importance  cannot  be  contested,  namely,  that  a  just  proportion  exist  be- 
tween the  dimensions  of  the  canal,  and  those  of  the  body  that  must  traverse  it; 
for,  whenever  this  relation  does  not  appear,  whether  owing  to  a  retraction  of  the 
pelvis,  or  to  an  abnormal  size  of  the  child,  the  delivery  is  no  longer  possible ; 
and  whenever  this  disproportion  is  carried  to  an  extreme,  we  have  only  to  choose 
between  two  resources  that  are  equally  disastrous  in  their  consequences,  that  is, 
to  diminish  the  volume  of  the  infant,  or  to  enlarge  the  way  it  has  to  pass  through. 
The  retractions  of  the  pelvis,  therefore,  are  the  most  terrible  accidents  that  can 
occur  in  the  practice  of  our  art,  and  their  importance,  in  every  point  of  view, 
sufficiently  warrants  the  detail  into  which  we  are  about  to  enter. 

The  various  degrees  of  retraction,  the  differences  in  their  seat,  and  the  varieties 
of  form  the  pelvis  then  assumes,  are  so  numerous,  that  it  is  indispensably  neces- 
sary to  adopt  some  general  arrangement;  to  collect  them  into  classes,  to  form 
groups,  and  then  to  attach  these  to  certain  principal  types  that  are  easily  recog- 
nized; the  number  of  which,  however,  to  aid  their  acquisition  by  students, 
should  not  be  too  great.  After  having  thus  classified  the  difi'erent  varieties  of 
deformities  from  retraction,  we  must  study  their  principal  characters,  and  en- 
deavor to  point  out  their  causes,  their  mode  of  development,  the  means  of  recog- 
nizing them,  and,  lastly,  the  indications  for  treatment  that  each  of  them  presents. 


DYSTOCIA. 

ARTICLE   I. 

PATHOLOGICAL   ANATOMY. 

As  regards  their  form  and  external  configuration,  the  retracted  pelves  may  be 
divided  into  two  very  distinct  groups;  for  either  the  pelvis,  although  greatly 
retracted  in  all  its  dimensions,  is  properly  formed,  and  presents  no  irregularity  in 
its  exterior  aspect,  or  else  the  retraction  affects  only  one  or  more  of  its  diameters 
(the  others  maintaining  very  nearly  their  normal  length),  and  this  partial  altera- 
tion completely  changes  its  form. 

§  1.  Of  the  Simple  Contracted  Pelvis,  without  Curvature  or  Mal- 
formation OF  the  Bones.     (Absolute  Contraction. —  Velpeau.) 

Before  the  researches  of  Professor  Naeg^le,  whose  principal  works  on  the  pelvis 
will  soon  be  disseminated  throughout  France,  by  means  of  the  translation  just 
published  by  M.  Danyau,  there  was  scarcely  any  mention  made  of  this  variety  of 
contraction,  in  the  leading  classic  works ;  for  most  of  the  French  and  English 
authors  merely  stated  that  a  narrowness  is  rarely  met  with  in  all  parts  of  the 
pelvis  at  one  and  the  same  time,  and  that  it  is  still  more  rarely  carried  to  a  point 
demanding  the  intervention  of  art. 

It  was  reserved  for  M.  N^gele  to  point  out  the  importance  of  this  particular 
variety.  In  his  collection,  he  numbers  four  pelves  that  are  contracted  through- 
out, and  all  their  diameters  are  one  inch  less  than  the  normal  dimensions;  these 
all  required  either  the  Caesarean  operation  or  the  mutilation  of  the  foetus.  Three 
of  them  were  obtained  from  women  of  ordinary  stature,  the  fourth  belonged  to 
a  dwarf  thirty-one  years  of  age,  and  only  forty-six  inches  in  height,  though  other- 
wise well  formed.  As  regards  the  respective  lengths  of  their  different  diameters, 
and  the  form  of  the  pubic  arch,  each  one  of  these  presents  the  characters  of  a 
regularly-formed  pelvis,  whose  dimensions  may  be  supposed  to  have  been  reduced  ; 
and,  as  to  the  condition  of  the  bones,  that  is  to  say,  their  color,  strength,  and 
texture,  there  is  no  departure  from  the  healthy  standard.  In  one  of  them  there 
is  even  a  tendency  to  a  greater  density  of  the  osseous  tissue.  Further,  these 
pelves  have  nothing  in  common  with  those  deformed  in  consequence  of  rachitis, 
as  the  consistence,  density,  thickness,  and  size  of  the  bones,  and  the  regular 
shape  of  the  pubic  arch  sufficiently  prove ;  besides,  the  individuals  from  whom 
they  were  procured,  presented  no  traces  of  that  affection  during  life;  and  the 
examination  of  other  parts  of  the  skeleton  fully  confirmed  this  distinction,  which 
we  hope  to  prove  in  a  still  more  decisive  manner  hereafter,  when  the  causes  and 
particular  development  of  this  species  of  contraction  shall  be  studied. 

M.  Naeg^le  admits  two  distinct  varieties  in  the  malformed  pelvis  under  con- 
sideration. In  one,  he  says,  the  pelvis,  with  respect  to  its  thickness,  strength, 
texture,  and  indeed  all  the  physical  characters  of  the  bones,  size  excepted,  does 
not  differ  from  a  normal  one ;  and  it  is  met  with  in  persons  of  either  a  small,  an 
ordinary,  or  a  high  stature,  who  may  be  otherwise  well-formed  and  thin,  and 
whose  external  appearance  would  not  cause  the  least  suspicion  of  such  a  forma- 


MALFORMATIONS    OF    THE     PELVIS.  537 

tion ;  whence  it  can  only  be  recognized  by  a  local  exploration.  In  the  other, 
the  pelvis  is  wholly  different;  for,  as  regards  their  volume,  substance,  and 
strength,  the  bones  exhibit  the  characteristics  of  childhood;  and  the  same  re- 
mark is  applicable  to  their  mode  of  union  with  each  other.  This  variety  is  only 
observed  in  very  small  individuals,  such  as  dwarfs ;  and  the  relations  of  the  dia- 
meters with  one  another,  and  the  form  of  the  pubic  arch  are  such  as  are  found 
in  the  girl,  when  the  sexual  system  has  just  completed  its  development.  Thus, 
for  example,  in  the  dwarf  before  cited,  whose  height  was  but  forty-six  inches,  the 
pelvis  had  the  following  dimensions,  viz.  : — 


From  the  promontory  of  the  sacrum  to  the  point  of  the  coccyx, 
The  antero-posterior  diameter  of  the  superior  strait,    . 
Transverse  diameter  of  u  it  _         _ 

Antero-posterior  diameter  of  the  excavation,         .  ,         . 

Transverse  diameter  •'    .  "  ... 

Transverse  diameter  of  the  inferior  strait,   .... 


3^  inches. 

H     " 

3|      « 
3i       « 

H     ■'■ 

3i       « 


Depth  of  the  symphysis  pubis, nearly  1  inch. 

§  2.  Of  the  Pelvis  Contracted  by  the  Curvature  amd  Malforma- 
tion OF  the  Bones.     (Relative  Contraction. —  Velpeau.) 

In  those  cases  where  the  pelvis  is  contracted  by  the  curvature  and  malforma- 
tion of  its  constituent  bones,  the  deformity  may  be  referred  to  one  of  the  three 
principal  types  described  by  M.  Dubois;  that  is,  either  to  a  flattening  from  before 
backwards,  to  a  compression  on  the  sides,  or  to  the  depression  of  the  anterior  and 
lateral  parts ;  the  first  variety,  or  flattening,  shortens  the  antero-posterior  dia- 
meters, the  lateral  compression  diminishes  the  transverse  ones,  and  the  depression 
of  the  antero-lateral  walls  contracts  the  oblique  diameters.  Again,  each  of  these 
varieties  may  aff"ect  either  the  superior  strait,  the  inferior  strait,  or  the  excava- 
tion, though  frequently  both  straits  are  contracted  at  the  same  time. 

A.  T\xe  flattening  from  before  hacJcwards,  or  shortening  of  the  antero-posterior 
diameter,  results  from  a  more  or  less  marked  approximation  of  the  anterior  and 
posterior  pelvic  walls ;  and  this  species  of  malformation  exhibits  several  varieties, 
as  regards  the  extent  of  contraction,  whether  in  height  or  width.  For  instance, 
the  superior  strait  alone  may  be  contracted,  while  the  excavation  retains  its 
normal  capacity;  this  phenomenon  is  caused  by  the  unusual  curvature  of  the 
sacrum,  which  is  sometimes  so  bent  anteriorly  as  almost  to  represent  an  obtuse 
angle  at  its  middle  part,  whereby  the  base  of  the  bone  is  thrown  forward  in  such 
a  way,  as  to  singularly  augment  the  prominence  of  the  sacro-vertebral  angle.  But 
the  contrary  may  also  occur,  and  the  sacrum,  instead  of  presenting  an  anterior 
concavity,  be  quite  plane,  or,  occasionally,  even  convex  in  front;  and  then  the 
excavation  is  contracted  simultaneously  with  the  superior  strait,  in  its  antero- 
posterior diameter,  and  it  really  seems  as  if  the  sacrum,  having  lost  its  natural 
curvature,  had  been  pushed  forward  in  totality. 

The  shortening  of  the  antero-posterior  diameter  of  the  superior  strait,  some- 
times accompanies  an  enlargement  of  the  corresponding  one  at  the  inferior  strait. 
This,  indeed,  is  the   most  frequent  arrangement,  and  is  what  generally  takes 


538 


DYSTOCIA. 


A  pelvis,  in  wliich  ihe  contraclioii  of  llie  ?acro-puhic 
diameter  is  produced  by  the  unusual  prominence  of  the 
sacro-vertebral  angle. 


pliice,  when  the  sacrum,  yielding  under  the  weight  of  the  trunk,  transmitted  to  it 
through  the  spinal  column,  becomes  tilted,  that  is,  the  base  is  projected  forward, 
while  its  coccygeal  extremity  is  forcibly  pushed  backward. 

Lastly,  the  coccy-pubic  and  the  sacro-pubic  diameters  may  be  shortened,  at  the 
same  time,  if  it  should  happen  that  the  sacrum,  instead  of  performing  the  tilting 

movement  just  alluded  to,  yields  in 
^'S-  ^1-  such  a  way  that  its  two  extremities 

are  thrown  forward ;  the  anterior 
curvature  is  then  greatly  augment- 
ed, and  consequently  the  corre- 
sponding diameter  of  the  excava- 
tion enlarged. 

In  the  approximation  of  the 
antero-posterior  walls,  the  sacrum 
is  nearly  always  the  displaced  bone; 
but  although  much  more  rare,  a 
flattening  of  the  anterior  wall  is 
also  met  with ;  and  then  the  sym- 
physis pubis,  instead  of  presenting 
a  convexity  in  front,  is  perfectly 
flat,  or  even  (as  in  one  instance  re- 
presented by  Madame  Boivin)  presents  a  depression,  which  seems  to  protrude 
inwardly  towards  the  prominence  of  the  sacrum.  This  double  inclination  of  the 
pubis  and  sacrum  towards  each  other,  gives  to  the  superior  strait  the  form  of  a 
figure-of-eight ;  that  is,  its  plane  is  divided  into  two  rounded  portions  on  the 
sides,  corresponding  to  the  iliac  fossae,  and  is  separated  in  the  middle  by  a  re- 
stricted part,  of  variable  width.  If  the  depression  is  considerable,  the  antero- 
posterior diameters  of  both  straits,  and  of  the  excavation,  must  evidently  be 
afiected  by  it. 

But  there  is  yet  another  way  in  which  the  symphysis  pubis  may  contribute  to 

the  narrowness  of  the  pelvis;  for  in- 
stance, its  vertical  extent  is  sometimes 
much  greater  than  usual,  and  this  ex- 
traordinary length  gives  rise  to  what  is 
termed  the  har  pelvis;  or  the  same 
efl'ect  may  be  produced  by  an  excessive 
inclination  backwards  at  its  lower  end. 
Again,  the  coccy-pubic  diameter  may 
be  shortened,  it  is  said,  by  an  elonga- 
tion, or  rather  an  almost  horizontal 
direction  of  the  coccyx,  and  more  par- 
ticularly by  an  immobility  of  the  sacro-coccygeal  articulation.  This  latter  cir- 
cumstance has  been  invoked  in  explanation  of  the  slowness  and  difficulty  of  first 
labors,  in  middle-aged  women ;  but,  as  M.  A.  Dubois  has  remarked,  the  delay  in 
the  delivery  of  the  head  in  such  persons  does  not  usually  depend  on  an  immo- 


The  shape  of  the  superior  strait  in  the  figure-of-eight 
pelvis. 


MALFORMATIONS     OF     THE     PELVIS.  539 

bility  of  the  coccyx,  but  upon  the  rigidity  of  the  soft  parts,  which  then  offer 
great  resistance. 

B.  The  compression  of  the  lateral  walls,  by  which  the  transverse  diameter  is 
shortened,  is  the  rarest  of  all  the  vices  of  conformation,  at  least  so  far  as  con- 
cerns the  superior  strait  and  upper  part  of  the  excavation ;  for  the  inferior  strait, 
on  the  contrary,  the  approximation  of  the  two  ischial  tuberosities,  which  consti- 
tutes this  species  of  deformity,  is  quite  as  frequent  as  the  shortening  of  the  coccy- 
pubic  diameter;  the  malformation  resulting  from  the  approach  of  those  tuberosi- 
ties, as  well  as  that  of  the  branches  of  the  pubic  arch ;  this  latter  then  assumes 
the  triangular  form  peculiar  to  the  male  sex.  Besides  which,  the  lower  part  of 
the  excavation  may  be  notably  diminished  in  the  transverse  direction,  by  the 
inward  projection  of  the  spines  of  the  ischia. 

The  transverse  contraction  is  seldom  as  well  marked  as  the  flattening  from 
before  JDackwards,  especially  at  the  superior  strait,  where  it  is,  in  general,  limited 
to  diminishing  the  bis-iliac  diameter  from  a  few  lines  to  an  inch  in  its  length,  by 
elongating  the  antero-posterior  one  to  the  same  extent ;  for  the  coxal  bones  are 
then  less  curved,  and  the  sacrum  is  thrust  backwards,  while  the  pubes  are  more 
prolonged  in  front.  Of  course,  the  upper  strait  will  be  more  or  less  altered  in 
form  according  to  the  degree  of  compression,  for  where  this  is  inconsiderable,  its 
peripher}'  is  nearly  circular;  but,  when  greater,  it  represents  an  ovoid,  the  larger 
extremity  of  which  is  posterior. 

Another  variety  of  transverse  contraction  is  owing  to  the  fact  of  the  pelvis 
being  less  developed  in  one  of  its  halves  than  in  the  other,  and  consequently  to 
its  exhibiting  a  less  degree  of  curvature  in  that  part,  than  upon  the  opposite  side. 
In  this  case,  the  articulation  of  the  spine  with  the  sacrum  no  longer  corresponds 
to  the  middle  of  the  pelvis,  and  the  vertebral  column  is  found  nearer  to  the  hip 
of  the  contracted  side;  the  transverse  diameter  is  likewise  diminished  at  the 
inferior  strait  by  reason  of  the  obliquity  of  the  entering  part  of  the  coxal  bone. 
The  antagonism  before  alluded  to,  as  existing  between  the  antero-posterior  dia* 
meters  of  the  superior  and  the  inferior  straits,  whereby  the  elongation  of  one 
most  frequently  coincides  with  a  shortening  of  the  other,  rarely  exists  in  the 
transverse  direction  ;  the  deformity  produced  by  a  congenital  displacement  of  the 
femurs  is  probably  the  only  condition  in  which  the  transverse  diameter  of  the 
inferior  strait  augments  at  the  same  time  that  the  bis-iliac  one  diminishes ;  the 
enlargement  in  the  lower  part  of  the  pelvis,  in  this  instance,  being  marked  by 
an  unusual  width  in  the  pubic  arch,  a  great  obliquity  of  the  isehio-pubic  rami,  a 
separation  of  the  ischial  tuberosities,  &c.     (See  art.  Causes.) 

C.  The  depression  of  the  antero-lateral  walls,  which  diminishes  the  oblique 
diameters,  is  much  more  frequent  than  the  preceding  variety,  though  it  is  more 
rare  than  the  flattening  from  before  backwards,  and  it  may  exist  on  one,  or  both 
sides  at  the  same  time.  This  deformity  consists,  essentially,  in  the  flattening,  or 
inward  projection  of  the  coxal  bone,  at  the  part  corresponding  to  the  cotyloid 
cavity,  and  to  the  junction  of  its  three  constituent  pieces;  whence  there  results 
at  this  point  a  greater  or  less  diminution  of  the  curve  which  the  pelvic  circum- 
ference usually  describes;  and  when  existing  in  a  high  degree,  the  curvature  is 


540 


DYSTOCIA. 


even  reversed,  its  convexity  being  turned  towards  the  sacrum,  while,  at  the  same 
time,  the  pubis  departs  from  its  normal  transverse  direction  and  runs  almost 
directly  forwards;  so  that  the  deformity  is  produced  by  the  coxal  bones  having 
then  assumed  the  form  of  an  old  italic  S,  instead  of  presenting  a  regular  arch. 

Where  this  takes  place  to  the  same  extent  on  both  sides,  the  pelvis  maintains 
a  degree  of  symmetry,  and  the  superior  strait  is  shaped  like  the  trefoil  leaf;  that 
is,  it  presents  three  lobes,  one  anteriorly,  which  corresponds  to  the  more  acute 
angle  of  the  pubis,  and  two  posteriorly  and  laterally,  formed  by  the  union  of  the 
iliac  bones  with  the  sacrum.  But,  it  far  oftener  happens  that  the  deformity  is 
more  marked  in  the  coxal  bone  of  one  side  than  upon  the  other,  and  then  the 
shape  of  the  pelvis  is  the  more  irregular  as  the  deformity  of  the  ossa  innominata 
is  greater. 

Where  this  double  disfiguration  of  the  hip  bones  exists  in  a  high  degree,  more 

especially  when  it  aifects  the  ante- 
^ig-  S'^-  rior  pelvic  wall,  it  vitiates  both  the 

oblique  and  antero-posterior  diame- 
ters at  the  same  time.  In  fact, 
these  bones  are  then  approximated 
in  a  parallel  manner,  being  only 
separated  from  each  other  by  a 
slight  distance,  for  the  extent  of  an 
inch  or  two,  while  the  rest  of  the 
pelvis  is  comparatively  regular;  and 
hence,  although  the  symphysis  pubis 
may  be  at  the  normal  distance  from 
the  sacro-vertebral  angle,  yet  it  is 
not  the  less  true,  that  the  antero- 
posterior diameter  of  the  superior 
strait  will  be  virtually  shortened  in  all  its  forward  part  comprised  in  the  fissure 
left  between  the  two  deformed  antero-lateral  walls,  because  this  contracted  por- 
tion cannot  contribute  in  anywise  to  the  passage  of  the  foetal  head. 

Again,  we  may  remark,  with  M.  P.  Dubois,  that  as  the  anterior  arch  of  the 
pelvis  has  but  very  little  depth  at  the  point  corresponding  to  the  depression  of 
its  lateral  walls,  and  as  the  surface  compressed  by  the  head  of  the  femur  occu- 
pies the  largest  portion  of  it,  the  whole  of  that  region  must  almost  necessarily  be 
pressed  in ;  and,  consequently,  that  the  shortening  must  atfect  all  the  diameters 
at  once,  those  of  the  excavation  and  of  the  abdominal  and  perineal  straits;  though 
the  retraction  is  in  general  less  marked  at  the  inferior  strait  than  elsewhere, 
because  the  lower  part  of  the  ischium  is  not  carried  so  far  backwards  as  the 
cotyloid  region. 

As  to  the  variety  of  deformity  recently  described  by  M.  Naeg^le,  the  celebrated 
professor  of  Heidelberg,  under  the  title  o?  oblique  contraction,  we  may  evidently 
refer  it  also  to  a  shortening  of  one  of  the  oblique  diameters.  His  book  on  the 
subject  has  recently  been  translated  with  the  greatest  care  by  M.  Danyau,  who 
has  enhanced  the  value  of  this  admirable  work  by  the  addition  of  learned  notes; 


A  pelvis  in  which  the  siiiking-in  of  ihe  antero-lateral 
walls  exists  on  both  sides. 


MALFORMATIONS    OF    THE     PELVIS. 


541 


but,  as  we  had  induced  Dr.  Steege,  before  the  publication  of  Danyau's  transla- 
tion, to  prepare  for  us  the  chapter  in  which  M.  Naegele  describes  the  principal 
characters  of  his  oblique  pelvis,  we  submit  the  following  translation  of  it,  which 
we  owe  to  the  courtesy  of  our  professional  brother. 

The  special  conformation  of  a  neio  variety  of  deformed  j^elvis,  forming  the 
subject  of  Ncegele's  monograph. 

"  The  principal  characteristics  of  these  deformed  pelves  are  the  following, 
namely : 

"  1.  A  complete  anchylosis  of  one  of  the  sacro-iliac  articulations,  or  a  perfect 
fusion  of  the  sacrum  and  one  of  the  iliac  bones  together.* 

"2.  An  arrest  of  development,  or  an  imperfect  development  of  the  lateral  half 
of  the  sacrum,  and  deficient  size  or  contracted  opening  of  the  anterior  sacral 
foramina  on  the  anchylosed  side. 

"3.  On  the  same  side,  a  reduced  size  of  the  os  ilium,  and,  consequently,  a 
diminished  extent  of  the  ischiatic  notches  of  this  latter;  that  is  to  say,  the 

distance  between  its  anterior  supe- 

1   •  •  •  •  Fi"  84 

nor  and  its  posterior  superior  spi-  "' 

nous  processes,  as  well  as  an  ima- 
ginary line,  drawn  at  the  entrance 
of  the  pelvis,  commencing  at  the 
spot  where  the  sacro-iliac  symphysis 
would  be  (if  it  existed),  and  run- 
ning along  the  linea  innominata 
and  the  linea  ilio-pectinea  as  far  as 
the  pubic  symphysis,  is  shorter  here 
than  on  the  opposite  side.  Further, 
the  part  corresponding  to  the  arti- 
cular  surface,    on    the    anchylosed 

bone,  which  is  here  continued  into  ^  ^^^^6  taken  from  M.Ntcgele's  work,  ^vhich  exhibits 
the   sacrum  without   any  transition,     'he  characters  of  the  ohlique-oval  pelvis  in  a  high  de- 

extends  neither  so   high    up,   nor   ^^'^^' 

descends  so  low,  as  upon  the  opposite  side,  or  as  it  would  in  a  well-formed  ilium; 
or,  to  explain  myself  more  clearly,  if  we  suppose  the  ilium  and  sacrum  of  the 
anchylosed  side  to  be  temporarily  separated,  and  then  reunited  through  the  inter- 
vention of  a  fibro-cartilaginous  disc,  as  occurs  in  the  natural  state,  the  articular 
surface  or  the  junction  of  these  two  bones  would  be  found  shorter,  and,  of  course, 
would  not  descend  so  low  as  on  the  opposite  side,  which  is  exempt  from  fusion, 
or  as  it  does  in  a  well-formed  pelvis. 

"4.  The  sacrum  seems  to  be  distorted  toward  the  fused  side,  and  it  also  has 
its  anterior  surface  turned  more  or  less  towards  this  side,  whilst  the  sympliysis 

'  We  retain  the  expression  anchylosis  on  account  of  brevity,  and  because  it  is  the  one  gene- 
rally used  to  designate  the  condition  under  consideration;  but  we  formally  protest  against 
the  imputation  of  having  admitted  that  these  bones  had  originally  been  well  formed,  and 
had  only  contracted  this  continuity  of  structure  in  consequence  of  some  disease.  Perliaps 
the  term  synostosis  or  synezizis  would  better  designate  the  perfect  fusion  here  alluded  to. 


542  DYSTOCIA. 

pubis  is  pressed  over  to  the  opposite  one ;  in  consequence  of  which  arransrement 
the  symphysis  is  no  longer  found  directly  in  front  of  the  promontory,  as  it  ought 
to  be,  but  is  caused  to  assume  an  oblique  position. 

"  5.  The  internal  surface  of  the  ilium,  on  the  anchylosed  half,  is  more  flat- 
tened in  that  part  which  contributes  to  the  formation  of  the  pelvic  cavity,  and 
sometimes  even  (in  cases  of  great  deformity)  is  almost  entirely  plane;  so  that, 
for  example,  a  line  drawn  from  the  middle,  or  even  the  posterior  extremity  of 
the  linea  innomiuata,  and  manning  along  the  body  and  horizontal  branch  of  the 
pubis  as  for  as  the  symphysis,  will  be  nearly  a  straight  line ;  but  we  have  never 
seen  an  inclination  inwards  at  this  part,  nor  have  we  particularly  observed  that 
inward  projection  of  the  horizontal  branch  of  the  pubis  that  is  found  in  pelves 
deformed  in  consequence  of  malacosteon  in  the  adult. 

'•  6.  The  other  lateral  half  of  the  pelvis,  or  the  one  where  the  sacro-iliac  arti- 
culation still  exists,  likewise  departs  from  the  normal  condition ;  although,  where 
the  obliquity  is  inconsiderable,  we  may  easily  deceive  ourselves  at  first  sight,  and 
be  induced  to  suppose  that  there  is  a  natural  conformation  of  the  non-anchylosed 
half;  such,  however,  is  not  the  fact,  as  can  be. proved  by  supposing  two  pelves 
to  be  similarly  deformed,  with  this  difference  only,  that  in  one  the  fusion  of  the 
sacro-iliac  articulation  takes  place  on  the  left  side,  while  in  the  other  it  is  on  the 
right ;  and  then  making  a  section  of  each  through  the  symphysis  pubis  and  the 
middle  line  of  the  sacrum ;  when,  by  attempting  to  fit  the  right  half  of  the  first 
of  these  pelves  to  the  left  half  of  the  second,  by  bringing  the  cut  surfaces  of  the 
two  sacrums  against  each  other,  we  shall  find  that  the  pubic  bones  are  separated 
by  an  interval  of  three  to  four  inches. 

"  Consequently,  the  lateral  half  of  the  pelvis,  exempt  from  fusion,  not  only  par- 
ticipates in  the  abnormal  situation  and  direction  of  the  bones,  but  also  in  their 
irregular  form ;  and  this  to  such  an  extent  that,  if  a  line  should  be  drawn  on  the 
non-fused  side  from  the  middle  of  the  promontory,  along  the  linea  innominata 
and  linea  ilio-pectinea  as  far  as  the  symphysis  pubis,  it  would  be  more  curved  in 
its  posterior,  and  less  so  in  its  anterior  half,  than  in  a  normal  pelvis." 

Whence  it  follows  : 

"  7.  A.  That  the  pelvis  is  contracted  obliquely,  that  is  to  say,  in  the  direction 
of  one  of  the  ordinary  oblique  diameters,  while  in  the  other  (which  runs  from 
the  point  of  anchylosis  to  the  opposite  cotyloid  cavity)  it  is  not  at  all  diminished, 
but  may  even  be  larger  than  usual,  when  the  obliquity  of  the  pelvis  is  greater. 

"  Wherefore,  the  superior  strait,  or,  in  other  words,  the  surface  limited  by  a 
line  traced  along  the  spines  of  the  two  pubes,  and  thence  along  the  linese  inno- 
minatai  and  prolonged  on  the  sacrum,  as  well  as  the  imaginary  plane  at  the 
centre  of  the  pelvic  excavation  (in  the  place  where  we  usually  admit  the  middle 
opening  of  the  pelvis,  apertnra  pelvis  media),  will  resemble,  strictly  speaking, 
an  oblique  oval  when  viewed  in  front ;  the  transverse  or  small  diameter  of  which 
will  be  represented  by  the  contracted  oblique  diameter,  and  its  great,  or  longitu- 
dinal one,  by  the  opposite  oblique  diameter.*     Therefore,  as  regards  their  form, 

1  From  this  it  is  evident  that  the  lines  connecting  those  points,  between  which  we  are 
accustomed  to  imagine  the  antero-posterior  and  transverse  diameters  as  passing,  do  not  cross 


MALFORMATIONS     OF    THE     PELVIS.  543 

the  pelves  in  question  might  very  properly  be  designated  by  the  title  of   the 
ohilque-oval pelvis  (^pelvis  uhlique-ovatci). 

"  B.  That  the  distance  from  the  promontory  of  the  sacrum  to  the  point  corre- 
sponding to  either  cotyloid  cavity  (the  sacro-cotyloid  interval),'  as  well  as  that 
from  the  apex  of  this  bone  to  the  spines  of  the  ischia,  would  be  less  on  the  side 
where  the  anchylosis  exists. 

"  C.  That  the  distance  from  the  tuber  ischii  on  the  anchylosed  half  to  the  pos- 
terior superior  spinous  process  of  the  opposite  ilium,  as  also  that  between  the 
spinous  process  of  the  last  lumbar  vertebra  and  the  anterior  superior  spine  of  the 
ilium  on  the  anchylosed  portion,  are  smaller  than  the  corresponding  dimensions 
of  the  opposite  side. 

"  D.  That  the  distance  from  the  inferior  border  of  the  symphysis  pubis  to  the 
posterior  superior  spinous  process  of  the  ilium  is  greater  on  the  anchylosed  bone 
than  on  the  opposite  side. 

"  E.  That  the  walls  of  the  pelvic  excavation  converge  somewhat  obliquely 
from  above  downwards,  whereby  the  pubic  arch  is  more  or  less  narrowed,  and 
therefore  made  to  approach  in  a  measure  to  the  form  of  the  male  pelvis,  as  a 
natural  consequence  of  the  improper  direction  of  its  ramus  which  is  turned  to- 
wards the  flattened  pelvic  wall.  Of  course,  these  two  dispositions,  as  also  the 
narrowing  of  the  ischiatic  notch,  the  diminution  of  the  distance  between  the  two 
ischiatic  spines  and  the  one-sided  and  defective  development  of  the  sacrum,  will 
be  in  direct  relation  with  the  degree  of  obliquity. 

"  F.  And  finally,  that  on  the  flattened  side  the  acetabulum  is  inclined  mucli 
more  anteriorly  than  in  the  normal  state,  whilst  on  the  opposite  side  it  is  turned 
almost  directly  outwards;  and  hence,  when  examining  the  pelvis  from  in  front, 
we  can  look  directly  into  the  first  cotyloid  cavity,  but  the  view  will  only  graze 
the  second,  or  possibly  may  embrace  a  small  part  of  its  excavation.  Further,  to 
give  as  clear  an  idea  of  the  deformity  as  possible  to  those  who  have  never  seen  a 
pelvis  of  the  kind,  we  will  observe  that  at  first  sight  the  pelvis  looks  as  if  it  had 
been  pressed  in  by  some  external  force  acting  in  an  oblique  direction  from  below 
upwards  and  from  without  inwards,  and  making  its  influence  felt  on  the  anterior 
pelvic  wall  at  the  cotyloid  region,  whilst  the  other  half  of  the  lateral  wall  has 
been  simultaneously  pressed  from  without  inwards,  at  its  posterior  part. 

"Another  peculiarity  of  these  pelves  is,  that  they  only  difi'er  from  each  other 
by  the  degree  of  obliquity,  and  on  that  side  only  where  the  anchylosis  takes 
place ;  whereas,  in  all  other  points,  that  is,  in  the  principal  characteristics  of 
their  malformation,  they  are  as  similar  as  two  eggs.  This  remark  is  so  true,  that 
an  experienced  person,  who  was  unaware  of  the  circumstance,  would  be  disposed 
to  take  two  difi'ercnt  specimens,  if  presented  to  him  separately,  for  one  and  the 

at  ri;,'lit  angles  in  the  oblirjne-oval  pelvis,  and  that  the  latter  cannot  be  regarded  as  possessing 
oblique  diameters  such  as  are  attributed  to  symmetrica!  pelves. 

'  For  sake  of  brevity,  we  use  this  expression  here  in  order  to  indicate  the  distance  referred 
to,  it  being  one  which  J.  Burns  thought  it  necessary  to  measure  and  establish,  for  the  purpose 
of  assisting  in  an  exact  representation  of  the  form  of  the  pelvic  opening. 


644  DYSTOCIA. 

saiue,  and  it  would  even  be  difficult  to  persuade  him  of  his  error;  an  instance 
of  which  we  shall  presently  give. 

"  As  to  the  other  conditions  of  the  bones  in  the  oblique-oval  pelvis  (laying 
aside  the  deviations  just  enumerated),  that  is,  as  regards  their  strength,  size,  tex- 
ture, color,  &c.,  they  do  not  differ  in  anywise  from  healthy  bones,  such  as  those 
met  with  in  young  persons  exempt  from  all  deformity.  Thus,  for  example,  none 
of  those  signs  are  observed  in  them,  neither  as  to  their  form  nor  in  other  respects, 
which  are  so  often  found  after  rachitis  or  malacosteon;  for  if  the  existing  defor- 
mities were  supposed  to  disappear,  all  the  pelves  we  have  yet  had  an  opportunity 
of  examining  would  bear  a  general  resemblance  to  well-formed  ones  j  most  of 
them  were  of  the  medium  size,  and  the  others  were  either  above  or  below  it,  but 
in  no  one  of  the  cases  that  we  have  particularly  traced  out  has  there  been  a 
rachitic  diathesis,  and  in  no  one  did  the  phenomena,  symptoms,  or  morbid  modi- 
fications exist,  which  would  have  either  preceded  or  followed  the  English  malady, 
or  mollities  ossium,  after  puberty;  and  further,  in  no  instance  could  the  action 
of  external  prejudicial  influences,  such  as  falls  or  blows,  &c.,  be  detected,  and 
there  were  never  any  antecedent  pains  or  lameness;  although,  in  one  instance, 
we  suspected  a  slight  limping,  from  seeing  the  patient  walk,  but  other  skilful 
persons,  who  were  present  at  the  examination,  did  not  detect  it,  and  the  relatives 
and  all  the  family  of  the  woman  in  question  positively  declared  they  had  never 
xemai'ked  anything  of  the  kind. 

"  In  two  of  the  specimens  of  this  variety  in  our  collection  which  have  the 
lower  vertebras  attached,  the  spinal  column  is  straight  in  the  lumbar  region  ;  but 
in  the  others  it  is  inclined  on  the  side  exempt  from  anchylosis.  In  all  that  are 
provided  with  the  lumbar  vertebrae,  the  anterior  face  of  the  bodies  of  these  bones 
is  more  or  less  directed  towards  the  anchylosed  side." 

The  reader  will  see,  by  the  translation  just  given,  that  M.  Njegele  attaches  a 
very  great  degree  of  importance  to  the  anchylosis  of  the  sacro-iliac  articulation, 
which  he  makes  a  pathognomonic  character  of  the  deformed  pelvis,  described  by 
him  under  the  name  of  the  oblique-oval ;  but,  if  I  might  hazard  an  opinion  after 
such  high  authority,  I  should  unhesitatingly  reject  this  proposition,  because  there 
are  numerous  pelves  which  present  all  the  characters  of  those  oblique  ones,  de- 
scribed in  the  monograph  of  the  Heidelberg  professor,  and  yet  in  which  there  is 
no  fusion  of  either  sacro-iliac  articulation  to  be  found.  M.  Naegele  himself,  with 
that  candor  characteristic  of  the  truly  learned  man,  speaks  in  his  admirable 
work,  of  pelves  that  were  similar  to  those  previously  described  by  him,  and  which 
only  differed  from  them  by  the  absence  of  anchylosis.  He  alludes  to  several 
others,  and  states  that  he  knows  of  the  existence  of  many  more,  the  exact  de- 
scription of  which  has  been  promised  him.  I  shall  have  occasion  hereafter  to 
revert  to  this  subject,  but  I  cannot  refrain  from  saying  now,  that  if  the  anchylosis 
is  no  longer  to  be  considered  as  a  constant  phenomenon,  as  a  pathognomonic 
character  of  the  pelvis  in  question,  if  it  is  nothing  more  than  a  pathological  coin- 
cidence, happening  in  most  cases,  then  I  can  only  see  in  the  oblique-oval  pelvis 
the  association  of  two  of  the  three  types,  to  which  we  have  referred  all  the 
varieties  of  pelvic  malformation;  for,  in  considering  it  in  a  practical  point  of 


MALFORMATIONS     OF     THE     PELVIS.  545 

view,  and  laying  aside  its  extraordinary  anatomical  peculiarities,  it  will  exhibit, 
simultaneously,  the  compression  of  one  of  the  antero-lateral  walls,  and  the  oblique 
prominence  of  the  sacro-vertebral  angle. 

This  remark  naturally  leads  us  to  the  important  observation  that,  hitherto  we 
have  considered  each  of  the  species  of  deformity  that  may  alter  the  various  pelvic 
diameters,  as  being  separate  and  distinct,  since  there  are  some  which  may  exist 
alone,  and  only  change  the  corresponding  diameters;  but,  besides  the  fict  that 
different  points  of  the  pelvic  circle  may  be  simultaneously  deformed,  and  thus 
contract  the  pelvis  in  several  directions  at  once,  the  form  and  extent  of  the 
pelvis  are  such  that  it  is  difficult  for  a  flattening,  a  lateral  compression,  or  a  de- 
pression of  the  antero-lateral  parts  to  take  place,  even  separately,  without  its 
being  thereby  contracted  in  several  of  its  diameters.  Let  us  suppose,  for  in- 
stance, that  one  of  the  oblique  diameters  has  been  diminished  by  the  depression 
of  the  bottom  of  the  acetabulum ;  and  it  must  be  evident  that,  should  the  de- 
pression be  considerable,  the  body  of  the  ischium  cannot  be  thus  thrust  inwards 
and  backwards,  without  drawing  along  with  it  at  the  same  time,  some  considerable 
portion  of  the  anterior  part  of  the  pelvis,  and  of  the  arch  formed  by  its  lateral 
half,  and  consequently,  without  contracting  more  or  less,  certain  of  the  antero- 
posterior and  transverse  diameters.  Again,  where  the  sacro-vertebral  ano;le,  from 
being  projected  forward,  diminishes  the  length  of  the  antero-posterior  diameter 
of  the  superior  strait,  we  have  supposed  that  it  followed  the  sacro-pubic  line,  in 
its  movement  of  progression ;  but,  as  readily  foreseen,  it  would  most  often  prove 
otherwise,  for  the  very  frequent  obliquity  in  the  direction  of  the  forces  transmit- 
ted through  the  vertebral  column,  nmst  compel  it  to  lean  towards  the  right  or 
the  left,  as  well  as  to  the  front ;  whence,  the'shortening  of  the  antero-posterior 
diameter  necessarily  entails  that  of  the  sacro  cotyloid  interval,  and,  as  a  conse- 
quence, narrows  the  whole  corresponding  half  of  the  pelvis.  Now,  should  the 
depression  of  the  antero-lateral  wall  on  the  same  side  be  joined  to  this,  as  just 
supposed,  we  should  have  the  oblique-oval  pelvis  of  M.  Nteg^le,  excepting  the 
anchylosis  of  the  sacro-iliac  articulation.* 

Again,  the  three  principal  types  may  be  found  united  in  the  same  pelvis, 
whereby  the  latter  is  greatly  deformed  in  all  its  diameters.  This  occurs  more 
particularly  in  the  deformities  produced  by  malacosteon,  but  it  is  also  sometimes 
met  with,  even  in  a  high  degree,  in  cases  dependent  on  rachitis,  as  fully  proved 
by  the  facts  observed  by  M.  Naegele. 

From  all  this,  we  learn  what  great  diversities  of  shape  may  be  presented  by 
deformed  pelves.  Madame  Lachapelle  has  gone  so  far  as  to  designate  these 
varieties  by  the  titles  of  the  renifurm.,  the  trianyular,  the  bi-lobed,  the  rounded, 
the  oval,  the  cordiform,  the  trajn-zoid,  the  pyramidal,  and  the  three-hhed 
straits;  but  she  has  greatly  multiplied  the  species  without  any  practical  utility 

'  Tliis  anchylosis  is  nothin}^  more  than  a  curious  pathological  fact,  one  in  reality  having  no 
practical  value,  and  therefore  not  worthy  nf  the  importance  accorded  to  it  by  ]\I.  N;j^dle, 
on  which  account  we  have  determined  not  to  make  a  particular  variety  of  the  oblique-oval 
pelvis,  but  have  concluded  to  refer  it  to  the  compression  of  the  anterolateral  walls. 

35 


546  DYSTOCIA. 

and  she  further  admits  that  there  are  numerous  undcseribed  varieties  for  each  of 
these  orders. 

The  De<jric  of  Contraction. — The  two  extremes  of  contraction  of  the  straits 
are  from  three  and  three-quarters  to  four  inches  for  the  highest,  and  from  two 
to  three  lines  for  the  least,  and  between  these  two  the  pelvis  may  exhibit  all  the 
intermediate  degrees  of  narrowness.  The  causes  which  produced  the  deformity 
greatly  influence  the  degree  of  contraction,  and  in  this  point  of  view  they  may 
be  arranged  in  the  following  order,  viz.,  malacosteon,  rickets,  congenital  luxa- 
tions of  the  femur,  deformities  of  the  spinal  column,  &c. ;  we  shall  take  occasion 
hereafter  to  revert  to  the  mode  in  which  each  of  these  acts. 

Of  the  Variations  in  the  Depth  of  the  Pelvis. — The  vices  of  conformation, 
just  spoken  of,  rarely  exist  without  modifying  the  depth  of  the  pelvis,  in  a  greater 
or  less  degree;  which  circumstance  has  been  particularly  dwelt  upon  by  M. 
Bouvier,  in  the  able  work  presented  by  him  to  the  Institute.  For  instance,  the 
depth  may  be  either  augmented  or  diminished  by  the  variable  inclination  of  the 
expanded  portion  of  the  iliac  bones,  or  of  the  branches  of  the  pubic  arch,  as  also 
by  the  diversities  in  the  length  of  the  sacrum. 

Sometimes  this  latter  bone  is  very  short,  its  contraction  being  produced  either 
by  an  excess  of  the  anterior  curvature,  which  brings  the  two  extremities  nearer 
to  each  other,  or  by  an  arrest  of  development. 

Occasionally,  the  iliac  fossae  are  elevated,  as  if  they  had  been  forcibly  pressed 
from  without  inwards,  thus  giving  it  the  appearance  of  a  male  pelvis;  and  this 
elevation  may  be  further  augmented  by  exterior  and  lateral  pressure,  whereby 
the  bones  are  rendered  quite  vertical,  and  the  normal  depth  of  the  pelvis  is 
greatly  increased.  The  contrary  may  occur  where  the  iliac  crests,  from  being 
strongly  depressed  and  thrust  outwards,  enlarge  the  margin  of  the  pelvis,  but 
evidently  diminish  its  height.  It  would  be  difficult  to  misinterpret  the  influence 
of  the  weight  of  the  viscera  in  such  cases  when  there  is  no  congenital  deformity 
in  question.     (Bouvier,  ojj.  citato.) 

In  conclusion,  a  widening  of  the  pubic  arch  must  clearly  diminish  its  height 
to  a  corresponding  extent ;  while  the  latter,  as  well  as  the  whole  depth  of  the 
pelvis,  must  be  increased,  where  the  ischio-pubic  rami  are  very  close  together. 

ARTICLE   II. 

OF  THE  CAUSES  AND  MODE  OF  PRODUCTION  OF  THE  PELVIC  DEFORMITIES. 

For  a  long  time  the  vices  of  conformation  of  the  pelvis,  as  also  most  of  the 
deformities  occurring  in  the  skeleton  at  large,  were  attributed  to  the  operation  of 
a  single  cause,  rachitis;  but  the  more  careful  researches  of  modern  surgeons, 
enable  us,  at  the  present  day,  to  ascertain  more  precisely  the  cflects  of  rickets  on 
the  osseous  system,  and  to  appreciate  the  influence  that  other  general  or  local 
diseases  may  have  over  the  perfect  or  the  defective  conformation  of  the  pelvis. 
And  here  I  must  again  extract  largely  from  the  valuable  works  of  Nivgcle, 
Bouvier,  Guerin,  Sedillot,  and  others. 


MALFORMATIONS    OF    THE    PELVIS.  547 

An  examination  of  facts  clearly  proves  that  the  pelvis  may  be  deformed  under 
circumstances  where  there  has  been  no  rachitis  properly  so  called ;  and  where 
causes  that  are  purely  mechanical  in  their  operation  have  altered  the  configura- 
tion of  its  constituent  parts  at  a  period  when  their  power  of  resistance  was  in- 
considerable, not  in  consequence  of  any  pathological  softening,  but  solely  from 
the  tender  age  of  the  patient,  or  the  feebleness  of  its  constitution.  And  hence, 
as  regards  the  causes  that  produce  the  changes  in  their  form,  we  might  classify 
all  the  irregular  pelves  under  three  principal  types,  namely,  A.  Deformities, 
dependent  on  a  softening  of  the  bones,  whether  from  rachitis  or  from  mollities 
ossium ;  B.  Those  consecutive  to,  and  dependent  upon,  a  previous  deformity  of 
another  part  of  the  skeleton  ;  and  C.  Vices  of  conformation  by  absolute  narrow- 
ness. 

§  1.  Of  the  Pelvis  Deformed  by  Rachitis  ok  Malacosteon. 

We  are  not  about  to  enter  here  into  a  detailed  consideration  of  the  causes  that 
preside  over  the  development  of  the  disorders  known  as  rachitis  and  mollities 
ossium,  for  the  general  phenomena  produced  by  them,  and,  more  especially,  the 
greater  softening,  fragility,  and  flexibility  of  the  osseous  tissue,  are  so  well  known 
to  pathologists  that  we  need  only  mention  them ;  but  our  present  duty  is  to  study 
their  influence  in  the  production  of  the  numerous  deformities  summed  up  in  the 
preceding  article.  For  an  indication  of  the  characters  that  distinguish  a  pelvis 
deformed  by  rachitis  from  one  distorted  in  consequence  of  a  softening  of  the 
bones,  we  refer  the  reader  to  the  article  on  Diagnosis ;  nevertheless,  we  maj^  ob- 
serve here  that,  although  these  two  diseases  difter  from  each  other  in  numerous 
anatomical  characteristics,  yet  they  produce  the  same  result ;  for,  by  softening 
the  osseous  tissue,  they  diminish  its  resistance. 

But  this  softening,  or  want  of  resistance  on  the  part  of  the  bones,  is  not  of 
itself  sufficient  to  explain  the  various  deformities  exhibited  by  the  pelvis;  because, 
except  in  certain  very  rare  cases,  in  which  the  osseous  tissue  is  almost  gelatinous 
in  its  consistence,  it  must  be  evident  that  the  bones  can  only  give  way  and  become 
distorted  by  the  action  of  an  exterior  force,  without  which,  their  conformation 
would  remain  intact.  For  where  rachitis  aff"ects  them,  it  has  no  other  imme- 
diate consequence  than  to  diminish  their  solidity,  and  of  itself  contributes  in 
nowise  to  the  alteration  of  their  shape ;  though  it  is  true  that  the  softening  pro- 
duced in  the  adult  by  malacosteon  may  be  so  great,  that  the  weight  of  the  supe- 
rior parts  of  the  body  alone  might  produce  a  yielding  of  the  bones ;  but,  laying 
aside  these  unusual  instances,  we  must  seek  in  the  influence  of  some  external 
force,  which  is  wholly  independent  of  the  principal  disease,  for  the  cause  of  the 
deformity.  Now,  this  exterior  force  sometimes  resides  in  the  muscular  action, 
though  still  more  frequently  (so  far  as  regards  the  pelvis)  in  the  weight  of  the 
parts  it  has  to  support;  for,  being  placed,  as  we  have  elsewhere  described,  below 
the  trunk  and  directly  upon  the  lower  extremities,  to  which,  in  the  erect  posi- 
tion, it  transmits  the  whole  weight  of  the  upper  parts  of  the  body,  the  pelvis  is 
found  in  the  most  favorable  conditions  for  the  production  of  deformity.  The 
weight  of  the  trunk,  which,  in  the  erect  posture,  is  transmitted  from  the  lumbar 


548  DYSTOCIA. 

vertebrff!  to  the  heads  of  the  femurs  in  the  direction  of  two  oblique  lines  that 
intersect  the  sides  of  the  superior  strait,  manifestly  tends  to  augment  the  curva- 
ture of  the  posterior  part  of  the  ilium,  and  to  depress  the  osseous  circle  which 
the  pelvic  cavity  represents;  and  this  weight,  acting  at  first  more  especially  on 
the  base  of  the  sacrum,  has  a  tendency  to  push  the  latter  insensibly  forwards. 
The  pubic  bones  would  be  equally  pressed  towards  the  sacrum,  though  in  such  a 
manner  that  their  posterior  extremity  (the  one  nearest  to  the  acetabulum,  which 
supports  the  weight)  gets  somewhat  nearer  to  the  sacro-vertebral  angle  than  does 
their  anterior  or  symphyseal  extremity ;  whence  we  may  learn  why  the  contrac- 
tions of  the  pelvis  oftener  affect  the  superior  strait  than  other  parts ;  and  why, 
at  this  strait,  the  antero-posterior  and  oblique  diameters  and  the  sacro-cotyloid 
interval,  are  far  more  frequently  contracted  than  the  transverse  ones. 

And  it  will  be  equally  evident  why,  when  the  weight  acts  more  particularly  on 
one  side  of  the  pelvis,  the  collapse  is  more  marked  in  that  direction,  if  we  bear 
in  mind  the  change  that  then  takes  place  in  the  centre  of  gravity  from  the  incli- 
nation of  the  spine,  the  curvature  of  which  so  often  precedes  the  deformity  of  the 
pelvis,  as  also  the  very  unequal  pressure  of  the  weight  of  the  body  on  the  two 
sides  of  the  pelvis,  where  a  difference  of  length  in  the  lower  extremities  de- 
presses one  of  the  coxal  bones  more  than  the  other;  whereby  the  acetabulum  of 
one  side  is  thrown  almost  directly  under  the  sacrum,  and  at  the  same  time 
receives  the  weight  very  obliquely.  (Bouvier.)  It  is  further  evident  that  the 
customary  attitude  of  the  individual,  and  the  nature  of  her  exercises,  must  like- 
wise add  to  the  irregularity  in  the  figure  of  the  pelvis. 

After  having  studied  the  causes  that  determine  the  oblique  projection  of  the 
sacro-vertebral  angle,  and  the  flattening  of  one  of  the  antero-lateral  walls  of  the 
pelvis,  we  explained  the  production  of  the  deformity  described  by  M.  Naegele, 
which,  as  already  stated,  appeared  to  us  to  result  simply  from  a  conjunction  of 
these  two  varieties  in  the  same  person  ;  but  there  is  one  circumstance  yet  remain- 
ing to  be  explained,  that  is,  the  complete  fusion  of  the  sacrum  and  ilium  together, 
and  the  consequent  disappearance  of  the  sacro-iliac  articulation  on  the  contracted 
side.  Now,  is  this  anchylosis  congenital  ?  Is  it  the  result  of  some  inflammation 
occurring  after  infancy  ?  or  is  it  to  be  attributed  to  the  curvature  of  the  verte- 
bral column  ?  We  confess  that  sufiicient  materials  are  still  wanting  to  decide 
the  question,  although  M.  Naegele  seems  to  think  that  this  fusion,  as  well  as  the 
deformity  of  which,  in  his  estimation,  it  is  the  essential  character,  results  from  an 
anomaly  of  original  development;  "but,"  he  adds,  in  conclusion,  "I  am  not 
prepared  to  decide  positively."  (For  further  details,  see  M.  Danyau's  trans- 
lation.) 

Whether  congenital,  or  the  consequence  of  an  accidental  disease.  Professors 
Gravarret  and  Paul  Dubois  regard  this  anchylosis  as  the  cause  of  the  flattening  of 
the  ilium  upon  the  same  side.  When,  says  M.  Dubois,  one  of  the  sacro-iliac 
symphyses  is  affected  with  anchylosis,  the  corresponding  coxal  bone  becomes  flat- 
tened, and  the  same  alteration  is  produced  on  both  sides  when  the  two  symphyses 
are  ossified.  For  my  own  part,  I  cannot  admit  this  relation  of  cause  and  effect, 
for  there  is  nothing  to  prove  that  in  M.  Naegele's  oblique  oval  pelves,  the  defor- 


MALFORMATIONS     OF     THE     PELVIS.  549 

mity  of  the  ilium  had  been  preceded  by  anchylosis.  On  the  contrary,  we  have 
shown  that,  as  M.  Naegele  himself  acknowledges,  there  are  pelves  which  present 
all  the  characters  of  the  oblique  oval  ones,  excepting  the  anchylosis  of  the  sacro- 
iliac symjihysis.  How,  then,  can  the  anchylosis  be  regarded  as  causing  the 
deformity  ? 

If  the  child  is  in  the  habit  of  sitting  much,  the  weight  transmitted  by  the 
lumbar  vertebrae  may  likewise  press  the  sacro-vertebral  angle  forward;  but  the 
sacrum  also  often  yields,  and  its  base  is  carried  forward  simultaneously  with  the 
point  of  the  coccyx,  whereby  its  anterior  concavity  is  augmented,  and  the  antero- 
posterior diameters  of  both  the  superior  and  the  inferior  straits  are  aflFected. 

The  lateral  compression,  operating  from  one  side  to  the  other,  or  the  shorten- 
ing of  one  or  more  of  the  transverse  diameters,  supposes  an  action  diametrically 
opposite  to  the  preceding,  and  it  generally  results  from  a  lateral  force  acting  from 
without  inwards ;  which  force  may  be  referred  either  to  the  weight  of  the  body, 
where  the  child  uniformly  reposes  on  its  side,  or  to  the  unequal  pressure  of  some 
improperly  adjusted  bandage,  or  the  arms  of  an  awkward  nurse.  But  if,  on  the 
contrary,  the  infant  habitually  leans  more  towards  one  side  than  the  other  when 
seated,  one  of  the  ischial  tuberosities  having  to  support  a  more  considerable 
weight  than  its  fellow  may  be  distorted  inwardly;  sometimes  even  the  pressure 
will  be  applied  successively  to  each,  with  the  eifect  of  bringing  them  very  near 
to  each  other. 

Having  now  studied  the  softening  of  the  bones  as  an  immediate  source  of  the 
deformity,  a  few  observations  are  yet  to  be  made  concerning  the  causes  that  pro- 
duce this  softening;  for  it  must  not  be  supposed  that  mollities  ossium  and  rachitis 
exercise  the  same  influence  upon  the  osseous  tissue.  Indeed,  as  a  general  rule, 
the  softening  determined  by  the  former  is  much  more  marked  than  the  default 
of  resistance  occasioned  by  the  latter ;  whence  it  follows  that,  with  the  exception 
of  certain  rare  cases,  such  as  the  one  cited  by  M.  Nasgele,  the  more  considerable 
contractions  may  be  referred  to  malacosteon. 

Mollities  ossium  affects  all  parts  of  the  skeleton  indifferently.  Rachitis,  on 
the  contrary,  affects  first  the  bones  of  the  lower  extremities,  and  ascends  gradu- 
ally to  the  upper  parts ;  in  a  word,  it  has  an  upward  tendency.  From  this 
results  a  most  important  practical  consequence,  namely,  that  a  deformity  of  any 
part  of  the  skeleton  from  rachitis,  implies,  almost  necessarily,  deformity  of  the 
bones  situated  below  it. 

Rachitis  is  a  disease  peculiar  to  infancy,  while  mollities  ossium  only  occurs  in 
the  adult;  and  this  peculiarity  appertaining  to  the  former,  of  only  exerting  its 
action  during  the  early  years  of  life,  satisfoctorily  explains  how  this  affection  may 
have  two  different  modes  of  acting  on  the  pelvis ;  one  of  which  consists  of  a 
softening  of  the  bones,  and  their  consequent  yielding ;  and  the  other  of  a  sort  of 
arrest  in  their  development.  ''Thus,"  M.  Guerin  says,  ''it  would  appear  from 
my  researches  that  most  of  the  bones  of  a  rachitic  skeleton,  when  compared  with 
those  of  a  normal  one,  exhibit  an  arrested  development  as  regards  their  different 
dimensions;  which  reduction,  independently  of  what  residts  from  the  deforviity 
of  the  bones,  may  amount  to  one-half  of  their  ordinary  size;  and  further,  that  this 


550  DYSTOCIA. 

reduction  is  generally  greater  in  the  lower  parts  of  the  sJ^eleton,  and  gradually 
diminishes  from  below  upwards,  from  the  bones  of  the  legs  to  the  femurs,  from 
these  latter  to  the  pelvis,  and  from  the  pelvis  to  the  upper  extremities  and  spine, 
&c."  It  is,  therefore,  on  the  lower  extremities  particularly,  and  on  the  coxal 
bones,  which  are  appendages  of  them,  that  this  arrested  development  exerts  its 
action.  ''Whence/'  says  M.  Dubois,  "it  necessarily  results  that  the  ossa  inno- 
minata  are  generally  much  less  developed  in  rachitic  pelves  than  in  others;  and 
this  disposition  must  powerfully  contribute,  together  with  the  deformity  that 
usually  accompanies  it,  to  contract  the  limits  of  the  cavity,  which  these  bones,  in 
a  great  measure,  circumscribe;  and  I  am  the  more  convinced  of  the  importance 
of  this  fact,  since,  in  several  instances  of  deformity  occurring  in  individuals  known 
to  be  rachitic  during  infancy,  it  has  appeared  to  me  that  the  yielding  of  the 
bones  to  the  degree  in  which  it  existed,  would  have  been  wholly  insufficient  to 
create  such  insurmountable  difficulties,  if  the  bones  themselves  had  been  as 
fully  developed  as  they  ought  to  have  been."  (^These  de  Concours.')  And  we 
may  mention,  as  another  fact  bearing  on  the  same  point,  that  the  pelvis  of  the 
patient  on  whom  M.  Moreau  performed  the  Csesarean  operation,  had  experienced 
the  double  influence  of  rachitis  just  mentioned;  for,  though  but  little  deformed, 
its  antero-posterior  diameter  was  only  two  and  three-eighths  of  an  inch  in  length. 

This  influence  over  the  development  of  the  pelvic  bones,  is  dependent  solely 
on  the  tender  age  at  which  the  affection  appears,  since  it  occurs  in  childhood  as 
stated,  that  is,  at  a  period  when  the  pelvis  is  far  from  having  acquired  its  perfect 
organization ;  whereas  malacosteon  docs  not  appear  until  after  puberty,  in  other 
words,  at  an  age  when  the  ossa  innominata  have  reached  their  normal  develop- 
ment; and,  therefore,  although  it  may  soften  the  bones,  it  cannot  oppose  their 
growth. 

Lastly,  this  action  is  not  set  aside  by  the  cure  of  the  disease,  but  it  continues 
to  be  felt  during  the  whole  period  of  development,  so  that,  says  M.  Guerin,  the 
sum  of  reduction  exhibited  by  the  bones  of  rickety  adults,  is  made  up  of  two 
successive  results,  namely,  of  the  reduction  dependent  on  an  absolute  arrest,  or  a 
mere  diminution  of  growth  during  the  disease,  and  of  that  caused  by  a  retarded 
o-rowth  subsequent  to  the  malady.  This  is  an  important  practical  remark,  show- 
ino-  how  far  the  influence  of  rachitis  over  the  osseous  system  may  extend. 

§  2.  Malformations  dependent  upon  a  Previous  Deformity  in  an- 
other Part  of  the  Skeleton, 

We  have  already  alluded,  in  advance,  to  the  influence  that  a  malformation  of 
the  spinal  column,  or  of  the  lower  extremities,  might  have  over  the  shape  of  the 
pelvis,  and  we  now  proceed  to  illustrate  the  mode  of  action  in  both  cases. 

A.  Deviation  of  the-  Vertebral  Column. — For  a  very  long  period  all  the  devia- 
tions of  the  spinal  column  were  attributed  to  the  baneful  influences  of  rachitis ; 
but  owing  to  the  able  researches  of  Bouvler,  of  Guerin,  and  many  others,  this 
opinion  is  no  longer  tenable,  since  it  is  now  well  ascertained  that  several  other 
diseases  may  produce  abnormal  curvatures  in  this  column ;  and  this  distinction  is 
quite  as  important  to  the  accoucheur  as  it  is  to  the  orthopedists,  for  it  establishes 


JIALFORMATIONS     OF    THE     PELVIS.  551 

at  once  a  line  of  division  between  those  deviations  which  nearly  always  coincide 
with  an  imperfect  conformation  of  the  pelvis,  and  those  which  often  exist,  even 
•where  the  latter  is  well  formed.  The  former  are  of  a  rachitic  nature;  but  the 
latter  are  developed  under  the  influence  of  some  other  affection.  For  instance, 
in  sixty-nine  cases  of  deformity  in  the  vertebral  column,  described  by  M.  Bou- 
vier,  the  pelvis  was  in  a  normal  condition,  and  the  extremities  were  nearly  all 
exempt  from  alteration  in  fifty-seven,  and  but  twelve  were  accompanied  by  a  mal- 
formation of  this  cavity,  and  by  an  incurvation  of  the  limbs. 

It  must  not  be  supposed,  however,  that  the  deviations  of  the  spine  which  are 
not  dependent  on  rickets,  have  no  influence  whatever  over  the  direction  and 
shape  of  the  pelvis.  It  is  only  in  subjects  of  advanced  age,  as  a  general  rule, 
that  curvatures  of  this  column,  happening  after  infancy,  will  ultimately  deter- 
mine changes  in  the  form  and  direction  of  the  pelvis;  and,  therefore,  they  have 
but  little  interest  for  the  accoucheur. 

As  regards  the  curvatures  produced  by  rickets,  thougb  they  be  not  the  essen- 
tial cause  of  pelvic  deformities,  yet  they  do  not  the  less  exercise  an  unfavorable 
influence  over  the  degree  of  contraction,  and  the  irregularity  in  the  shape  of  the 
pelvis;  for  the  same  action  which  gives  rise  to  these  deformities  in  old  persons, 
also  produces  them,  in  a  great  measure,  in  rickety  children.  In  either  ease,  the 
pelvis  yields  under  the  influence  of  the  spinal  deviation ;  with  this  difference 
only,  that  what  takes  place  slowly  in  the  aged,  is  rapidly  eff'ected  in  the  child, 
because,  in  the  latter,  the  softening  of  the  bones  favors  the  action  of  the  cause. 

The  principal  alteration  consists  of  an  increase  of  the  angle  formed  by  the 
junction  of  the  lumbar  column  with  the  base  of  the  sacrum,  which  gives  the 
pelvis  a  figure  more  or  less  similar  to  that  described  by  Professor  Noegele,  under 
the  title  of  the  oblique- oval. 

B.  Congenital  Luxations  of  the  Femur. — M.  Sedillot,  in  a  very  interesting 
memoir  on  the  congenital  luxations  of  the  femur,  first  called  attention  to  the 
influence  which  these  displacements  might  exercise  on  the  conformation  of  the 
pelvis.  The  eff'ects  of  this  accident  are  manifested  both  in  the  greater  and  lesser 
pelvis,  as  may  be  seen  from  the  following  distances  which  he  obtained  in  a  case 
of  double  dislocation  upwards  and  outwards,  into  the  external  iliac  fossae,  by 
measuring  the  principal  dimensions  of  the  pelvis  : — 

1.  From  one  anterior  superior  spinous  process  to  the  other,  .  .         .8  inches. 

2.  From  the  micklle  of  one  ihac  crest  to  the  same  point  on  the  opposite 

side, ^     "■ 

3.  From  the  middle  of  the  iliac  crest  to  the  margin  of  the  abdominal 

strait, 3^     " 

4.  From  the  middle  of  the  iliac  crest  to  tlie  tuber-ischii,         .         .  •      f'i     " 

Superior  or  Mdominal  Strait. 

5.  Antero  posterior  diameter,       ....  ....     4^     " 

6.  The  same  diameter  taken  from  the  pubis  to  the  articulation  of  the 

first  piece  of  the  sacrum  with  the  second,'     .  .         .  .  .     4|     " 

'  The  aniero-posterior  diameter  is  generally  measured  from  the  upper  and  internal  part 
of  the  symphjsis  pubis  to  the  superior  border  of  the  sacrum;  b.t  M.  Sedillot  very  justly 


552  DYSTOCIA. 

7.  Bis-iliac  or  transverse  diameter,       .......     4^  incheSr. 

8.  Oblique  diameter,  ..........     4|     " 

Perineal  Strait. 

9.  Coccy-pubic  diameter,    .  .  .  .  .  .  .  .  .      3^     " 

10.  Transverse  diameter, 5:^^     " 

11.  Oblique  diameter,  ..........  4|     " 

12.  Summit  of  tlie  pubic  arch,      ........  1^  inch. 

13.  Base  of  the  arch  (taken  on  a  level  with  the  inferior  border  of  the  oval 

foramen),    .         .         .         .  .         .  .         .  .         .         •     4^  inches. 

Pelvic  Excavation. 

14.  Depth  of  the  posterior  wall,   ........  5       " 

15.  Depth  of  the  anterior  wall,     ........  l-g-  inch. 

16.  Thickness  of  the  pubic  symphysis,  .  .  .  ;  .  •  i     '' 

17.  Depth  of  th3  sacral  concavity,  .  .  .  .         .  .  .  Ig-     " 

18.  From  the  summit  of  one  ischiatic  tuberosity  to  the  same  point  on  the 

opposite  side,      ..........      5j  inches. 

From  these  measurements  it  appears  :  1st.  That  the  transverse  dimensions  of 
the  greater  pelvis  are  considerably  lessened  by  the  vertical  elevation  of  the  iliac 
fossae,  which  approximate  each  other  to  such  an  extent  as  only  to  leave  an  in- 
terval of  eight  and  a  half  inches,  whereas  the  normal  distance  is  ten  and  a  half 
inches.  2d.  That  the  relation  which  exists  in  the  normal  state,  between  the 
antero-posterior  and  transverse  diameters  of  the  superior  strait  is  changed ;  since 
the  transverse  diameter  is  somewhat  shorter  here  than  the  antero-posterior  one  j 
whereas,  in  the  ordinary  state,  it  is  nearly  an  inch  longer.  .Sd.  That  an  inverse 
change  takes  place  at  the  inferior  strait,  the  bis-i.schiatic  diameter  being  five  and 
a  quarter  inches,  while  the  coccy-pubic  one  is  but  three  and  a  half  inches. 

remarks,  that  in  many  of  the  pelves  which  are  the  seats  of  a  double  congenital  luxation,  the 
upper  margin  of  the  sacrum,  in  consequence  of  the  great  prominence  of  the  sacro-vcrtebral 
angle,  is  found  far  above  the  pubis,  and  the  articulation  between  the  first  two  pieces  of  the 
sacrum,  is  then  on  a  level  with  the  superior  surface  of  this  bone.  Now,  in  such  a  case,  the 
true  antero-posterior  diameter  of  the  abdominal  strait  would  extend  from  the  upper  border 
of  the  pubis  to  the  part  of  the  sacrum  found  on  the  same  level,  and  this  interval,  therefore, 
is  the  only  important  measurement.  But  this  observation  is  not  new,  as  it  had  previously 
been  made  by  Bland,  and  repeated  by  iNIerriman,  in  the  following  note:  "Although  the 
sacrum  be  carried  so  far  forward  that  it  seems  to  reduce  the  antero-posterior  diameter  at  the 
entrance  of  the  excavation  to  two  or  three  inches,  it  is  necessary  in  determining  the  degree 
of  contraction  to  observe  the  difference  in  elevation  between  the  sacro-vertebral  angle  and 
the  upper  part  of  the  symphysis.  The  pubes  being  placed  something  lower  than  the  greatest 
projection  of  the  sacrum,  and  opposed  to  a  part  of  that  bone  that  is  directed  strongly  back- 
ward, the  real  distance  between  them  may  be  much  more  considerable  than  to  the  touch  it 
may  seem  to  be.  Whence  it  happens  that  in  cases  where  the  projection  of  the  sacrum  has 
occasioned  exceeding  great  difficulty  in  the  beginning  of  the  labor,  opposing  an  almost  in- 
superable bar  to  the  entrance  of  the  head  of  the  child  i«to  the  pelvis,  by  directing  it  too  far 
forward  over  the  pubes,  yet  when  that  direction  has  been  altered  by  the  use  of  instruments, 
or  by  any  other  means,  and  the  head  brought  into  the  line  of  the  centre  of  the  pelvis,  the 
conclusion  of  the  labor  has  been  frequejitly  eflecied  with  very  little  exertion  or  force."— 
Bland  s  Observations. 


MALFORMATIONS     OF     THE     PELVIS.  553 

These  last  modifications,  says  M.  Sedillot,  are  easily  explained,  being  the  con- 
sequence of  the  unnatural  position  of  the  femurs  in  the  external  iliac  fossas;  for 
individuals  aflSicted  with  a  double  luxation  of  this  kind,  walk  with  the  legs  wide 
apart,  so  as  to  bear  and  rest  the  heads  of  the  thigh  bones  against  the  sides  of  the 
ilia;  though  the  effect  would  still  be  the  same,  even  if  their  progression  were  not 
performed  in  this  manner,  because  the  external,  lateral,  and  superior  surfaces  of 
these  bones,  which  usually  incline  outwards,  will  always  be  pressed  upon  to  a 
certain  extent,  by  the  heads  of  the  femurs,  which  have  a  tendency  to  straighten 
and  carry  them  inwards.  Whence  the  pelvis,  from  being  thus  compressed  late- 
rally, is  elongated  from  behind  forwards,  and  forms,  in  this  latter  direction,  a 
more  or  less  acute  angle.  The  iliac  fossie,  experiencing  the  pressure  more 
directly,  have  yielded  in  a  marked  degree,  though  more  at  their  middle  than  in 
front,  because  the  head  of  the  thigh  bone  is  thrown  far  back,  and  compresses  the 
middle  more  than  the  anterior  part  of  these  fossae.  The  ilium  is  often  rendered 
more  straight  and  nearly  vertical,  instead  of  being  inclined  outwards ;  and,  should 
this  phenomenon  exist  on  both  sides,  it  might  interfere  with  the  regular  develop- 
ment of  the  womb ;  but  if  on  one  side  only,  it  might  occasion  an  obliquity  of  this 
organ  in  the  opposite  direction. 

The  anterior  margin  of  the  ilium  also  presents  a  singular  disposition ;  for  the 
conjoint  tendon  of  the  psoas  magnus  and  iliacus  internus  muscles,  which  is  in- 
serted in  the  lesser  trochanter,  is  then  changed  from  its  usual  direction,  and  is 
carried  upward  by  the  ascent  of  the  thigh  bone,  and,  as  a  consequence,  this 
tendon  deepens  and  changes  the  direction  of  its  groove;  whereby  the  anterior 
inferior  spinous  process  is  turned  aside  in  a  more  or  less  sensible  degree. 

The  shortening  of  the  transverse  diameter  of  the  upper  strait  is  evidently  due 
to  the  lateral  pressure  made  by  the  heads  of  the  femurs  almost  perpendicular  to 
this  strait ;  and  as  a  flattening  in  the  transverse  direction  is  necessarily  accompa- 
nied by  an  elongation  antero-posteriorly,  the  sacro-pubic  diameter  is  found  aug- 
mented in  a  corresponding  degree. 

The  examination  of  the  inferior  strait  also  exhibits  a  very  curious  phenomenon, 
just  the  reverse  of  what  we  have  met  with  at  the  abdominal  one ;  that  is,  there 
is  a  considerable  increase  in  the  extent  of  its  transverse  diameter,  with  a  notable 
diminution  in  that  of  its  coccy-pubic  one.  Here,  also,  the  situation  of  the  femurs 
must  be  referred  to,  in  explanation  of  the  circumstance ;  for  these  latter  are  car- 
ried far  upwards,  outwards,  and  backwards,  since  their  superior  articular  extre- 
mity has  escaped  up  into  the  external  iliac  fossa ;  and  they  keep  the  surrounding 
muscles  constantly  tense  (more  particularly  the  quadrati,  the  gemelli,  and  the 
internal  obturator  muscles,  which  run  from  the  ischiatic  tuberosities  to  the  extre- 
mity of  the  thigh  bones),  and  thus  drag  the  ischium  outwards ;  the  lower  fibres 
of  the  obturator  externus  and  adductor  muscles,  and  the  internal  part  of  the  arti- 
cular capsule  act  in  the  same  manner  on  the  columns  of  the  pubic  arch;  thereby 
producing  a  wide  separation  of  the  two  ischia.  The  latter,  in  turn,  draw  on  the 
greater  and  lesser  sacro-sciatic  ligaments,  thereby  creating  a  greater  curvature  in 
the  inferior  bones  of  the  sacrum  and  coccyx,  and  consequently  the  diminution  of 


554  DYSTOCIA. 

the  coccy-pubic  diameter,  as  also  a  greater  depth  in  the  concavity  of  the  sacrum. 
The  want  of  depth  in  the  pelvic  excavation  depends  on  the  same  cause;  for, 
when  the  ischium  is  drawn  towards  the  external  iliac  fossa,  the  lower  part  of  the 
pubic  arch  is  necessarily  bent  out,  and,  as  a  consequence,  the  depth  of  the  pelvis 
anteriorly  is  diminished.     (Sedillot.^ 

The  weight  of  the  body,  when  erect,  is  the  principal  agent  of  this  deformity ; 
which  essentially  results,  as  just  stated,  from  the  tension  exerted,  from  within 
outwards  on  both  sides  by  the  capsular  ligaments  of  the  two  deformed  articula- 
tions, which  hold  the  trunk  suspended,  as  it  were,  between  the  thigh  bones;  and 
the  force  exerted  by  these  ligaments  on  the  pelvis  is  equal  in  power  to  the  ten- 
dency of  the  weight  of  the  body  to  elongate  them.  Lastly,  the  contraction  of 
the  cotyloid  cavity  has  some  little  influence  over  the  change  in  extent,  which  the 
pelvis  undergoes,  though  it  explains  but  a  very  small  part  of  the  deformity. 

The  deformity  is  often  irregular,  or  non-symmetrical,  because  the  changes 
effected  in  the  pelvis  are  more  marked  on  one  side  than  on  the  other;  though, 
generally  speaking,  they  are  found  to  bear  a  relation  to  the  degree  of  organization 
in  the  new  joint;  and,  if  any  accidental  articular  cavity  exists,  they  are  more 
developed  on  that  side. 

A  pelvis,  which  has  been  referred  to  by  M.  Gerdy  in  his  learned  report,  read 
before  the  Academy,  on  congenital  luxations,  and  which  presents  some  very  sin- 
gular modifications,  may  be  seen  at  the  Musee  Dupnytren  ;  it  only  has  one  femur 
attached,  which  is  fused  outside  of  the  anterior  inferior  spinous  process  of  the 
ilium  on  the  left  side.  The  anterior  superior  spine  of  the  opposite  coxal  bone  is 
two  inches  higher  than  the  left  one,  and  both  bones  are  fixed  with  an  equal 
degree  of  solidity  in  these  relative  situations ;  the  sacrum,  though  very  short,  is 
quite  broad,  and  the  superior  strait  exhibits  a  modification  similar  to  what  has 
just  been  described;  as  to  the  inferior  strait,  it  is  very  large  in  every  direction, 
because  the  sacrum  is  exceedingly  short,  and  the  anterior  pelvic  wall  is  bent,  as 
it  were,  forward  and  downward,  on  the  same  transverse  and  vertical  plane,  instead 
of  being  curved  or  bent  downwards  and  backwards  as  in  the  normal  state.  (See 
No.  252,  Musee  Dupvi/tren.) 

We  have  extracted  from  the  memoir  of  M.  Sedillot  only  those  peculiarities 
that  seemed  important  to  be  known,  though  we  trust  that  enough  has  been  given 
to  prove  that  Dupuytren  was  greatly  mistaken,  when  he  asserted  that  the  pheno- 
mena of  primitive  luxations  had  no  influence  whatever  over  the  development  of 
the  pelvis,  and  that  the  latter  offered  no  greater  obstacles  to  delivery  than  it  does 
in  well-formed  persons ;  the  incorrectness  of  which  assertion  is  doubtless  suffi- 
ciently proved  by  the  details  into  which  we  have  entered.  However,  it  must  be 
acknowledged  that  in  such  cases  the  delivery  is  seldom  impossible,  although  it 
may  be  attended  with  some  difficulties ;  at  least,  no  instance  has  yet  been  re- 
corded in  which  the  expulsion  of  the  foetus  could  not  take  place  without  having 
recourse  to  a  bloody  operation  on  the  mother  or  child ;  which  is  most  certainly 
owing  to  the  fact  that,  in  congenital  luxations,  the  contraction  takes  place  in  the 
longest  diameters,  both  of  the  superior  and  inferior  straits. 


MALFORMATIONS     OF    THE     PELVIS.  555 

In  a  recent  publication,  M.  Lenoir  expresses  an  opinion  so  far  contrary  to  that 
of  M.  Sedillot,  as  to  suppose  that  double  congenital  luxations  produce  no  notable 
alteration  of  the  shape  of  the  pelvis ;  and  he  mentions  in  support  of  his  view, 
the  pelvis  of  a  young  -woman,  the  dimensions  of  which  he  gives.  These  dimen- 
sions hardly  differ  from  those  of  the  normal  pelvis,  except  as  regards  the  inferior 
strait,  where  they  present  an  increase  in  extent  of  rather  less  than  half  an  inch. 

The  observations  of  M.  Lenoir  prove  merely  that  the  remarks  of  M.  Sedillot 
are  not  applicable  to  all  cases;  still,  the  ficts  observed  by  the  latter  surgeon  are 
of  great  value,  showing,  as  they  do,  that  congenital  luxations  may,  in  some  cases, 
produce  a  marked  change  in  the  form  and  dimensions  of  the  various  parts  of  the 
pelvis. 

M.  Lenoir  insists  much  more  strongly  than  M.  Sedillot  upon  the  effect  of 
simple  congenital  luxation.  The  latter  is,  he  states,  accompanied  by  an  arrest  in 
the  development  of  all  that  side  of  the  pelvis  corresponding  to  the  luxation, 
which  atrophy  produces  so  great  a  deformity  of  both  straits  and  the  excavation, 
that  we  may  be  certain,  that  although  delivery  is  not  always  rendered  impossible 
thereby,  the  labor  will  at  least  be  longer  and  more  diflScult. 

The  latter  proposition  is,  I  think,  by  far  too  absolute,  and  facts  are  wanting  to 
prove  it.  The  deformity  which  follows  simple  luxation  is  much  less  than  that 
resulting  from  a  double  displacement,  and  the  specimen  of  M.  Pacoud,  described 
by  M.  Lenoir,  seems  to  me  in  nowise  to  justify  his  assertions. 

Is  M.  Lenoir  more  fortunate  in  his  endeavor  to  trace  a  resemblance  between  a 
pelvis  deformed  in  consequence  of  a  simple  luxation  than  the  oblique  oval  pelvis 
of  M.  Naegele  ?  The  points  of  difference  between  these  two  pelves  are  so  nume- 
rous, that  he  has  seemed  to  me  to  force  whatever  analogies  may  exist,  by  placing 
them  in  the  same  category.  The  anatomical  characters  do  not  justify  it,  and  the 
prognosis,  especially,  is  much  less  serious ;  finally,  the  indications  to  be  fulfilled 
in  both  cases  are  essentially  different. 

c.  JSon-covrjenital  Luxations. — The  atrophy  of  the  iliac  bone  corresponding 
to  the  dislocated  femur  may  also  be  met  with  in  luxations  occurring  after  birth, 
whether  the  luxation  be  the  result  of  an  accident,  or  consecutive  to  an  organic 
alteration  of  the  articular  surfaces,  as  in  coxalgia.  To  produce  this  effect,  all 
that  is  necessary  is,  that  the  luxation  should  remain  unreduced,  and  that  it 
should  have  occurred  within  the  first  years  of  existence.  Now,  as  this  atrophy 
was  the  cause  of  the  deformities  of  the  pelvis  studied  in  the  preceding  paragraph, 
it  may  have  the  same  consequences  in  the  case  under  consideration.  It  is  also 
plain  that  the  pelvic  deformity  will  be  great  in  proportion  as  the  luxation  shall 
have  occurred  at  a  very  early  age. 

D.  Lesions  of  the  Inferior  Extremities. — The  curvatures,  so  often  met  with  in 
the  lower  limbs,  do  not  always  diminish  their  length  in  an  equal  degree;  and  this 
unequal  shortening  determines  a  variation  in  the  pressure  they  make  on  the 
bottom  of  the  cotyloid  cavities ;  and,  consequently,  may  affect  the  pelvis  on  the 
side  where  it  is  the  greater.  It  is  so  true  that  the  imperfect  conformation  of  the 
pelvis  is  then  dependent  on  a  difference  in  the  length  of  the  lower  extremities, 
that  the  latter  may  often  be  curved  (provided  they  maintain  the  same  length), 


556  DYSTOCIA. 

without  the  pelvis  being  necessarily  vitiated ;  and  also,  that  where  any  inequality 
does  exist  between  theu»,  there  is  quite  a  constant  relation  between  the  direction 
of  the  depression,  and  the  side  corresponding  to  the  shortest  limb. 

It  is  further  possible,  that  a  shortening  of  one  of  the  legs,  whether  resulting 
from  a  fracture,  a  luxation,  or  an  atrophy  of  the  limb,  may  produce  the  same 
result;  more  especially  if  these  accidents  take  place  in  early  childhood,  when  the 
pelvis  is  still  far  from  having  acquired  its  full  development.  Persons  affected 
with  chronic  di.seases  of  one  of  these  limbs,  and  therefore  under  the  necessity  of 
walking  with  crutches,  and  of  bearing  the  whole  weight  of  the  body  on  the  sound 
leg,  incur  the  same  danger.  Nevertheless,  this  latter  circumstance  has  not 
alwaj's  such  an  unfortunate  influence ;  for  Dr.  Campbell  mentions  that  he  had 
an  opportunity  of  examining  the  body  of  a  woman  who  had  made  use  of  a  crutch 
since  the  fourth  year  of  her  age,  in  consequence  of  a  disease  in  her  right  lower 
extremity;  this  person,  who  died  some  time  after  delivery,  had  a  perfectly  formed 
pelvis.     (Campbelf,  page  249.) 

Amputation  of  the  thigh,  in  a  young  girl,  particularly  in  early  childhood,  is 
likewise  capable  of  deforming  the  pelvis  :  thus,  for  example,  Madame  Lacha- 
pelle  found  the  superior  strait,  in  a  female  aged  eighteen  years,  reduced  to  a 
moiety  of  its  extent  on  the  right  side  only,  and  pushed  in  totality  towards  the  left 
thigh,  which  had  been  amputated  four  years  previously.  Indeed,  we  can  readily 
imagine  that,  as  the  artificial  limb  only  derives  its  point  of  support  from  the 
ischium,  the  acetabulum  of  the  sound  side  will  alone  continue  to  be  compressed 
by  the  weight  of  the  body.* 

§  3.  Pelves  deformed  by  Absolute  Narrowness. 

To  complete  our  remarks  on  the  causes  of  pelvic  deformities,  we  have  yet  to 
sum  up  the  various  opinions  that  have  been  given  forth  concerning  those  vitiated 
by  absolute  narrowness.  According  to  most  authoi"s,  the  absolute  contraction  of 
the  pelvis  results  from  an  arrest  of  development,  whereby  this  part  still  retains, 
after  puberty,  the  principal  characters  that  it  had  during  childhood,  and  ap- 
proaches in  its  form  more  or  less  closely  to  that  of  the  male.  But,  as  M.  N^egele 
remarks,  if  this  were  really  the  case,  the  relation  of  the  diameters  with  each 
other,  and  the  character  of  the  pubic  arch,  should  be  such  as  are  observed  in  the 
young  girl  and  the  male.     But  all  the  known  pelves  of  this  variety  exhibit  quite 

'  According  to  Campbell,  tlie  deformity  of  the  pelvis  may  also  be  produced  by  contusions 
received  on  the  dorsal  region  during  childhood.  I  have,  he  says,  met  with  several  examples 
of  the  kind.  A  few  years  ago,  I  saw  a  patient  who,  when  three  years  old.  received  a  violent 
blow  upon  the  lumbar  region;  the  pelvis  was  in  her  case  so  deformed,  that  I  thought  it 
right  to  induce  labor  at  the  end  of  the  seventh  month.  Although  the  pains  were  powerful, 
the  head  remained  for  seven  hours  in  the  excavation,  but  the  child  was  nevertheless  ex- 
pelled. It  lived  eight  days,  and  died  in  convulsions.  Several  fractures  of  the  cranium 
were  discovered  at  the  autopsy,  and  several  subcutaneous  ecchymoses,  caused  evidently  by 
the  pressure  to  wliich  the  fa?tus  had  been  subjected  during  labor.  (Campbell,  Introduction 
to  the  Study  of  Midu-ifery,  p.  248.) 

This  observation  is  too  incomplete  to  justify  the  opinion  of  the  author.  Was  the  pelvis 
really  contracted?     Was  not  the  woman  rachitic?  &c.  &c. 


MALFORMATIONS     OF     THE     PELVIS.  557 

the  contrary.  Nor  are  tliey  more  in  consonance  'witli  that  of  a  rickety  person ; 
and,  besides,  the  rest  of  the  skeleton  has  none  of  the  characters  appertaining  to 
this  disease. 

Wherefore,  it  is  certainly  the  wisest  plan  to  say,  with  the  illustrious  Professor 
of  Heidelberg,  that  we  have  no  positive  data  concerning  the  causes  that  give  rise 
to  the  general  narrowing  of  the  pelvis;  and  that  such  pelves,  as  well  as  unusually 
large  ones,  should  rather  be  considered  as  a  freak  of  nature,  belonging  to  the 
same  category  as  a  want  of  proportion  in  the  head,  which  is  not  unfrequently 
found  too  large,  or  too  small,  relatively  to  the  rest  of  the  body. 

ARTICLE    III. 

INFLUENCE   OP   DEFORMITIES   OF   THE   PELVIS   UPON   PREGNANCY   AND 

PARTURITION. 

The  malformations  may  certainly  have  an  unfavorable  influence  over  the  pro- 
gress of  gestation  ;  for,  as  we  have  already  stated  in  the  article  on  abortion,  where 
the  contraction  of  the  straits  accompanies  an  enlargement  of  the  excavation,  the 
womb,  finding  a  more  considerable  space  than  usual  in  the  cavity  of  the  lesser 
pelvis,  may  become  developed,  and  remain  there  beyond  the  ordinary  period ; 
and  we  have  considered  this  circumstance  as  one  of  the  causes  of  abortion,  from 
the  impossibility  of  its  getting  subsequently  above  the  superior  strait;  and,  when 
treating  of  retroversion,  we  remarked  that  this  displacement  was  singularly 
favored  by  an  increased  depth  in  the  concavity  of  the  sacrum. 

Even  in  cases  of  slight  contraction  of  the  superior  strait,  the  sort  of  impaction 
which  the  uterus  undergoes  from  the  early  stages  of  pregnancy,  may  produce  a 
violent  compression  of  the  organs  situated  in  the  excavation.  Van  Doeveren  men- 
tions a  very  curious  case,  in  which  the  patient  experienced  such  acute  pain  in 
the  hypogastric  region  from  the  third  month  of  gestation  as  at  first  to  excite 
fears  of  abortion.  The  symptoms  continued,  notwithstanding  the  use  of  the  most 
rational  means.  B}'  careful  examination,  he  detected  an  oval  tumor,  painful  to 
the  touch,  and  extendino;  above  the  umbilicus.  The  patient  urinated  frequently, 
though  in  but  small  quantity  at  a  time.  He  suspected  dropsy  of  the  uterus. 
The  suffering  continued  in  spite  of  all  that  could  be  done,  and  the  patient  grew 
worse  and  worse,  until  one  morning  when  he  found  her  much  better  and  relieved 
of  her  excruciating  pains.  She  no  longer  had  fever  nor  diflScult  respiration,  and 
the  tumor  had  disappeared;  the  abdomen  was  flatter,  softer,  and  presented  an 
obscure  fluctuation.  He  thought  that  the  uterus  had  been  ruptured,  and,  not- 
withstanding the  contentment  of  the  patient,  gave  the  most  unfovorable  prog- 
nosis. She  died,  indeed,  two  days  afterward.  At  the  autopsy,  it  was  discovered 
that  the  greatly  distended  bladder  had  given  way  at  its  upper  part.  The  uterus 
filled  the  lesser  pelvis  so  completely  as  to  leave  no  space  between  it  and  the  walls 
of  the  pelvis.  It  compressed  the  vessels,  the  pelvic  nerves,  and  the  rectum,  as 
also  the  urethra  against  the  pubis.  The  sacro-pubic  diameter  was  but  three 
inches  and  eitrht  lines  in  extent. 


558  DYSTOCIA. 

When  the  transverse  diameter  of  the  greater  pelvis  is  contracted  by  the 
straightening  out  of  the  iliac  crests,  as  occurs  in  double  congenital  luxations  of 
the  femur,  the  development  of  the  uterus  is  considerably  impeded  during  the 
latter  months  of  pregnancy;  and  this  difficulty,  according  to  Ant.  Dubois,  may 
prove  a  cause  of  premature  labor.  Where  the  straightening  exists  on  one  side 
only,  the  inconvenience  is  less ;  but  still  it  may  possibly  contribute  to  the  pro- 
duction of  considerable  uterine  obliquity  on  the  opposite  side. 

In  general,  however,  with  the  exception  of  certain  inconveniences,  which  evi- 
dently depend  more  on  the  extraordinary  obliquity  of  the  planes  of  the  pelvis 
than  on  a  diminution  of  its  cavity,  and  to  which  we  shall  take  occasion  hereafter 
to  revert,  such  contracted  pelves  rarely  interrupt  the  course  of  gestation ;  but 
they  have  a  far  different  influence  upon  the  labor,  to  which  we  now  ask  the 
reader's  attention  more  particularly. 

The  impediments  to  the  delivery  will  usually  be  greater,  as  the  deformity  of 
the  pelvis  is  the  more  considerable ;  however,  this  proposition,  although  true  in 
the  majority  of  cases,  is  not  absolutely  so,  since  the  degree  of  narrowing  is  not 
the  only  point  that  demands  the  accoucheur's  attention ;  for,  the  child's  position, 
the  size  of  its  head,  the  flexibility  of  the  cranial  bones,  the  power  of  the  uterine 
contractions,  and  the  variable  degree  of  relaxation  of  the  pelvic  articulations,  are 
so  many  important  circumstances  which  claim  his  consideration.  One  woman, 
perhaps,  is  happily  delivered  at  terra,  whilst  another,  whose  pelvis  offers  the  same 
dimensions,  will  require  the  intervention  of  art  for  her  relief.  The  same  woman 
may  be  spontaneously  delivered  of  her  first  child,  and  yet  present  such  difficul- 
ties at  the  second  labor,  that  the  mutilation  of  the  foetus  may  be  deemed  to  be 
the  only  remedy  for  sparing  her  a  bloody  operation,  without  our  thereby  conclu- 
ding that  her  pelvis  had  become  contracted  between  these  two  pregnancies;  for 
these  differences  might  depend  solely  on  the  greater  volume,  or  a  less  degree  of 
reducibility  of  the  head,  or  the  bad  position  of  her  second  child,  &c.  Most 
accoucheurs  have  observed  facts  of  this  nature,  but  we  only  present  the  follow- 
ing:  A  patient  presented  herself  at  the  Clinique,  in  1838,  whose  pelvis  was  only 
two  and  three-quarter  inches  in  its  sacro-pubic  diameter;  she  was  delivered  in 
eighteen  hours  of  a  living  inflint,  at  term,  the  dimensions  of  which  were  nearly 
normal,  and  whose  head  was  scarcely  deformed.  Baudclocque  relates  having 
seen,  at  the  amphitheatre  of  Solayres,  the  head  of  a  foetus  which  was  elongated 
to  such  an  extent,  that  its  greatest  diameter  measured  nearly  eight  and  a  half 
inches,  whilst  the  bi-parietal  one  was  reduced  to  two  and  three-eighths,  or  two 
and  three-quarter  inches;  and  he  speaks  of  another  very  similar  instance;  but 
in  neither  of  these  cases  was  the  child's  life  compromised  for  a  single  instant. 
M.  Martin,  of  Lyons,  has  known  a  rachitic  woman  to  be  delivered  of  a  healthy 
infant  at  term,  by  the  efforts  of  nature  alone;  where  the  autopsical  examination 
showed  that  the  antero-posterior  diameter  was  only  two  and  a  half  inches  in 
extent  (page  270).  What  rendered  this  case  still  more  extraordinary,  was  the 
existence  of  scirrhous  tumors  in  the  substance  of  the  uterine  walls.  The  redu- 
cibility of  the  head,  therefore,  is  sometimes  excessive,  but  unfortunately  it  is 
almost  impossible  to  appreciate  this  in  a  positive  manner  beforehand. 


MALFORMATIONS    OF    THE    PELVIS.  559 

To  this  source  of  uncertainty,  says  Madame  Lachapelle,  let  us  add  that,  in 
certain  women,  the  degree  of  mobility  of  the  symphyses  does  not  permit  a  general 
separation  of  the  bones  (which,  even  if  it  existed,  would  scarcely  enlarge  the 
area  of  the  strait  or  of  its  diameters) ;  but  rather  a  mutual  gliding  of  the  arti- 
cular surfaces  upon  each  other,  an  overriding  of  the  pubes,  so  that  one  of  the 
innominata  advances  to  a  range  with  the  sacro-vertebral  angle,  whilst  the  other 
recedes  to  a  greater  or  less  extent.  It  follows  from  this  mechanism  that  one  of 
the  oblique  diameters  at  the  superior  strait,  the  one  corresponding  to  the  long 
diameter  of  the  head,  is  notably  increased ;  and  the  sacro-pubic  one  is  also  found 
augmented  by  the  advancement  of  one  of  the  coxal  bones.  Finally,  continues 
this  skilful  midwife,  it  may  be  possible  for  both  hip-bones  to  glide  forward  simul- 
taneously, thereby  enlarging  still  more  the  antero-posterior  diameter. 

In  most  cases  of  deformity,  the  child's  position  is  far  from  being  an  indifferent 
matter;  for  when  the  sacrum,  in  being  carried  forward,  is  at  the  same  time  turned 
to  one  side,  whereby  one  of  the  lateral  portions  of  the  pelvis  is  more  contracted 
than  the  other,  who  does  not  foresee  that  the  labor  may  then  be  accomplished 
spontaneously,  if  the  head  presents  in  such  a  way  as  to  offer  its  great  occipital 
extremity  to  the  well-formed  side ;  and  that,  on  the  contrary,  it  would  become 
impossible,  if  the  occiput  should  correspond  to  the  contracted  one  ? 

Where  the  contraction  is  so  limited  that  it  might  possibly  permit  a  spontaneous 
delivery,  any  unfiivorable  position  of  the  foetus  would  greatly  add  to  the  existing 
difficulties  caused  by  the  malformation  of  the  pelvis;  if,  for  example,  instead  of 
presenting  by  the  vertex,  the  child  should  offer  its  pelvic  extremity,  there  would 
be  reason  to  fear  an  arrest  of  the  head  above  the  superior  strait,  after  the  escape 
of  the  trunk ;  the  slowness  of  its  passage  through  this  strait  would  not  often 
warrant  the  abandonment  of  the  delivery  to  the  resources  of  nature,  both  from 
the  dangers  the  infant  incurs  from  a  compression  of  the  umbilical  cord,  and  from 
the  feebleness  of  the  contractions  of  the  womb,  which,  being  almost  entirel}' 
emptied  and  retracted,  no  longer  retains  its  contractile  properties.  (See  Presen- 
tation by  the  Breech.) 

We  need  scarcely  add,  in  conclusion,  that  a  proper  degree  of  energy  in  the 
uterine  contractions  bears  so  prominent  a  part  in  the  accomplishment  of  labor, 
that  it  cannot  be  overlooked.  In  certain  cases,  for  instance,  where  the  pelvis 
is  so  little  contracted  that  the  child's  delivery  is  still  possible  by  the  application 
of  the  forceps,  it  is  evident  that  frequent  and  strong  contractions  of  the  womb 
would  render  this  instrument  useless;  again,  the  labor  will  terminate  alone,  in  a 
case  where  the  physician  would  have  been  obliged  to  interfere,  if  the  pains  had 
been  too  feeble  or  too  slow. 

We  may  conclude,  therefore,  that,  in  the  question  before  us,  there  are  a  num- 
ber of  elements  which  may  influence  the  result;  and  that,  if  the  degree  of  nar- 
rowing of  the  pelvis  is  the  most  important  point  to  be  well  ascertained,  it  is  not 
the  only  circumstance  upon  which  the  obstetrician  ought  to  base  his  determina- 
tions. For  although  the  means  of  arriving  at  an  exact  knowledge  of  the  extent 
of  contraction  are  almost  sure,  yet,  unfortunately,  the  same  does  not  hold  good 
with  regard  to  the  volume  and  the  reducibility  of  the  foetal  head,  or  the  mobility 


560  DYSTOCIA. 

and  possible  separation  of  the  pelvic  symphyses ;  and  it  is  impossible  to  calculate 
in  advance  all  the  resources  of  the  organism,  or  to  know  how  far  the  uterine 
efforts  will  go.  From  our  ignorance,  on  most  of  these  points,  arise  the  uncer- 
tainties and  hesitations  which  so  often  prove  fatal  either  to  the  mother  or  the 
child ;  uncertainties  and  hesitations  that  never  influence  persons  who  are  not 
versed  in  all  the  difficulties  of  our  art,  but  which  are  well  understood  by  learned 
and  experienced  practitioners,  who  have  frequently  been  under  the  painful  neces- 
sity of  making  a  decision  and  of  deteruiining  a  question,  whose  solution  might 
cost  the  lives  of  two  individuals  whom  our  mission  is  to  save. 

The  foregoing  reflections  will,  I  hope,  be  sufficient  to  show,  that  what  we  are 
about  to  say  concerning  the  influence  of  the  pelvic  deformities  upon  .the  labor 
is  not  positive  and  absolute,  but  is  only  applicable  to  the  majority  of  cases. 

Under  the  head  of  the  difficulties  and  indications  presented  by  these  deformi- 
ties, we  shall  admit,  with  M.  P.  Dubois,  three  principal  divisions.  The  first  is 
composed  of  pelves,  in  which  the  contraction,  in  whatever  part  it  may  exist,  still 
leaves  at  that  part  an  opening  of  at  least  three  and  three-quarter  inches  in  all  its 
diameters;  the  second  comprises  those  in  which  the  contraction  leaves,  at  the 
point  of  the  canal  it  occupies,  a  passage,  one  or  more  of  whose  diameters  will  be 
three  and  three-quarter  inches  as  a  maximum,  and  two  and  a  half  inches  as 
the  minimum;  and,  lastly,  we  shall  include  in  the  third  all  the  cases  where  the 
narrowing  is  such,  that  the  dimensions  of  the  resulting  space  will  be  under  two 
and  a  half  inches. 

A.  Of  the  Pelvis  having  at  least  three  and  three-quarter  inches  in  its  Con- 
tracted Fart. — Here  the  labor,  although  in  general  longer,  more  difficult,  and 
therefore  more  dangerous,  both  for  the  mother  and  child,  than  in  ordinary  cases, 
may  however  be  accomplished  spontaneously ;  and,  indeed,  we  might  hope  fur 
such  an  expulsion  in  most  cases.  The  slowness  of  the  labor  is  observable  in  the 
dilatation  of  the  os  uteri,  as  well  as  in  the  expulsive  stage ;  for,  during  the  first 
stage,  the  uterine  contractions,  though  energetic  and  often  regular,  have  but  little 
action  on  the  dilatation  of  the  cervix;  the  head  is  high  up,  and  has  no  tendency 
to  engage  in  the  excavation,  and  it  remains  above  the  symphysis  pubis,  against 
■which  it  is  strongly  applied,  being  thrown  forwards  by  the  prominence  of  the 
sacro-vertebral  angle.  Indeed,  it  is  highly  probable  that  the  extreme  slowness 
of  the  dilatation  is  attributable  to  this  latter  circumstance ;  for  the  lower  front 
part  of  the  womb  is  so  compressed  between  the  child's  head  and  the  pubic  sym- 
physis, that  the  longitudinal  fibres  of  the  body  can  scarcely  act  at  all  on  the  cir- 
cular ones  of  the  cervix,  notwithstanding  the  energy  of  their  contractions;  for 
we  often  find,  after  the  size  of  the  head  has  been  diminished  by  a  perforation  of 
the  cranium,  whereby  this  compression  is  relieved,  at  least  in  a  great  measure, 
that  the  dilirtation  that  was"  hitherto  stationary  now  progresses  very  rapidly. 

As  to  the  modifications  that  take  place  in  the  period  of  expulsion,  they  vary 
according  to  the  seat  of  the  contraction;  for  instance,  when  the  superior  strait  is 
the  place  of  deformity,  the  engagement  of  the  head  might  be  so  much  retarded 
that  it  could  only  succeed  in  clearing  this  obstacle  under  the  influence  of  the 
most  powerful  contractions;  though,  should  these  be  sustained,  the  labor  would 


MALFORMATIONS    OF    THE    PELVIS.  561 

terminate  happily.  But  if,  as  is  sometimes  observed  (see  Pathol.  Anat.),  the 
corresponding  diameter  of  the  inferior  strait  is  simultaneously  enlarged,  the 
child's  head,  after  having  surmounted  the  difficulties  offered  at  the  upper  one, 
will  not  find  a  sufficient  degree  of  resistance  at  the  perineal  strait  to  moderate 
the  rapidity  of  its  descent;  and,  consequently,  it  might  strike  violently  against, 
and  lacerate  the  perineum  ;  the  disastrous  consequences  of  which  are  well  known. 
Where  the  superior  strait  retains  its  normal  dimensions,  the  inferior  one  alone 
being  contracted,  the  head  descends  rapidly  enough  into  the  excavation,  but  it 
can  only  clear  the  last  parts  of  the  canal  with  the  greatest  difficulty ;  for,  as  the 
dimensions  of  the  lower  strait  are  in  general  somewhat  smaller  than  those  of  the 
upper,  it  follows  that  the  same  degree  of  contraction  here  is  much  more  unfavor- 
able to  the  delivery,  and  oftener  requires  the  application  of  the  forceps. 

Finally,  where  the  two  straits  are  contracted  in  the  same  degree,  all  the  causes 
of  difficulty  just  mentioned  are  found  conjoined.  Most  frequently,  the  head 
succeeds  in  passing  the  superior  strait ;  but,  having  reached  the  excavation,  and 
being  unable  to  advance  any  further,  it  there  remains  wedged  in  until  the  ex- 
hausted or  enfeebled  forces  are  sufficiently  renovated  to  effect  its  delivery.  During 
all  this  time,  the  head,  which  had  been  forcibly  compressed  in  order  to  clear  the 
upper  strait,  and  had  its  dimensions  reduced  by  the  overlapping  of  the  parietal 
bones,  gradually  regains  its  natural  size,  now  that  it  has  entered  a  larger  space, 
departing  also  from  the  conical  shape  it  had  acquired  in  the  first  stage,  as  its 
delay  there  is  the  more  prolonged,  and,  consequently,  meeting  with  new  obstruc- 
tions at  the  inferior  strait,  which  are  so  much  the  more  difficult  to  overcome  as 
the  uterine  forces  are  already  the  more  exhausted. 

These  differences  in  the  seat  of  the  contraction  ought  to  be  known,  for  they 
will  enable  the  accoucheur  to  avoid  an  error  in  diagnosis  which  otherwise  he 
might  very  readily  commit;  for  example,  in  the  cases  where  the  superior  strait 
alone  is  contracted,  the  head  gets  into  the  excavation  only  after  very  long-conti- 
nued pains,  but  then  it  clears  the  inferior  one  almost  immediately  afterwards; 
whereas  the  contrary  happens  when  this  latter  is  the  only  one  contracted,  and  the 
attending  physician,  judging  of  the  future  by  the  past  duration  of  the  labor, 
announces  that  it  will  terminate  sooner  or  later,  according  as  the  head  has  de- 
scended more  or  less  rapidly  into  the  excavation  ;  but  he  will  most  always  deceive 
himself;  because,  in  the  former  instance,  the  termination  will  be  very  rapid, 
though  he  believed  it  still  distant;  and,  in  the  latter,  it  will  be  delayed  far 
beyond  the  time  that  he  had  fixed. 

B.  Where  the  Pelvis  has  at  least  two  and  a  half  inches  in  its  Contracted  Part. 
— A  spontaneous  expulsion  of  the  foetus  is  still  barely  possible,  where  there  is 
from  three  and  one-eighth  to  three  and  three-quarter  inches  in  the  contracted 
part;  though  in  reflecting  on  the  length  of  the  head's  smallest  diameter,  which 
at  term  is  at  least  three  and  one-half  inches,  it  must  be  evident  that,  in  order  to 
render  the  delivery  practicable  under  such  circumstances,  the  diameters  of  the 
cranial  vault  should  present  a  great  reducibility,  and  the  contractions  of  the  womb 
be  strong  and  prolonged.  But  in  an  immense  majority  of  the  cases  under  three 
and  one-eighth  inches,  the  resources  of  art  become  indispensable,  unless  the 


562  DYSTOCIA. 

child's  parts  should  be  softened  by  putrefaction,  or  the  infant  itself  not  have 
acquired  the  development  it  usually  exhibits  at  the  ordinary  term  of  gestation. 

c.  Where  the  Contracted  Diameter  is  less  than  two  and  a  half  inches. — This 
degree  of  contraction  renders  a  natural  labor  at  term  physically  impossible ;  be- 
cause too  great  a  disproportion  exists  between  the  dimensions  of  the  canal  and 
those  of  the  body  which  has  to  traverse  it ;  and  no  other  alternative  remains  for 
the  accoucheur  than  to  augment  the  former  by  symphyseotomy,  or  to  diminish 
the  latter  by  embryotomy ;  unless,  indeed,  he  should  rather  prefer  to  open  for  it 
a  new  and  more  easy  route  by  practising  the  Caesarean  operation. 

As  regards  the  prognosis,  it  is  very  important  to  distinguish  a  pelvis  deformed 
by  rachitis  from  one  whose  contraction  is  dependent  on  mollities  ossium ;  for 
although,  in  the  former  case,  the  gravity  of  the  prognosis  is  only  in  proportion 
to  the  degree  of  contraction,  yet  it  is  not  exactly  or  always  so  in  the  latter.  Here, 
indeed,  arises  the  important  consideration  that  the  first  eflPect  of  malacosteon  is  to 
produce  an  excessive  softening  of  the  osseous  tissue,  the  deformity  of  the  skeleton 
being  consecutive  thereto;  but  this  softening  only  reaches  its  summum  of  inten- 
sity by  degrees,  and  the  disease  may  be  arrested  in  its  progress,  may  be  amelio- 
rated, or  even  entirely  cured  under  the  influence  of  a  proper  treatment.  Whence 
it  is  evident  that,  during  the  period  of  increase  and  that  of  its  amelioration,  which 
may  extend  over  several  years,  the  softening  passes  successively  through  diflferent 
degrees,  and  where  it  happens  to  exist  at  the  time  of  labor,  furnishes  the  prac- 
titioner a  very  valuable  resource,  whatever  may  be  the  degree  of  contraction.  la 
fact  it  would  appear,  from  the  cases  reported  in  the  dissertation  of  M.  Spengel, 
that  the  bones  often  retain,  at  the  time  of  labor,  a  sufficient  degree  of  suppleness 
to  enable  them  to  dilate  spontaneously,  and  to  allow  the  expulsion  of  the  foetus, 
or,  at  least,  its  artificial  extraction.  Thus,  in  a  case  furnished  by  Homberger, 
the  sacro-pubic  diameter  was  scarcely  two  inches  in  length ;  nevertheless,  after 
having  ascertained  the  flexibility  of  the  bones  caused  by  the  malacosteon,  he 
declared  that  the  delivery  might  be  effbcted  by  the  powers  of  nature.  He  rup- 
tured the  membranes  at  the  end  of  twenty-four  hours ;  then,  after  waiting  as 
much  longer,  the  engagement  was  sufficiently  advanced  to  enable  him  to  apply 
the  forceps ;  when,  by  the  aid  of  powerful  tractions,  he  succeeded  in  bringing 
away  a  girl  who  lived  four  weeks.  In  another  woman,  whose  sacro-pubic  dia- 
meter was  two  and  a  quarter  inches  (French  measurement)  at  the  most,  Hass- 
locher,  a  physician  of  Landau,  was  enabled,  by  the  aid  of  external  pressure,  to 
make  the  child's  head  engage  in  the  cavity  of  the  pelvis ;  he  then  applied  the 
forceps,  and  found  that  only  a  moderate  efibrt  was  required  to  deliver  a  dead 
child,  weighing  six  pounds  and  a  half. 

Facts  of  this  nature  are  certainly  consolatory,  and  they  well  merit  attention ; 
but,  unfortunately,  it  is  a  very  difficult  matter  to  recognize  that  precise  degree  of 
flexibility  in  the  bones,  under  which  there  is  no  reason  to  hope  for  a  spontaneous 
dilatation  ;  for,  between  the  first  stages  of  softening  in  them  and  that  advanced 
period  when  they  scarcely  have  the  consistence  of  a  gelatinous  pulp,  there  are 
numerous  interu)ediate  degrees;  and  the  great  difficulty  consists  in  determining 
the  cases  in  which  we  can  trust  to  the  efforts  of  nature,  and  those  in  which 


MALFORMATIONS     OF    THE     PELVIS.  563 

nothing  can  be  hoped  from  this  source.  A  misplaced  confidence  might  be  at- 
tended with  the  most  serious  consequences ;  for,  on  the  one  hand,  a  prolonged 
delay  may  compromise  the  child's  life,  that  might  have  otherwise  been  saved,  by 
resorting  to  the  Csesarean  operation  at  the  most  favorable  moment ;  and  on  the 
other,  the  tentatives  uselessly  made  with  the  forceps  expose  the  mother  to  the 
greatest  dangers ;  for  bones  affected  by  this  disease  are,  it  is  true,  most  generally 
softened,  but  sometimes  it  happens  that  the  affection  has  only  rendered  them 
more  friable,  and,  of  course,  any  tractions  made  by  the  instrument,  in  such  cases, 
might  give  rise  to  dangerous  fractures.  It  would,  therefore,  be  highly  desirable 
to  have  a  rule  of  procedure,  but  in  the  present  state  of  our  science  it  is  impos- 
sible to  lay  down  any  positive  one  ;  and  the  accoucheur  must  found  his  opinion 
on  the  whole  of  the  phenomena  exhibited  in  the  particular  case.  "Without 
supposing,"  says  M.  Spengel,  "  that  it  will  be  possible  to  ascertain,  positively,  to 
what  extent  the  softening  of  the  pelvic  bones  has  advanced,  we  believe  that,  by 
paying  attention  to  the  symptoms  which  preceded  and  those  that  accompany  the 
labor,  it  may  be  determined  in  quite  a  probable  manner.  We  have  collected 
forty  cases  of  general  moUities  ossium  that  occurred  in  females ;  in  nineteen  of 
which  the  time  when  the  pains  first  began  is  not  noted,  and  no  conclusions  there- 
fore can  be  drawn  from  them ;  but,  in  twelve  cases,  the  first  pains  appeared 
during  the  lying-in,  in  two  others,  shortly  after  the  accouchement,  and  in  the 
remaining  seven  during  the  course  of  gestation ;  and,  whenever  the  period  has 
been  carefully  noted  when  the  pains,  after  having  been  once  calmed,  were  aggra- 
vated anew,  it  has  been  found  that  this  exacerbation  came  on  during  a  new  preg- 
nancy. Whence  we  may  suppose  that  the  softening  of  the  bones  is  more  consi- 
derable towards  the  end  of  gestation  than  it  was  before  its  commencement. 
Therefore,  when  the  alteration  progressively  increases  until  term,  and  the  diffi- 
culty in  the  patient's  movements  or  the  pains  exhibit  no  diminution,  we  believe 
the  degree  of  softening  may  be  regarded  as  bearing  a  relation  to  the  violence  and 
duration  of  these  symptoms.  Further,  by  resorting  to  the  manual  exploration, 
we  are  enabled  to  detect  in  some  cases  a  softening  to  such  an  extent  that  the 
bones  yield  to  the  pressure  of  the  fingers.  Under  such  circumstances,  the  accou- 
cheur may  doubtless  rely  on  a  spontaneous  delivery,  or  at  least  on  the  success  of 
a  prudent  application  of  the  forceps ;  which  latter  should  then  be  made  rather 
than  resort  to  the  Cfesarean  operation,  which  is  so  grave  at  all  times,  but  is  still 
more  so  when  practised  on  women  affected  with  malacosteon." 

Independently  of  the  difficulties  which  the  contractions  of  the  pelvis  give  rise 
to  in  the  accomplishment  of  the  mechanical  phenomena  of  labor,  they  often 
become  the  source  of  serious  accidents  to  the  mother,  and  subject  the  foetus  to 
the  greatest  dangers.  For,  by  forming  an  invincible  obstacle  to  the  passage  of 
the  head,  they  expose  the  woman  to  a  rupture  of  the  womb  or  bladder,  to  a  vio- 
lent contusion,  and  the  consecutive  inflammation  of  those  organs  and  of  the  peri- 
toneum, and,  lastly,  to  a  febrile  or  adynamic  state,  which  is  serious  enough  of 
itself  to  cause  her  death  before  the  delivery  is  effected ;  since  this  condition  is 
the  most  frequent  source  of  mortality  in  those  patients  who  are  not  relieved. 
Again,  even  where  the  delivery  has  taken  place  either  spontaneously  or  artifi- 


5G4:  DYSTOCIA. 

cially  through  the  natural  passages,  the  duration  of  the  preceding  travail  and  the 
pressure  of  the  child's  head  upon  all  the  soft  parts  lining  the  straits  and  excava- 
tion, expose  these  latter  to  prolonged  contusions,  which  are  most  frequently 
followed  by  gangrene ;  whence  we  have  following  in  their  train  utero-vesical,  or 
vesico-vaginal  fistulas,  &c.  &c.,  according  to  the  point  that  has  been  more  parti- 
cularly compressed.  The  forced  engagement  of  the  head  in  a  contracted  pelvis 
often  determines  the  separation  of  the  symphyses,  from  which  inflammations  and 
suppurations,  that  are  often  very  tedious  in  their  cure,  result  as  the  immediate 
consequences,  and  a  great  mobility  of  the  pelvic  articulations,  limping,  and  some- 
times even  an  inability  to  walk  or  stand,  as  the  remote  ones.     (^Lacliapdle.^ 

As  regards  the  child,  the  slowness  of  the  labor  may  evidently  occasion  its 
death  j  for,  in  the  case  before  us,  the  head  being  retained  above  the  superior 
strait  does  not  prevent  the  discharge  of  the  amniotic  liquid  by  plugging  up  the 
OS  uteri,  and  this  nearly  all  escapes;  consequently,  the  foetus  is  subjected,  soon 
after  the  membranes  give  way,  to  the  direct  pressure  of  the  contracted  uterine 
walls  during  all  the  time  necessary  to  the  termination  of  the  labor.  The  cord 
also  is  very  frequently  compressed,  either  in  the  uterine  cavity,  between  its 
parietes  and  the  body  of  the  child,  or  subsequently  in  the  excavation  into  which 
it  may  have  slipped ;  the  descent  of  the  cord  is  here  singularly  favored  by  the 
elevation  of  the  head.  This  latter  itself  having  to  support  all  the  pressure  from 
the  resistance  offered  by  the  pelvis,  is  exposed  to  very  unequal  compressions, 
which  may  fracture  the  cranial  bones  or  wound  the  cerebral  matter.  Lastly, 
when  the  foetus  presents  by  the  pelvic  extremity,  the  violent  tractions  sometimes 
made  on  the  trunk,  for  the  purpose  of  disengaging  the  head,  may  produce  a 
luxation  of  the  cervical  vertebra?  or  a  tension  of  the  spinal  marrow,  both  of 
which  speedily  prove  fatal. 

ARTICLE   IV. 

DIAGNOSIS   OF   PELVIC   DEFORMITIES. 

The  circumstances  whereby  the  existence  of  a  deformity  of  the  pelvis  may  be 
recognized,  have  been  divided  into  the  rational  and  the  sensible  signs.  The  first 
include  all  those  that  may  be  learned  from  the  previous  history,  and  a  general- 
examination  of  the  individual — her  constitution,  height,  and  physical  strength ; 
the  second,  on  the  contrary,  are  deduced  from  an  external  and  an  internal  exami- 
nation of  the  pelvis. 

§  1.  Rational  Signs. 

The  accoucheur  who  may  be  called  upon  to  decide  on  the  good  or  imperfect 
conformation  of  a  female,  should,  before  proceeding  to  an  exploration  of  the 
pelvis,  inform  himself  minutely  of  all  the  antecedent  circumstances  which  might 
throw  any  light  on  bis  diagnosis,  or  direct  his  subsequent  researches.  He  ought 
to  ascertain  from  the  near  relatives,  all  the  accidents  which  the  young  girl  sub- 
mitted to  his  care  may  have  met  with  in  infancy ;  at  what  age  she  began  to  walk ; 


MALFORMATIONS     OF     THE     PELVIS.  565 

whether  standing  in  the  erect  position  was  easy,  or  even  possible,  in  the  early 
years  of  life  ;  or  whether,  after  having  walked  without  any  marked  ditSculty,  she 
was  subsequently  aflflicted  with  a  weakness  in  her  lower  extremities  j  and,  should 
there  be  an  existing  curvature  of  the  spine  or  limbs,  the  period  at  which  such 
incurvations  appeared  is  to  be  carefully  ascertained ;  as,  also,  whether  those  in 
the  lower  extremities  preceded  or  followed  that  of  the  spine.  Where  any  limp- 
ing is  observed,  he  will  endeavor  to  verify  the  information  derived  from  the 
family,  by  examining  whether  this  depends  on  a  difference  in  the  deformity  of 
the  two  limbs ;  on  the  atrophy  of  one  of  them ;  on  the  flattening  of  the  antero- 
lateral pelvic  walls ;  on  an  old  or  a  recent  afiection  of  the  femoro-coxal  articula- 
tion ;  on  a  spontaneous  or  a  congenital  luxation,  followed  by  the  permanent 
displacement  of  the  head  of  the  femur;  or  whether  upon  an  old  and  imperfectly 
consolidated  fracture ; — because  the  answer  to  all  these  questions  will  render  the 
examination,  which  is  afterwards  to  be  resorted  to,  much  easier. 

The  history  of  the  earlier  years  of  life  is  particularly  important,  as  it  will  not 
only  enable  us  to  divine  the  perfect  or  defective  conformation  of  the  pelvis  with 
a  tolerable  degree  of  certainty,  but  will  even  serve  to  enlighten  us  as  to  the 
nature  of  the  general  affection  that  has  produced  the  deformity.  In  fact,  it 
would  appear  from  the  researches  of  modern  pathologists  that  rachitis,  properly 
so  called,  is  a  disease  of  childhood,  though  it  is  seldom  observed  in  the  infant  at 
term;  it  generally  begins  about  the  eighteenth  or  twentieth  month,  and  is  rarely 
found  after  the  age  of  puberty.  Thus,  in  three  hundred  and  forty-six  cases, 
examined  in  this  respect  by  M.  Jules  Guerin,  its  invasion  took  place  as  follows : 
in  three  cases,  before  birth ;  in  ninety-eight,  during  the  course  of  the  first  year ; 
in  one  hundred  and  seventy-six,  during  the  second ;  in  thirty-five,  in  the  third ; 
in  nineteen,  in  the  fourth ;  in  fifty,  in  the  fifth ;  and  in  five  children  from  the 
sixth  to  the  twelfth  year  of  life. 

From  these  and  numerous  other  cases  reported  by  Bouvier,  Ruff,  &c.,  it  is  ap- 
parent that  deformities  occurring  in  infancy  are  nearly  always  of  a  rickety  nature; 
whilst  all  the  varieties  of  softening  that  take  place  in  adult  bones,  as  also  all  the 
disfigurations  occurring  exclusively  in  young  girls  about  the  period  of  puberty, 
are  not  caused  by  this  disease.     (  Guerin.') 

A  rachitic  origin  of  the  deformity  can,  therefore,  be  almost  constantly  relied 
on  where  the  disease  that  determined  the  latter  existed  during  the  early  years  of 
life ;  and  this  suspicion  will  be  confirmed,  if  it  should  appear,  conformably  to  the 
law  laid  down  by  the  orthopedists,  and  stated  formally  by  M.  Guerin,  that  the 
malformation  proceeded  from  below  upwards,  and  that  the  tibias,  the  femui'S,  and 
the  spinal  column  were  successively  affected.  But  if,  on  the  contrary,  the  first 
ten  years  have  passed  away  without  any  accident  of  the  kind;  and  if,  moreover, 
the  patient  has  been  happily  delivered  before,  but  has  exhibited  since  that  event 
all  the  phenomena  of  an  acute  softening,  the  deformities  may  safely  be  considered 
as  having  been  caused  by  malacosteon. 

After  attending  to  all  these  points,  the  accoucheur  might  proceed  to  a  more 
careful  inspection  of  the  individual ;  and  the  vertebral  column  and  lower  extre- 
mities should  particularly  claim  his  attention.     He  ought  to  bear  in  mind  that 


566  DYSTOCIA. 

rachitic  deviations  of  the  spine  (and,  when  dating  from  early  infancy,  they  will 
be  nearly  always  rachitic)  are  almost  constantly  accompanied  by  deformity  of  the 
pelvis ;  and  that,  on  the  contrary,  the  other  varieties,  more  especially  when  they 
first  occurred  about  the  age  of  puberty,  do  not  affect  the  normal  regularity  of  the 
pelvis.  It  is  also  to  be  remembered  that  rickets  may  possibly  give  rise  to  curva- 
ture of  the  lower  extremities  without  altering  the  pelvis,  though  these  two  parts 
of  the  skeleton  are  most  generally  affected  at  the  same  time ;  as  also  that,  even  if 
the  form  of  the  pelvic  cavity  should  remain  intact  after  the  disease  is  cured,  it 
is  rarely  that  deformity  of  the  pelvis  does  not  result  from  the  unequal  length  of 
the  lower  extremities,  particularly  if  this  inequality  is  well  marked,  and  has 
existed  from  early  infancy;  but  if,  on  the  other  hand,  the  limbs  although  curved, 
retain  the  same  length,  this  consecutive  malformation  of  the  pelvis  will  not  take 
place. 

An  attempt  has  been  made  to  establish  a  certain  relation  between  the  direction 
of  the  curvature  of  the  spine  or  lower  extremities,  and  the  particular  species  of 
malformation  the  pelvis  may  exhibit.  For  instance,  the  sacrum,  being  an  assem- 
blage of  vertebrae,  which  are  naturally  consolidated  together,  is  occasionally  modi- 
fied by  incurvations  that  are  continuous  with  those  of  the  spine,  and  these  are 
further  kept  up  by  the  coccyx.  Sometimes,  the  lateral  inflexion  of  these  two 
bones  is  continuous  with  the  lumbar  curve;  though,  more  frequently,  they 
describe  an  inverse  curvature  with  one  or  two  of  the  last  lumbar  vertebrae,  and 
the  point  of  the  coccyx  is  then  turned  aside.  According  to  M.  Hohl,  the  lateral 
inflexion  of  the  lumbar  column  often  determines  a  greater  contraction  of  the 
pelvis  on  the  side  towards  which  these  vertebrae  lean. 

Agreeably  to  the  same  author,  the  curvature  of  the  femurs  occasions  a  trans- 
verse contraction  of  the  pelvis,  and  a  consequent  elongation  antero-posteriorly, 
when  these  bones  are  curved  forward ;  whilst  their  outward  curvature  is  followed 
by  a  transverse  enlargement ;  but  if  one  bends  outward  and  the  other  forward,  a 
corresponding  shortening  will  thence  result  in  the  latter  direction.  However,  all 
these  approximations  must  be  substantiated  by  a  more  extended  experience  to 
render  them  deserving  of  confidence,  although  it  would  be  improper  in  practice 
to  neglect  them  altogether. 

The  relations  that  M.  Weber  has  endeavored  to  establish  between  the  dimen- 
sions of  the  cranium  and  those  of  the  pelvis  are  not  constant  enough  to  merit  any 
consideration  whatever  in  an  examination  which  requires  so  much  precision. 

Quite  recently,  M.  Guerin,  after  having  ascertained  that  rachitis  proceeds  from 
below  upwards,  and  that  the  reduction  in  the  dimensions  of  the  bones  follows  the 
same  progression,  attempts  to  prove  further,  that  the  dimensions  of  a  rickety 
bone  being  known,  the  size  of  other  parts  of  the  skeleton  may  be  approximately 
determined ;  and  that  the  reduction  in  the  three  diameters  of  the  pelvis  in  rachitic 
women,  follows  the  diminution  in  the  size  of  its  component  parts ;  also  that  the 
degree  of  this  reduction  is  intermediate  to  what  takes  place  in  the  femur,  and  in 
the  humerus. 

These  results,  so  valuable  in  themselves,  had  they  been  deduced  from  a  large 
number  of  cases,  are,  unfortunately,  based  upon  a  very  limited  observation  ;  and. 


MALFORMATIONS     OF     THE     PELVIS.  567 

consequently,  have  not  all  the  weipht  that  I  hope  they  will  hereafter  acquire ;  for 
the  great  importance  of  being  able  to  determine,  with  certainty,  from  the  degree 
of  shortening  of  the  femur  and  humerus,  not  only  that  the  pelvis  is  deformed,  but 
even  the  extent  of  the  malformation,  must  be  self-evident. 

In  conclusion,  it  is  apparent  that  the  rational  signs  just  spoken  of  can  only 
give  us  probabilities  or  approximations.  Now,  the  indications  pi*esented  by  the 
deformities  of  the  pelvis  demand  an  exact  and  a  rigorous  solution  of  all  the  ques- 
tions of  diagnosis  appertaining  thereto ;  because  it  is  not  on  a  mere  probability 
that  an  accoucheur  can  venture  to  prohibit  a  young  girl  from  marriage,  or  decide 
on  the  performance  of  an  operation  that  mutilates  the  child,  or  exposes  the 
mother  to  the  most  serious  dangers.  Such  a  decision  can  only  be  made  after  a 
thorough  and  minute  examination  of  the  external  form,  and  the  internal  dimen- 
sions of  the  pelvis ;  and  this  examination  alone,  can  enable  him  to  detect  those 
sensible  signs  which  afford  a  positive  certainty. 

§  2.  Sensible  Signs. 

The  accoucheur  should  not  content  himself,  therefore,  with  the  foregoing 
characters,  but  he  ought  to  seek,  in  the  mensuration  of  the  pelvis,  for  the  ele- 
ments necessary  to  his  diagnosis.  This  process  is  performed  both  on  the  exterior 
and  interior  of  the  pelvis ;  in  the  former  case  it  constitutes  what  obstetricians 
have  termed  external,  and  in  the  latter,  internal 2yd vimeti-}/. 

When  we  described  the  pelvis,  in  the  early  part  of  the  work,  we  only  pointed 
out  the  dimensions  that  were  absolutely  necessary  to  the  full  comprehension  of 
the  mechanism  of  natural  labor;  but  we  must  now  supply  that  voluntary  omis- 
sion; for,  in  addition  to  the  distances  then  given,  there  are  several  others  which 
are  indispensable  to  the  practice  of  pelvic  mensuration;  and  we  give  the  follow- 
ing as  the  average  of  a  well-formed  pelvis,  viz. : 

1.  From  the  anterior  inferior  spinous  process  of  one  ilium,  to  the  same 

point  on  the  opposite  side,  .......      8^  inches. 

2.  From  the  anterior  superior  spinous  process  of  one  side  to  the  same 

point  on  the  other,      .  ........     9j       "' 

3.  From  the  middle  of  the  iliac  crest  of  one  side  to  the  same  point  op- 

posite,        10^       " 

4.  From  the  middle  of  the  iliac  crest  to  the  tuber  ischii,      .  .  •     ^J       " 
The  superior  strait  divides  this  distance  into  two  equal  parts,  whence 

the  lateral  portions  of  the  greater  and  lesser  pelvis  are  each         .      3^       " 

5.  From  the  anterior  superior  part  of  the  symphysis  pubis  to  the  apex 

of  the  first  spinous  process  of  the  sacrum,  .  .         .  .  •     ^J       " 

From  which  2J  inches  are  to  be  deducted  for  the  thickness  of  the 
base  of  the  sacrum,  and  J  an  inch  for  that  of  the  symphysis; 
therefore,  leaving  for  the  sacro-pubic  interval       .  .         .  .     4 ^       " 

6.  From  the  tuber  ischii  of  one  side  to  the  posterior  superior  spinous 

process  of  the  opposite  ilium,  the  mean  extent,  in  an  ordinary 

pelvis  is,  ...........     7  " 

7.  From  the  anterior  superior  spine  on  one  side  to  the  posterior  supe- 

perior  spine  of  the  other,  the  mean  is  .....     8^       " 


568 


DYSTOCIA. 


8.  From  the  spinous  process  of  the   last   Inmbar  vertebra,  to  the  ante- 

rior superior  iliac  side  of  either  spine,  the  mean  is,       .         .  .7  inches. 

9.  From  the  trochanter   major  of  one  side  to  the   posterior   superior 

spinous  process  of  tlie  opposite  one,    ...  .  .  .      9         " 

10.'   From  the  middle  of  the  lower  border  of  the  symphysis  pubis  to  the 

posterior  superior  spinous  process  on  either  side,  .  .  .     6|       " 


85. 


Baudelocque's  callipers  applied  to  the  mea- 


For  the  purpose  of  ascertaining  the  dimensions  just  given,  in  the  living  female, 
as  well  as  the  principal  modifications  they  may  have  undergone,  accoucheurs 

have  invented  a  great  number  of  instruments, 
to  which  the  title  oi  pelvimeters  has  been  ap- 
plied ;  but  T  can  only  allude  here  to  those  in 
most  common  use. 

The  pelvimeter,  or  callipers,  described  by 
Baudelocque  (Fig.  85),  consists  of  two  me- 
tallic blades  bent  in  a  semicircular  form,  so 
as  to  embrace  the  largest  part  of  the  pelvis  in 
their  concavity.  The  extremity  of  each  one 
is  terminated  by  a  lenticular  button,  which  is 
intended  to  be  applied  at  the  end  of  the  line 
to  be  measured ;  a  small  rule,  marked  by  a 
graduated  scale,  traverses  the  branches  just 
at  the  point  where  the  curved  blade  joins  the 
straight  handle,  and  shows  the  degree  of  sepa- 
ration at  the  points  exactly.     This  rule  shuts 

surciiieiit  of  the  aiitero-posterior  diameter  of  ^p  \^  ^  deep  grOOVe   along    the  handle  of  the 
the  superior  strait.  ,,.  mi        •      .  x    ■  t    j         x 

callipers.     The  instrument  is  appned  exter- 
nally, and  may  prove  very  useful  in  estimating  the  measurements  above  given. 

In  skilful  hands,  the  pelvimeter  of  Baudelocque  may  furnish  very  satisfactory 
results ;  but  it  must  be  acknowledged  that  it  is  far  from  affording  that  degree  of 
certainty  which  its  inventor  anticipated,  even  in  the  determination  of  the  antero- 
posterior diameter  of  the  superior  strait,  the  one,  of  all  the  pelvic  diameters, 
which  seems  the  best  adapted  to  this  mode  of  exploration ;  for,  although  one  of 
the  buttons  can  readily  be  applied  at  the  upper  front  part  of  the  pubic  symphysis, 
after  having  carefully  pushed  aside  the  .soft  parts,  yet  it  is  far  otherwise  with 
regard  to  placing  the  other  one  just  over  the  point  corresponding  to  the  spinous 
process  of  the  first  piece  of  the  sacrum.*^     The  difficulty  of  determining  this  latter 

'  The  last  five  measurements  are  taken  from  the  Meinoirs  of  M.  Na-gele,  translated  by  M. 
Danyau.  We  shall  hereafter  revert  to  their  importance,  in  connection  with  the  diagnosis  of 
the  oblique-oval  pelvis. 

2  I  have  repeatedly  made  such  attempts,  and  have  so  rarely  succeeded  in  adjusting  the 
point  of  the  callipers  over  the  spot  behind  where  it  is  directed  to  be  applied,  that  I  have 
rather  attributed  those  cases  to  chance,  in  which  the  touch  did  not  set  aside  my  first  diag- 
nosis; and  I  will  add,  further,  that  I  have  often  known  M.  P.  Dubois  to  abandon  this  mode 
of  exploration  after  frequent  inetfectual  trials,  and  to  rely  wholly  upon  the  vaginal  exami- 
nation. 


MALFORMATIONS     OF     THE     PELVIS.  569 

point  exactly,  and  the  thickness  of  the  soft  parts,  renders  this  mode  of  mensura- 
tion very  uncertain  in  its  results.  But,  even  supposing  the  instrument  could  be 
properly  adjusted,  the  results  thereby  obtained  would  be  scarcely  more  conclusive. 
When  the  pelvis  is  well-formed,  there  should  be,  it  is  said,  seven  and  a  half 
inches  between  those  two  points;  from  which  two  and  a  half  inches  for  the 
thickness  of  the  sacrum  at  its  base,  and  half  an  inch  for  that  of  the  symphysis 
pubis,  are  to  be  deducted.  But,  the  question  at  once  arises,  are  the  pelvic  bones 
always  uniform  in  thickness?  or  must  we  still  deduct  three  inches  for  the  sub- 
stance of  the  bones,  in  cases  of  rachitis,  where  the  skeleton  exhibits  a  more  or 
less  marked  arrest  in  its  development?  How  are  we  to  know  to  what  extent  this 
influence  of  rachitis  over  the  growth  of  the  osseous  system  is  carried  ?  And  may 
not  the  thickness  of  the  sacrum  at  its  base,  instead  of  exhibiting  the  normal 
average  of  two  and  a  half  inches,  be  reduced  to  two,  one  and  a  half,  or  even  one 
inch  ?^ 

If  such  sources  of  uncertainty  exist  in  respect  to  the  measurement  of  the  sacro- 
pubic  diameter,  what  must  it  be  with  regard  to  determining  the  transverse  or 
oblique  ones  by  the  pelvimeter  ?  For,  is  the  interval  between  the  anterior  iliac 
spines  always  the  same  ?  In  the  normal  state,  that  extending  from  the  middle 
of  the  iliac  crest  on  one  side  to  the  same  point  opposite  is  ten  and  a  half  inches, 
just  double  the  length  of  the  transverse  diameter  of  the  superior  strait;  but,  it 
is  well  known  the  iliac  fossje  may  vary  in  their  concavity,  and  that  the  crests 
may  approach  more  or  less  closely  towards  a  vertical  or  a  horizontal  direction, 
without  altering  the  form  of  the  abdominal  strait.  Therefore,  the  supposed 
relations  between  these  two  distances  exhibit  such  frequent  anomalies  that  we 
cannot  place  any  confidence  in  the  conclusions  endeavored  to  be  established 
therefrom. 

Again,  where  one  point  of  the  callipers  is  placed  on  the  external  surface  of  the 
trochanter  major,  and  the  other  on  the  salient  part  of  the  opposite  sacro-iliac  arti- 

'  We  have  had  opportunities  of  measuring  a  great  number  of  pelves  that  were  deformed 
in  various  ways  and  in  different  degrees,  says  Madame  Boivin,  in  which  the  thickness  of  the 
walls  in  question,  departed  from  the  three  inches  assigned  to  them  by  Baudelocque,  to  the 
extent  of  a  third  of  an  inch  to  an  inch  each,  either  larger  or  smaller.  This  difference  in 
thickness  was  sometimes  observed  in  the  pubis,  at  others  in  the  base  of  the  sacrum,  and 
again  in  both  of  these  bones  at  the  same  time.  Besides,  in  more  than  a  hundred  well-formed 
pelves,  covered  by  all  their  tissues,  which  had  not  been  altered  by  disease  in  any  way,  we 
have  noticed  considerable  variations  both  in  the  volume  and  the  thickness  of  the  parts  form- 
ing the  antero-posterior  diameter  at  the  superior  strait. 

Madame  Lachapelle  has  found  the  sacrum  alone  nearly  three  inches  thick,  in  many  well- 
formed  pelves,  whilst  in  some  deformed  ones  it  scarcely  measured  two  inches. 

"  I  consider  the  results,"  adds  this  skilful  midwife,  "that  are  obtained  in  measuring  the 
transverse  and  oblique  diameters  of  the  strait,  by  taking  certain  portions  of  the  iliac  crests, 
the  great  trochanters,  the  ischial  tuberosities,  &c.,  for  the  points  of  departure,  as  very  falla- 
cious :  Because,  1.  In  the  best-formed  women,  the  iliac  crests  are  sometimes  inclined  towards 
each  other,  and  at  others  are  turned  outwards,  so  that  both  an  everted  and  a  cylindroid 
variety  may  exist  in  natural  pelves;  2.  The  great  trochanters  are  more  or  less  separated, 
according  to  the  variable  direction  and  length  of  the  neck  of  the  femur,  &c." 


570  DYSTOCIA. 

culation,  with  a  view  of  determining  the  oblique  diameters,  no  account  is  made 
of  the  numerous  variations  in  the  length  and  inclination  of  the  cervix  femoris,  in 
the  depth  of  the  cotyloid  cavity,  or  in  the  thickness  of  the  soft  parts  behind. 

Consequently,  the  employment  of  Baudelocque's  pelvimeter  can  only  give 
approximate  results;  but  it  is  not  the  less  a  useful  instrument  in  those  cases 
where  it  would  be  impossible  to  introduce  a  foreign  body  into  the  vaginal  cavity; 
for  instance,  the  internal  exploration  is  not  permissible  in  young  girls,  and  then 
we  must  resort  to  the  use  of  the  callipers.  Fortunately,  at  such  times,  the  diag- 
nosis need  not  be  very  precise,  and  a  few  lines  more  or  less  cannot  affect  the 
decision  of  the  physician. 

But  the  case  is  far  different  when  the  woman  is  pregnant  or  in  labor,  for  then 
it  is  necessary  to  learn  the  dimensions  of  the  pelvic  cavity  with  the  greatest 
exactitude.  For  this  purpose,  accoucheurs  have  devised  various  instruments, 
which  they  have  designated  by  the  title  of  internal  pelvimeters. 

The  most  ancient  of  all  is  the  one  invented  by  Coutouly,  which  closely  re- 
sembles, in  its  general  appearance,  the  instrument  used  by  shoemakers,  some 
years  since,  for  taking  the  measure  of  the  foot ;  it  is  composed  of  two  iron  rules, 
which  slide  on  each  other,  and  each  having  a  short  plate  fixed  at  a  right  angle 
on  one  of  its  extremities.  When  it  is  introduced  into  the  vagina,  the  two  rules 
are  slipped  along  each  other,  so  as  to  get  one  of  the  plates  against  the  saero- 
vertebral  angle,  and  the  other  just  behind  the  posterior  face  of  the  symphysis 
pubis.  One  of  these  rules  is  marked  by  a  scale,  which  indicates  the  degree  of  se- 
paration of  the  two  plates,  and,  consequently,  the  length  of  the  sacro-pubic  diameter. 

The  use  of  this  instrument  is  attended  with  such  numerous  inconveniences,  as 
to  have  banished  it  almost  entirely  from  practice.  Its  application  is  difficult ;  it 
distends  the  vaginal  mucous  membrane  greatly,  and  this  distension  is  often  very 
distressing  to  the  patient.  The  extremity  of  the  plate  that  is  intended  to  be 
applied  on  the  sacro-vertebral  angle,  is  liable  to  slip  and  to  become  displaced ; 
besides  which,  the  organs  situated  in  the  excavation  oppose  its  free  use. 

Madame  Boivin  endeavored  to  obviate  most  of  the  objections  against  Cou- 
touly's  instrument,  by  substituting  a  new  one,  which  she  called  an  intro-pelvi- 
meter ;  which,  although  bearing  a  general  resemblance  to  the  former,  differs 
essentially,  in  having  its  two  constituent  branches  simply  articulated,  so  that 
they  may  be  unfastened  and  introduced  separately ;  the  one  into  the  rectum,  the 
plate  of  which  is  to  be  applied  against  the  sacro-vertebral  angle,  and  the  other 
into  the  vagina,  so  as  to  place  its  vertical  part  behind  the  symphysis  pubis. 
This  instrument  is  perhaps  less  painful  to  the  patient,  and  not  so  liable  to  be 
displaced  as  the  other,  but  it  will  not  furnish  us  any  more  accurate  results. 
Besides,  the  introduction  of  a  foreign  body  into  the  rectum  is  so  disagreeable  to 
most  women  that  very  few  are  willing  to  submit  to  it ;  for  where,  indeed,  is  the 
young  girl  (and  Madame  Boivin  recommends  it  particularly  for  virgins)  who 
would  ever  consent  to  its  employment? 

But  it  is  unnecessary  to  allude  here  to  all  the  other  pelvimeters  that  have  been 
proposed ;  and  I  shall  only  bring  forward  the  one  invented  by  Stein,  which  I 
should  adopt  rather  than  the  preceding,  because  it  is  more  simple  and  more  easily 
applied.     It  is  merely  a  metallic  stem,  of  the  length  and  size  of  the  female  cathe- 


MALFORMATIONS    OF    THE    PELVIS.  571 

ter,  provided  with  a  slide,  and  having  the  metrical  divisions  marked  on  one  of 
its  surfaces.  It  is  employed  by  passing  its  extremity  along  the  forefinger,  pre- 
viously introduced  into  the  vagina,  until  it  reaches  the  sacro-vertebral  angle ;  the 
external  part  is  next  pressed  upwards,  so  as  to  bring  the  graduated  foce  in  con- 
tact with  the  lower  portion  of  the  symphysis  pubis,  and  then,  by  means  of  the 
slide,  the  point  on  the  stem  corresponding  to  the  symphysis  is  marked.  The 
instrument  is  subsequently  withdrawn,  and  all  that  part  of  it  beyond  the  slide 
shows  the  length  of  the  sacro-pubic  diameter,  or  rather  the  interval  existing  be- 
tween the  sacro-vertebral  angle  and  the  inferior  part  of  the  pubis. 

However,  Stein's  pelvimeter  may  be  replaced  by  any  straight  rod  whatever, 
upon  which  the  finger  will  take  the  place  of  the  slide. 

Many  very  ingenious  instruments  have  been  proposed  during  the  last  few 
years,  for  the  purpose  of  obviating  the  various  objections  we  have  urged  against 
those  just  mentioned ;  such  are  Wellenbergh's,  a  description  of  which  is  given 
by  M.  P.  Dubois  in  the  twenty-third  volume  of  the  new  edition  of  the  Diction- 
naire ;  and,  more  particularly,  the  one  announced  quite  recently  by  M.  Van 
Huevel,  a  professor  at  Brussels.  This  latter,  in  my  estimation,  has  incontestable 
advantages  over  all  the  others;  and  I  feel  warranted  in  recommending  its  more 
general  use. 

It  is  composed  of  two  round  rods;  an  internal  or  vaginal  one  (Fig.  86,  A  a) 
flattened  like  a  spatula  at  each  extre- 
mity, and  having,  about  the  middle  of 
its  upper  face,  a  small  blunt  hook,  or 
catch,  the  concavity  of  which  looks  to- 
wards the  outer  extremity;  the  other, 
or  external  one,  B  B,  is  traversed  at  the 
upper  end,  and  perpendicularly  to  its 
direction,  by  a  long  screw,  c,  which  is 
drawn  back  by  unscrewing.  These 
rods  are  held  together  by  means  of  a 
nut,  or  articular  box,  thereby  forming     „, 

•'  .    ^      The  mensuration  of  llie  sucro  pubic  diameter  with 

a   kind    of  compass,  the    legs   of  which  M.  Van  Huevel's  pelvimeter. 

can  be  lengthened  out  or  shortened  at 

pleasure,  and  can  likewise  be  moved  in  every  direction.  A  turn  of  the  central 
screw  in  the  nut  presses  them  against  each  other,  and  retains  them  firmly  in  any 
desired  position. 

When  this  instrument  is  to  be  applied,  the  woman  lies  on  her  back,  having 
the  legs  as  well  as  the  thighs  flexed  and  separated.  We  then  begin  by  ascertain- 
ing, both  exteriorly  and  interiorly,  the  exact  situation  of  the  upper  border  of  the 
pubis,  marking  the  skin  with  ink  at  the  point  corresponding  to  the  middle 
thereof.  The  ilio-pectineal  eminence  on  each  side,  just  beyond  the  course  of 
the  crural  artery,  is  next  sought  out  and  marked  in  the  same  way ;  so  that  the 
anterior  extremities  of  the  sacro-pubic  and  the  two  obli(jue  diameters  of  the  supe- 
rior strait  are  indicated  by  the  three  ink  spots  on  the  skin,  which  are  afterwards 
easily  found.  This  being  done,  one  or  two  fingers  of  the  left  hand  are  introduced 
into  the  vagina,  and  placed  on  the  angle  of  the  sacrum;  and  then,  with  the 


572 


DYSTOCIA. 


87. 


The  mensuration  of  the  symphysis-pubis  by  the  same 
instrument. 


other,  the  curved  extremity  of  the  vaginal  rod  is  conducted  along  and  under 
these  fingers,  •which  support  it  against  the  promontory,  while  the  thumb  of  the 
same  hand,  pressed  into  the  blunt  hook,  firmly  retains  it  on  the  exterior.  The 
right  hand,  -which  hitherto  held  the  instrument,  now  turns  the  long  screw,  C,  in 
the  external  branch,  the  button  of  which  rests  on  the  ink  spot  made  upon  the 
mons  veneris.  While  the  operator  thus  holds  the  two  branches  in  their  respec- 
tive positions,  an  assistant  tightens  the  screw  in  the  articular  nut;  when  the  in- 
strument, being  thus  fastened,  is  carefully  withdrawn  (Fig.  86),  and  the  distance 
between  the  two  points,  that  is  to  say,  the  interval  which  separates  the  promon- 
tory from  the  anterior  face  of  the  pubis,  is  ascertained  by  a  scale.  This  distance 
being  known,  the  branches  are  rendered  movable  by  unfastening  the  articular 

screw ;  and  the  operator  again 
carries  the  left  forefinger  into 
the  vagina  behind  the  sym- 
physis pubis,  to  which  point 
he  conducts  the  extremity  of 
the  vaginal  branch  (its  conca- 
vity being  in  front),  by  slip- 
ping it  along  the  palmar  sur- 
face of  this  finger,  and  he 
sustains  it  there  by  one  hand, 
whilst  with  the  other  he  re- 
places the  screw  of  the  exter- 
nal branch  upon  the  ink  spot 
on  the  mons  veneris ;  taking  care  to  avoid  pressing  more  strongly  than  in  the 
first  operation ;  for  it  is  only  requisite  to  graze  the  skin  without  depressing  it. 
The  assistant  again  tightens  the  screw  in  the  nut,  and  the  operation  is  completed. 
(Fig.  87.)' 

In  order  to  withdraw  the  instrument,  which  now  comprises  the  thickness  of 
the  pubic  region,  the  screw  c  of  the  external  branch  is  unfastened,  and  again 
exactly  replaced  in  the  same  position  after  it  is  withdrawn.  This  distance  is  also 
measured,  which,  deducted  from  the  first,  gives  a  remainder  that  extends  from 
the  sacro-vertebral  angle  to  the  posterior  face  of  the  pubis,  or  more  properly 
speaking,  the  sacro-pubic  diameter. 

The  oblique  diameters  can  be  obtained  precisely  in  the  same  way.  The  index 
and  middle  fingers  are  carried  into  the  vagina,  and  their  extremities  placed  on 
one  of  the  sacro-iliac  articulations,  or  even,  if  this  cannot  be  reached,  on  the 
promontory  of  the  sacrum;  the  end  of  the  vaginal  branch  is  slipped  up  there  in 
turn,  and  then  the  button  of  the  screw  c  is  fixed  on  the  ink  spot  corresponding 
to  the  right  or  the  left  ilio-pectineal  eminence.  The  branches  having  been  fast- 
ened in  this  position,  are  gently  withdrawn  from  the  woman's  parts,  and  the  dis- 
tance between  their  points  is  taken  by  a  graduated  scale.  In  a  second  operation, 
the  thickness  of  the  cotyloid  wall  is  ascertained  by  conducting  the  vaginal  branch 
along  the  fingers  behind  this  cavity,  as  far  as  the  brim  of  the  pelvis,  and  by  re- 
placing the  button  of  the  external  branch  over  the  ink  spot  corresponding  to  the 

'  If  the  hook  should  impede  the  sliding  of  the  branch  B  B,  it  might  be  removed. 


MALFORMATIONS    OF    THE     PELVIS. 


573 


ilio-pectineal  eminence.  Is  it  necessary  to  repeat,  that  the  soft  parts  in  the  groin 
are  not  to  be  depressed,  and  that  the  direction  must  correspond  with  the  plane 
of  the  abdominal  strait  ?  The  branches  are  subsequently  fixed,  and  extracted 
by  turning  back  the  screw  c,  as  described  above ;  when,  by  deducting  this  second 
thickness  from  the  first,  the  remainder  will  show  the  extent  either  of  the  oblique 
diameter,  or  that  of  the  sacro-cotyloid  interval,  according  as  the  vaginal  branch 
had  originally  been  placed  on  the  sacro-iliac  symphysis  or  upon  the  promontory 
of  the  sacrum. 

We  may  observe  here  that  the  opening  between  the  promontory  and  the  coty- 
loid wall  is  the  most  essential  to  be  known  in  cases  of  oblique  deformity ;  for  the 
sacro-iliac  articulation  is  never  deformed  (saving  where  an  exostosis  or  some  other 
tumor  is  developed  on  its  surface)  ;  but  it  is  rather  the  base  of  the  sacrum,  or  the 
cotyloid  cavities  which  project  into  the  hollow  of  the  excavation.  In  fact,  the 
pelvis  sustains  the  vertebral  column  behind,  while  in  front  and  laterally  it  rests 
on  the  thigh  bones ;  and,  therefore,  it  lies  between  two  forces,  which,  in  the  erect 
position  and  in  walking,  have  a  continual  tendency  to  depress  this  osseous  ring 
at  the  three  points  indicated.  Whence  it  follows  that,  if  there  is  any  softening, 
there  will  be  a  forward  projection  of  the  sacral  angle,  or  a  pressing  backward  of 
the  acetabula ;  that  is  to  say,  a  contraction  of  the  antero-posterior  diameter,  and 
of  the  right  and  left  sacro-cotyloid  intervals,  which,  in  the  normal  state,  are  only 
from  three  to  three  and  three-quarter  inches  in  extent. 

As  regards  the  external  measurement,  we  can  convert  the  pelvimeter  into  a 
common  compass  for  the  inferior  strait,  by  taking  the  handle  part  of  the  two 
branches,  and  properly  adjusting  the  nut;  these  being  placed  on  the  tuberosities 
of  the  ischia,  or  one  at  the  point  of  the  coccyx,  and  the  other  under  the  pubic 
arch,  we  are  enabled  to  take  the  transverse  and  the  antero-posterior  diameters  of 
this  strait  directly. 

Lastly,  by  adding  a  piece  to  the  apex 
of  the  vaginal  branch  (Fig.  88,  D  d), 
we  form  a  species  of  callipers  similar  to 
themecometerof  Chaussier.  This  piece 
is  first  flattened  out  like  a  spatula,  and 
then  curved ;  and  its  concavity  is  placed 
along  the  anterior  surface  of  the  pubis ; 
the  branch  that  supports  it,  passes  back- 
wards between  the  woman's  thighs; 
and  the  button  of  the  screw  C,  traver- 
sing the  other  branch,  is  pressed  on  the 
spinous  process  of  the  last  lumbar  ver- 
tebra.'    The  operator  holds  the  extre- 


The  same  instrument  converted  into  a  pair  of 
callipers. 


'  If,  says  M.  Van  Huevel,  the  tubercle  of  the  spinous  process  of  the  last  lumbar  vertebra 
cannot  be  detected,  the  following  process  may  be  had  recourse  to :  Stretch  across  this  region 
a  string  which  shall  rest  upon  the  upper  and  middle  part  of  the  crests  of  both  iliac  bones; 
then  at  the  distance  of  an  inch  and  a  half  below  this  line,  upon  the  iniddle  of  the  sacrum, 
make  a  mark,  from  which  the  string  is  to  be  conducted  obliquely  forwartU  anil  downwards 


574 


DYSTOCIA. 


mities  of  the  instrument  in  his  two  hands,  whilst  an  assistant  tightens    the 
screw  in  the  articuhir  nut.     It  is  disengaged  by  turning  the  screw  c  back- 


Fig.  89. 


Fig.  90 


Fig.  91. 


2 


wards,  when  necessary,  which  is  returned  to  its  place  before  measuring  the  in- 

toward  tlie  upper  part  of  the  cotyloid  parietes  and  of  the  mons  veneris.  The  position  of  the 
string,  which  shouhl  follow  the  inclined  direction  of  the  plane  of  the  superior  strait,  may  be 
rectified,  if  necessary,  by  the  fingers.  Then  with  an  uncut  quill  dipped  in  ink,  the  points  to 
be  preserved  are  marked  out  along  the  line  of  the  cord.  These  points  should  be  made  lower 
at  the  pectineal  eminences  and  at  the  pubis,  by  from  one  and  a  half  to  two  and  a  half  inches, 
than  the  described  limit,  in  order  to  correspond  better  with  the  contraction  of  this  strait. 


MALFORMATIONS     OF    THE    PELVIS.  575 

terval  between  the  points  •with  the  scale.  (Extract  from  the  Memoir  of  M.  Van 
Muevel.^ 

Quite  recently  (February,  1855),  the  ingenious  accoucheur  of  Brussels  has 
still  further  improved  his  first  pelvimeters,  besides  suggesting  another,  which 
appears  to  me  quite  as  simple,  and  of  more  general  applicability  than  the  pre- 
ceding.    I  therefore  think  it  right  to  give  a  detailed  description  of  it. 

It  is  simply  a  pair  of  callipers  (Fig.  89)  composed  of  two  branches,  one  of 
which  is  fixed,  and  the  other  movable.  The  first,  A  B,  is  eleven  inches  in  length, 
slightly  curved,  and  flattened  at  its  extremity;  it  is  inserted  into  the  vagina  for 
the  internal  measurement,  and  bears  a  hooked  ring  near  its  middle,  beyond  which 
is  a  non-graduated  arc  of  a  circle.  It  articulates  below,  like  an  ordinary  pair  of 
compasses,  with  the  prolongation  of  a  sheath,  in  which  is  inserted  the  lower 
extremity  of  the  other  branch.  The  curvature,  length,  and  hooked  ring,  are  the 
same  as  in  the  small  geometric  pelvimeter. 

The  second  or  external  branch,  c  B,  may  be  lengthened  or  shortened  at  plea- 
sure. It  carries  at  its  upper  extremity  a  long  horizontal  screw,  like  the  preceding 
pelvimeter,  for  the  purpose  of  facilitating  the  disengagement  of  the  compass  after 
its  internal  ap^jlication  :  from  thence  it  curves  outwardly,  and,  finally,  in  de- 
scending becomes  straight  and  quadrangular,  and  enters  the  above-mentioned 
sheath.  The  latter,  which  is  open  at  both  ends,  is  furnished  with  a  groove 
externally,  for  the  purpose  of  receiving  a  projection  of  the  branch,  which  pre- 
vents its  escaping  from  the  sheath.  Its  inner  side  is  provided  with  a  spring, 
bearing  a  point,  which  passes  through  the  side,  and  lodges  in  a  small  hole  in  the 
branch,  so  as  to  prevent  the  latter  from  slipping  up  and  down,  and  to  keep  the 
two  extremities  of  the  branches  on  the  same  level.  When  the  spring  is  raised, 
the  point  escapes  from  the  hole  in  the  stem,  which  then  becomes  movable;  when 
released,  and  pressing  upon  its  surface,  it  keeps  it  at  any  height  desired. 

The  arc  of  a  circle  attached  to  the  vaginal  branch  is  applied  against  the  right 
side  of  the  external  branch.  A  slide  (Fig.  90)  is  traversed  by  the  latter  at  right 
angles,  and  also  by  the  arc.  On  the  opposite  side  is  fixed  a  vice,  moved  by  a 
lever,  which  presses  these  two  pieces  together,  and  prevents  all  motion.  Lastly, 
a  graduated  scale  (Fig.  91)  serves  to  measure  the  distance  between  the  extremi- 
ties in  any  given  position. 

Let  us  now  examine  the  mode  of  application  of  the  new  pelvimeter. 

The  compressing  vice  of  the  slide  is  relaxed,  and  the  point  of  the  spring 
engaged  in  the  small  hole  of  the  external  branch  keeps  the  extremities  of  the 
instrument  on  the  same  level,  so  as  to  form  a  pair  of  callipers.  The  extremities 
are  applied  either  to  the  anterior  superior  spinous  processes  of  the  iliac  bones,  to 
the  crest  of  the  ilium  and  the  tuberosity  of  the  ischium  of  the  same  side,  or 
the  bottom  of  the  horizontal  screw  is  placed  upon  the  spinous  process  of  the  last 
lumbar  vertebra,  and  the  extremity  of  the  vaginal  branch  against  the  mons 
veneris  by  passing  between  the  thighs  of  the  patient ;  again,  one  may  be  applied 
to  the  upper,  and  the  other  to  the  lower  edge  of  the  pubis,  to  the  tuberosity  of 
each  ischium,  or,  finally,  upon  the  coccyx,  and  under  the  pubic  arch. 

Thus  are  obtained  the  extent  of  the  transverse  diameter  of  the  greater  pelvis, 


576  DYSTOCIA. 

the  depth  of  the  entire  cavity,  the  distance  from  the  loins  to  the  pubis,  the 
length  of  the  symphysis  pubis,  and  the  transverse  and  anterior  posterior  diame- 
ters of  the  inferior  strait,  the  value  of  each  of  which  is  determined  by  the  scale. 

To  measure  the  interior  of  the  pelvis,  the  woman  is  placed  on  her  back  on  the 
bed,  with  the  breech  brought  to  the  edge  of  the  mattress.  The  extremities  of 
the  diameters  of  the  superior  strait  are  marked  in  the  manner  already  described, 
with  the  aid  of  a  cord  and  a  quill.  Then,  one  or  two  fingers  of  the  left  hand  are 
introduced  into  the  vagina  as  far  as  the  promontory  of  the  sacrum.  The  right  hand 
holds  the  callipers  unfastened  and  opened  to  its  full  extent,  and  with  the  external 
branch  depressed  in  its  sheath.  The  extremity  of  the  vaginal  branch  is  next 
passed  into  the  genital  organs  along  the  previously  introduced  fingers,  which 
press  it  against  the  sacro-vertebral  angle,  whilst  the  base  of  the  thumb  engages 
itself  in  the  hook.  The  instrument  is  held  motionless  in  its  position  by  a  single 
hand.  Then,  the  thumb,  fore,  and  middle  fingers  of  the  right  hand  grasp  the 
external  branch  above  the  arc  of  a  circle,  and  raise  or  lower  it  in  its  sheath  until 
the  button  of  the  horizontal  screw  corresponds  to  the  mark  made  upon  the  mons 
veneris.  As  soon  as  this  is  effected  by  merely  grazing  the  sJcin,  the  ring  finger 
presses  the  lever  of  the  vice  forwards,  to  fix  the  instrument  in  its  place.  It  is 
then  withdrawn  from  the  woman's  parts,  and  the  distance  between  the  two  extre- 
mities ascertained  by  means  of  the  scale. 

The  first  stage  of  the  operation  being  accomplished,  the  vice  is  relaxed,  and 
the  extremities  of  the  callipers  again  made  to  correspond.  The  index  finger  of 
the  left  hand  is  again  introduced  into  the  vagina,  and  applied  this  time  behind 
the  pubis.  The  extremity  of  the  vaginal  branch  is  conducted  thither,  with  its 
concavity  in  front,  by  the  right  hand.  As  soon  as  it  has  reached  the  upper  edge 
of  the  symphysis,  the  branch  is  seized  with  the  entire  hand,  and  the  little  finger 
passed  into  the  ring  of  the  hook.  The  external  branch  is  afterwards  seized  above 
the  arc  by  the  three  first  fingers  of  the  right  hand,  and  the  ring  finger  pushes 
the  lever  of  the  vice  forward,  as  soon  as  the  button  of  the  horizontal  screw  corre- 
sponds to  the  spot  on  the  mons  veneris.  This  second  application  should  be  made 
as  gently  as  the  first,  merely  grazing  the  skin.  Should  any  difficulty  be  expe- 
rienced in  the  withdrawal  of  the  pelvimeter,  the  horizontal  screw  may  be  screwed 
back,  provided  it  be  restored  to  its  position  after  the  extraction.  The  distance 
between  the  extremities  should  be  again  measured  by  the  scale,  and  subtracted 
from  the  first  result,  to  obtain  the  extent  of  the  sacro-pubic  diameter. 

The  only  error  possible  in  this  process,  results  from  the  unequal  pressure  upon 
the  skin  in  the  two  applications,  or  else  upon  the  irregular  position  of  the  branch 
behind  the  pubis,  which  may  be  either  higher  or  lower  than  the  sacro-pubic  line 
itself.  A  little  attention  only  is  necessary  in  order  to  avoid  these  slight  causes 
of  error. 

The  proceeding  is  exactly  the  same  for  obtaining  the  oblique  diameters.  The 
pelvimeter  is  first  loosened,  opened  widely,  and  the  external  branch  lowered  in 
its  sheath.  If  the  left  sacro-pubic  space  is  to  be  measured,  the  instrument 
should  again  be  taken  in  the  right  hand;  the  fore  and  middle  fingers  of  the  other 
hand  are  introduced  into  the  genital  organs,  and  placed  to  the  left  of  the  pre- 


MALFORMATIONS    OF    THE    PELVIS.  577 

vertebral  projection  ;  then  the  extremity  of  the  vaginal  branch  is  passed  up  to 
the  point  indicated,  and  retained  there  by  the  fingers  of  the  right  hand ;  the 
button  of  the  external  branch  is  placed  upon  the  mark  over  the  left  ilio-pectineal 
eminence,  and  the  vice  is  tightened  by  the  ring  finger.  The  instrument,  in  its 
diagonal  position,  is  withdrawn  from  the  parts,  and  the  distance  between  the  two 
extremities  ascertained  by  the  scale. 

Having  noted  the  latter,  the  vice  is  unfastened,  and  the  two  extremities  of  the 
callipers  brought  together.  Then,  the  fore  and  middle  fingers  of  the  left  hand 
are  again  introduced  into  the  vagina  behind  the  left  ilio-pectineal  eminence,  as 
also  the  extremity  of  the  vaginal  branch  with  its  concavity  forward;  the  branch 
is  next  grasped  with  the  left  hand,  and  the  little  finger  introduced  at  the  same 
time  into  the  ring  of  the  hook.  The  thumb,  fore,  and  middle  fingers  of  the 
right  hand  replace  the  button  of  the  external  branch  upon  the  mark  over  the 
left  ilio-pectineal  eminence,  whilst  the  ring  finger  presses  upon  the  lever  of  the 
vice.  The  same  precaution  should  be  taken,  as  in  the  first  instance,  of  turning 
the  horizontal  screw,  if  necessary,  in  order  to  withdraw  the  instrument,  and  to 
return  it  to  its  place,  for  the  purpose  of  measuring  the  new  distance  between  the 
extremities.  The  subtraction  of  this  quantity  from  the  other  gives  the  dimen- 
sions required. 

The  right  sacro-pectineal  distance  is  ascertained  in  the  same,  way,  except  that 
the  fingers  of  the  right  hand  are  then  introduced  into  the  vagina,  the  instrument 
being  held  in  the  left  hand. 

Finally,  the  measurement  of  the  transverse  diameter  of  the  superior  strait  is 
accomplished  in  nearly  the  same  manner.  The  callipers  being  prepared  as  usual 
and  held  in  the  right  hand,  two  fingers  of  the  left  hand  in  a  state  of  forced  supi- 
nation, the  thumb  being  directed  downwards,  are  carried  to  the  right  side  of  the 
pelvis.  The  convexity  of  the  vaginal  branch  is  directed  toward  that  point,  and 
held  there  by  the  pressure  of  the  introduced  fingers,  and  by  the  left  thumb, 
which  is  engaged  in  the  hook.  The  free  hand  conducts  the  external  branch 
beneath  the  left  thigh,  which  is  raised  for  the  purpose,  and  places  it  upon  the 
mark  made  upon  the  corresponding  hip.  The  ring  finger  of  the  right  hand  fixes 
the  instrument  in  its  transverse  position  by  pressing  upon  the  lever  of  the  vice, 
and  the  distance  between  the  extremities  is  measured  by  the  scale  after  the 
extraction. 

To  make  the  second  application,  the  vice  is  relaxed,  and  the  external  branch 
elongated  beyond  the  extremity  of  the  vaginal  one ;  then,  the  fore  and  middle 
fingers  of  the  left  hand,  are  placed  in  the  genital  organs  on  the  left  side  of  the 
pelvis.  The  extremity  of  the  vaginal  branch  is  conducted  thither  by  the  right 
hand,  and  kept  there  by  the  left  hand,  the  little  finger  of  which  is  inserted  in 
the  ring  of  the  hook.  The  external  branch  is  finally  directed  by  the  free  hand 
beneath  the  left  thigh  upon  the  hip  of  the  same  side,  and  fixed  as  usual.  The 
horizontal  screw  is  next  turned  for  the  purpose  of  withdrawing  the  pelvimeter. 
When  restored  to  its  place,  the  distance  between  the  extremities  is  again  taken, 
and  this  subtracted  from  the  first  measurement,  gives  the  length  of  the  transverse 
diameter. 

37 


578  DYSTOCIA. 

The  diameters  of  the  excavation  maybe  measured  in  the  same  manner;  it 
being  only  necessary  to  take  the  precaution  to  mark  spots  around  the  pelvis  be- 
tween the  limits  of  the  superior  and  inferior  straits. 

But,  after  all,  the  hand  of  an  accoucheur,  accustomed  to  practise  the  touch,  is 
certainly  the  best  and  most  satisfactory  of  all  pelvimeters ;  for,  with  the  excep- 
tion of  a  few  rare  cases,  in  which  I  would  give  the  preference  to  the  instrument 
last  described,  it  is  always  possible  to  ascertain  exactly  by  it  the  external  form  of 
the  pelvis,  and  also,  by  its  introduction  into  the  vagina,  the  perfect  or  defective 
conformation  of  the  cavity. 

By  the  exterior  palpation,  we  are  enabled  to  learn  the  external  characters  of 
the  pelvis,  to  find  out  what  interval  exists  between  the  two  iliac  crests,  and  to 
measure  the  depth  of  the  anterior,  the  posterior,  and  the  lateral  walls  of  the 
pelvis ;  and  this  might  possibly  be  all-sufl&cient ;  although,  in  our  opinion,  it  is 
better  to  resort  to  the  callipers  of  Baudelocque  for  the  external  mensuration. 

It  is  more  particularly  in  the  appreciation  of  the  dimensions  of  the  cavity,  the 
straits,  and  the  excavation,  that  the  hand  introduced  into  the  parts  serves  as  a 
sure  and  faithful  guide.  It  is  not  even  necessary  to  pass  the  whole  hand  into 
the  vagina,  for  the  introduction  of  one  or  two  fingers  is  usually  quite  sufiicient ; 
in  fact,  we  ought  to  be  satisfied  with  this,  when  the  woman  is  not  in  labor,  since 
the  entrance  of  the  entire  hand  would  often  prove  very  painful.* 

'  It  is  a  great  mistake,  says  M.  Guillemot,  to  suppose  that  it  is  possible  to  measure  the 
length  of  the  sacro-pubic  diameter,  by  the  introduction  of  a  single  finger  into  the  vagina. 
This  result  has  never  been  effected  when  the  diameter  has  exceeded  two  and  a  half  or  three 
inches  in  length ;  and  the  dimensions  of  this  strait  can  only  he  correctly  obtained  by  using 
the  whole  hand. 

Like  M.  Guillemot,  we  believe  that  the  hand  should  be  introduced,  whenever  this  can  be 
done  without  causing  too  much  suffering  to  the  patient;  but  we  have  elsewhere  stated  that 
this  was  often  very  painful,  even  at  the  moment  of  labor ;  and  we  will  add,  that  at  any  other 
period  it  would  appear  useless,  since  the  finger  alone,  by  depressing  the  perineum,  might 
measure  as  far  as  three  and  a  half  inches,  unless  there  was  an  unusual  resistance  at  this 
part,  and  beyond  this  a  natural  delivery  is  possible;  or,  at  least,  if  the  intervention  of  art 
should  become  necessary,  it  could  always  be  terminated  favorably  to  the  lives  both  of  the 
mother  and  child;  and,  therefore,  nothing  need  be  done  until  the  time  of  parturition. 

During  labor,  says  M.  Velpeau,  we  can,  if  necessary,  introduce  the  entire  hand  into  the 
vagina ;  the  thumb  and  index  finger  are  then  separated,  so  as  to  place  the  one  on  the  sacro- 
vertebral  angle,  and  the  other  behind  the  pubis;  the  hand  is  withdrawn  while  in  this  posi- 
tion, and,  by  the  aid  of  a  measure,  the  dimensions  of  the  sacropubic  diameter  are  deter- 
mined within  one  or  two  lines.  I  have  sometimes  used  the  index  and  middle  fingers,  car- 
ried high  up  into  the  vagina,  with  advantage ;  and  then,  after  having  separated  them  as 
much  as  possible,  and  placed  their  extremities  on  the  diameter  that  is  to  be  measured,  two 
fingers  of  the  other  hand  are  inserted  between  their  bases,  to  prevent  them  from  changing 
their  relations  while  being  withdrawn  from  the  woman's  parts.  But  these  directions,  given 
by  IM.  Velpeau,  appear  to  us  impracticable  at  the  superior  strait,  and  equally  so  as  regards 
the  bis-ischiatic  interval. 

Ramsbotham's  process  resembles  nearly  Velpeaus.  He  introduces  the  fore  and  middle 
fingers  into  the  excavation;  the  bent  extremity  of  the  forefinger  is  applied  closely  against 
the  symphysis  pubis  and  the  end  of  the  strongly-extended  middle  finger  endeavors  to  reach 
the  sacro-vertebral  angle ;  then  withdrawing  the  fingers  in  the  same  posili(»i,ihe  space  between 


MALFORMATIONS     OF     THE     PELVIS.  579 

The  following  is  the  proper  mode  of  using  the  finger :  the  index  having  been 
passed  into  the  vagina,  is  directed  upwards  and  backwards  towards  the  sacro- 
vertebral  angle,  which  is  easily  recognized  by  its  promi- 
nence, and  by  the  transverse  depression  formed  at  the 
lurabo-sacral  articulation.  When  the  extremity  of  the 
finger  is  well  applied  against  this  part,  the  wrist  is  car- 
ried upward  and  forward,  until  the  radial  border  of  the 
finger  conies  into  contact  with  the  lower  margin  of  the 
symphysis  pubis;  when  the  index  of  the  other  hand 
marks  this  point  with  the  nail  (the  precaution  having 
previously  been  taken  to  separate  the  labia-externa  and 
the  nymphre) ;  the  finger  is  then  withdrawn  and  placed 
on  a  scale,  whereby  the  distance  from  the  sacro-vertebral 
angle,  upon  which  its  extremity  was  applied,  to  the  infe- 
rior part  of  the  symphysis  pubis,  is  very  correctly  ascer- 
tained. But  this  oblique  line  is  longer  than  the  antero-  xhe  mensuration  of  ihe 
posterior  diameter  of  the  upper  strait,  which  terminates     sacro-puUic  diameter  by  the 

P  1  •  •  PI  1        •  finger. 

in  iront,  on  the  posterior  superior  part  ot  the  symphysis ; 

consequently,  the  excess  must  be  deducted ;  and,  by  subtracting  four  or  five  lines 
for  a  large  pelvis,  and  three  to  four  for  a  small  one,  we  shall  have  very  nearly 
the  extent  of  the  sacro-pubic  interval.  With  regard  to  the  exact  number  of  lines 
to  be  deducted,  the  attention  should  further  be  directed  to  the  thickness,  the 
length,  and  the  more  or  less  marked  obliquity  of  the  symphysis;  which  circum- 
stances can  easily  be  determined  by  the  touch. 

The  finger  introduced  into  the  parts  will  also  be  able  to  appreciate  the  extent 
of  the  antero-posterior  diameter  of  the  excavation ;  for  it  can  very  readily  pass 
over  the  whole  front  surface  of  the  sacrum  ;  and,  consequently,  can  judge  whether 
its  anterior  concavity  is  augmented  or  diminished. 

Lastly,  its  extremity  being  applied  against  the  point  of  the  coccyx,  the  accou- 
cheur should  again  elevate  his  wrist  until  the  radial  border  of  the  hand  is  arrested 
by  the  lower  part  of  the  symphysis ;  then,  marking  this  point  with  the  other 
forefinger,  he  should  withdraw  the  hand  and  apply  it  to  a  graduated  scale,  and 
he  can  thus  ascertain  very  correctly  the  extent  of  the  coccy-pubic  diameter;  fur- 
ther, by  pressing  gently  on  the  point  of  this  bone,  he  can  judge  very  readily  of 
the  degree  of  mobility  in  the  sacro-coccygeal  articulation.  In  cases  of  deformity 
caused  by  the  excessive  length  or  unusual  obliquity  of  the  pubic  symphysis,  the 
direction  of  the  vulvar  opening  will  be  so  much  changed  as  to  attract  attention ; 
it  being  then  situated  much  more  posteriorly  than  in  well-formed  women. 

Although  the  results  furnished  by  the  touch  are  perfectly  satisfactory  as  re- 
gards the  antero-posterior  diameters,  it  is  far  otherwise  with  the  transverse  and 

their  extremities  is,  he  says,  to  be  measured  by  a  rule  or  a  pair  of  compasses.  He  states 
that  this  process  has  the  advantage  of  giving  the  exact  dimensions,  even  when  the  head  is 
engaged  in  the  excavation,  since  one  finger  can  be  passed  behind  it  and  the  other  before  it. 
(Obstetric  Med.  and  Surg.,  p.  ]8.)  We  consider  this  procedure  quite  as  unavailable  as  that 
recommended  by  M.  Velpeau. 


580  DYSTOCIA. 

oblique  ones,  particularly  at  the  superior  strait ;  for  the  extent  of  these  can  only 
be  judged  of  approximately,  and  \ve  can  do  nothing  more  than  test  •with  the 
finger  the  dimensions  obtained  by  the  external  mensuration.  The  finger,  when 
entered,  is  to  be  carried  in  the  direction  of  those  diameters,  and  the  accuracy  of 
the  result  thereby  obtained  will  depend  on  the  experience  and  tact  of  the  accou- 
cheur. However,  we  shall  soon  have  occasion  to  be  more  explicit  on  this  point, 
by  extracting  from  the  works  of  MM.  Nsegole  and  Danyau  the  results  of  their 
researches. 

As  to  the  transverse  diameters  of  the  inferior  strait,  their  dimensions  can  evi- 
dently be  ascertained  by  the  aid  of  the  fingers. 

Again,  the  educated  finger  will  give  a  very  just  idea  of  the  length  of  the  sym- 
physis pubis,  the  spreading  and  height  of  the  pubic  arch,  the  depth  and  normal 
configuration  or  deviation  in  the  lateral  walls  of  the  excavation,  and  of  the  inward 
prominence  of  the  ischiatic  spine. 

The  existence  of  the  various  tumors  that  may  obstruct  the  pelvic  cavity,  or 
greatly  diminish  the  canal  intended  for  the  passage  of  the  child,  can  be  recog- 
nized by  the  finger  alone ;  for  it  can  detect  their  nature,  their  softness,  or  resist- 
ance, and  their  mobility,  or  adhesion  to  the  osseous  parietes,  or  to  the  soft  parts 
which  line  the  latter,  far  better  than  any  other  instrument.  But  during  parturi- 
tion, the  touch,  which  is  so  often  useful  at  other  times,  may  not  prove  adequate 
to  this  measurement ;  for,  if  the  contraction  is  not  very  extensive,  the  head,  after 
being  arrested  for  a  long  time,  may  finally  engage  at  the  upper  part  of  the  exca- 
vation, and  form  a  considerable  rounded  tumor  just  below  the  superior  strait, 
large  enough  to  prevent  the  finger  from  passing  up  to  the  sacro-vertebral  angle; 
and  if  the  sacrum  should  then  happen  to  be  strongly  pressed  backwards,  as  is 
most  commonly  the  ease,  so  that  the  antero-posterior  diameters  of  the  excavation 
and  of  the  inferior  strait  are  increased,  the  cause  of  the  head's  arrest  might  be 
misunderstood,  if  the  accoucheur  does  not  bear  in  mind  that,  before  engaging,  it 
remained  for  some  time  above  the  symphysis  pubis.  The  attention,  however,  will 
be  awakened,  if  the  finger,  in  traversing  the  anterior  surface  of  the  sacrum  from 
above  downward,  detects  the  absence  of  its  normal  curvature. 

Our  assertion,  that  the  accoucheur's  finger  is  the  most  perfect  of  all  instru- 
ments, was,  therefore,  well  founded,  though  its  importance  must  not  be  over- 
rated. In  fact,  many  practitioners  have  erred  in  declaring,  with  Madame  Lacha- 
pelle,  that  the  best  proof  of  a  good  conformation  of  the  pelvis,  is  the  impossibility 
of  i-eaching  the  sacro-vertebral  angle  with  the  finger.  Certain  others,  while 
admitting  the  imperfection  of  the  other  methods  of  exploration,  equally  err  in 
supposing  that  an  estimate,  correct  enough  to  guide  us  safely  in  practice,  will  be 
obtained  by  employing  them  simultaneously;  because,  there  are  some  cases  where 
the  best  known  methods  of  exploration  are  inadequate,  where  the  finger  cannot 
reach  the  promontory  of  the  sacrum,  and  yet  where  a  mutilation  of  the  foetus, 
and  sometimes  even  the  Cajsarean  operation  have  been  necessary. 

The  oblique-oval  pelvis  belongs  to  this  class;  and  M.  Naeg^le,  who  described 
it  with  .so  much  care,  after  having  experienced  the  inefficiency  of  the  means  of 
diagnosis  usually  employed,  has  made  some  researches,  with  the  view  of  over- 


MALFORMATIONS    OF    THE     PELVIS.  581 

coming  this  difficulty;  for  which  purpose,  he  has  taken  points  on  the  pelvis 
different  from  those  described  by  most  authors,  which  are  easily  accessible  and 
recognizable;  and  he  has  carefully  measured  the  distances  between  them  in  the 
normal  state,  as  already  pointed  out  (page  5G7,  Nos.  6,  7,  8,  9,  and  10).  "In 
forty-two  pelves  of  well-formed  females,  we  have  found,  says  he,  in  a  large  ma- 
jority of  cases,  but  little  or  no  difference  between  the  two  sides  of  the  same  pelvis, 
as  respects  the  above-mentioned  distances."  M.  Danyau,  responding  to  the  wish 
expressed  by  31.  Nfpgele,  has  repeated  those  researches  in  a  great  number  of 
livinsr  and  well-formed  women,  and  the  following  are  the  conclusions  at  which 
he  has  arrived,  namely,  that  in  eighty  females  it  appeared — 

1.  That  the  distance  from  the  tuber  ischii  of  one  side  to  the  posterior  superior 
spinous  process  of  the  opposite  ilium  was  the  same  on  both  sides  in  twenty-one 
persons ;  in  fifty-one,  the  difference  between  the  two  sides  was  from  one  to  three 
lines ;  and  in  eight  only  it  amounted  to  four,  five,  and  six  lines ;  whilst,  in  the 
oblique-oval  pelves,  the  smallest  difference  was  found  to  be  one  inch,  and  the 
greatest  two  inches. 

2.  That  the  distance  from  the  anterior  superior  spinous  process  of  one  side,  to 
the  posterior  superior  iliac  spine  of  the  other,  was  the  same  in  both  halves  of  the 
pelvis  in  twenty-two  females ;  in  fifty-one  there  was  a  difference  of  one  to  sis 
lines  between  the  two;  and  in  seven  women  only  was  this  difference  from  seven 
to  eleven  lines.  In  the  oblique-oval  pelvis,  the  smallest  difference  between  these 
sides  was  three-quarters  of  an  inch,  and  the  greatest  two  inches. 

3.  That  the  distance  from  the  spinous  process  of  the  last  lumbar  vertebra  to 
the  anterior  superior  iliac  spine,  was  the  same  on  both  sides,  in  twenty-nine  in- 
stances ;  in  fifty-one,  there  was  a  difference  of  one  to  seven  lines  between  the 
two.  But  in  the  oblique-oval  pelves,  the  least  difference  was  eight  lines,  and  the 
greatest  an  inch  and  a  third. 

4.  That  the  distance  from  the  trochanter  major  of  one  side  to  the  posterior 
superior  iliac  spine  of  the  opposite  one,  was  the  same  in  eighteen  cases ;  when 
measured  comparatively  on  the  two  sides  of  the  pelvis,  a  difference  of  one  to  six 
lines  in  this  distance  was  found  in  fifty-seven ;  and  in  five  only  it  ranged  from 
seven  to  nine  lines;  whilst,  in  the  oblique-oval,  the  smallest  difference  was  half 
an  inch,  the  greatest  an  inch  and  a  half. 

5.  That  the  distance  from  the  lower  border  of  the  symphysis  pubis  to  the  pos- 
terior superior  iliac  spine,  was  the  same  on  both  sides  in  thirty-two  women ;  in 
forty-sis,  the  difference  between  the  two  halves  of  the  pelvis,  in  this  respect,  was 
from  one  to  six  lines;  and  in  two,  from  eight  to  nine  lines;  but,  in  the  oblique- 
oval  pelves,  the  least  difference  in  this  distance,  taken  on  both  sides,  was  seven 
lines,  the  greatest  one  inch. 

It  will,  therefore,  appear  that,  by  a  proper  degree  of  care,  and  the  aid  of  the 
measurements  just  given,  we  would  be  able  to  recognize  the  deformity  in  ques- 
tion, by  measuring  the  aforesaid  distances  on  each  side,  and  then  comparing  the 
results  obtained  from  both. 

But  there  is  yet  another  method  for  detecting  the  oblique-oval  pelvis,  says  M. 
Naegele ;  that  is,  if  a  woman,  having  a  well-formed  pelvis,  be  placed  with  her 


582  DYSTOCIA. 

back  against  any  vertical  plane,  as  a  wall,  for  instance,  so  that  the  shoulders  and 
upper  part  of  the  buttocks  be  in  contact  with  this  plane,  and  then  two  plumb- 
lines  be  dropped,  the  one  from  the  point  corresponding  to  the  spinous  process  of 
the  first  sacral  or  the  last  lumbar  vertebra,  and  the  other  from  the  lower  border 
of  the  symphysis  pubis,  it  will  be  found  that  the  latter  nearly  or  quite  covers  the 
first ;  that  is  to  say,  that  a  line  perpendicular  to  the  wall  would  intersect  both  of 
these  plumbs  at  a  right  angle;  but  this  is  not  the  case  in  the  oblique-oval  pelvis. 
In  fact,  one  of  its  essential  characters  is,  that  the  symphysis  pubis  is  deviated 
towards  one  side,  and  the  sacrum  towards  the  other,  whence  the  middle  of  the 
pubic  symphysis  is  opposite  to  the  anterior  sacral  foramina,  or  even  to  the  sacro- 
iliac articulation,  on  the  non-anchylosed  side.  Consequently,  when  a  woman, 
whose  pelvis  is  thus  deformed,  assumes  the  position  just  indicated,  and  the 
plumb-lines  are  dropped  at  the  designated  points,  the  operator  will  find,  by  bring- 
ing his  view  perpendicular  to  the  wall,  that  the  line  placed  in  front  does  not 
cover  the  posterior  one ;  for  the  latter  will  deviate  to  the  right  or  the  left,  accord- 
ing to  the  anchylosed  side,  and  this  deviation  will  be  the  more  considerable,  as 
the  pelvis  is  the  more  deformed.     (^M.  Danyau's  Translation.) 


ARTICLE    V. 

INDICATIONS    PRESENTED   BY   THE   DEFORMITIES    OF   THE   PELVIS, 

It  is  not  our  intention  to  treat,  in  this  place,  of  the  measures  that  it  would, 
perhaps,  be  advisable  to  employ  for  the  purpose  of  remedying  deformities  of  the 
pelvis  when  they  exist,  for  this  subject  belongs  exclusively  to  the  surgery  of  the 
osseous  system ;  besides  which,  the  various  mechanical  and  gymnastic  means 
hitherto  used  for  correcting  the  deformities  of  the  skeleton  have  had  no  efficacy 
in  changing  the  form  of  the  pelvis.  But,  if  nothing  can  be  done  by  the  physi- 
cian to  cure,  he  is,  at  least,  not  wholly  destitute  of  resources  where  there  is  still 
a  possibility  of  preventing  such  deformities.  Thus,  during  the  earlier  years  of 
life,  especially,  he  ought  to  watch  over  all  the  circumstances  that  might  influ- 
ence the  regular  development  of  the  skeleton,  with  the  most  tender  solicitude ; 
he  should  relieve  rachitic  children  from  constriction  or  pressure  of  every  kind, 
which  might,  in  their  variable  attitudes,  modify  the  pelvic  circumference;  they 
ought  to  be  left  in  the  recumbent  position  as  much  as  possible ;  the  nurse  must 
not  always  have  the  child  in  her  arms,  as  she  is  very  apt  to  have,  if  not  cau- 
tioned; and  great  care  is  requisite  not  to  permit  them  to  walk  too  soon,  not, 
indeed,  until  their  bones  have  acquired  a  proper  degree  of  solidity;  and  even 
then  it  should  be  by  degrees,  and  only  in  proportion  as  their  strength  increases. 
We  must  not  yield,  says  M.  Bouvier,  to  the  chimerical  fears  of  augmenting  the 
debility  by  depriving  children  of  a  necessary  exercise ;  for  repose,  on  the  contrary, 
is  much  better  suited  to  that  state  of  languor  which  they  generally  exhibit;  and, 
besides,  we  may  obtain,  by  passive  motion,  by  exposure  to  sunlight,  and  by  gene- 
ral movements  in  the  horizontal  position,  a  sufficient  compensation  for  the  state 
of  inaction  in  which  they  are  kept  during  a  part  of  the  day. 


MALFORMATIONS    OF    THE    PELVIS.  583 

The  indications  presented  by  the  deformities  in  the  pelvis,  considered  only 
with  regard  to  the  unfavorable  influence  they  may  have  upon  the  puerperal  func- 
tions, will  evidently  vary  with  the  degree  of  deformity.  When  studying  this 
influence,  we  classified  all  the  malformed  pelves  in  three  categories,  namely,  all 
those  having  three  and  three  quarter  inches,  at  the  least,  in  their  smallest  dia- 
meter, were  placed  in  the  first ;  in  the  second,  we  have  included  those  presenting 
two  and  a  half  inches,  at  least;  and  in  the  third,  those  whose  smallest  dimen- 
sions are  under  two  and  a  half  inches :  and,  following  the  example  of  Professor 
Dubois,  we  shall  still  preserve  this  division  in  the  study  of  the  indications  offered 
by  the  deformities.' 

§  1.  What  is  to  be  done  when  the  Contraction  is  such,  that  the 
Pelvis  measures  at  least  three  and  three  quarter  Inches  in  its 

SMALLEST   DiAMETER  ? 

In  such  a  case,  the  child  may  evidently  present  either  by  the  vertex,  the  pelvic 
extremity,  the  face,  or  the  trunk. 

A.  Where  the  Child  Presents  hy  the  Vertex. — We  have  elsewhere  stated  that  a 
spontaneous  delivery  is  possible  under  such  circumstances ;  and,  consequently, 
that  the  wisest  course  is  to  wait  and  trust  to  the  efforts  of  natute.  But,  where 
the  uterine  contractions  are  exerted  in  vain  for  a  long  time  after  the  membranes 
are  ruptured,  and  the  amniotic  waters  are  partially  discharged  without  the  head 
making  any  progress,  an  application  of  the  forceps  is  the  only  remedy  to  which  we 
can  resort.^  But  the  exact  moment  for  the  employment  of  this  measure  is  to  be 
determined  with  greater  precision.  As  a  general  rule,  we  may  wait  six,  seven, 
or  even  eight  hours  after  the  membranes  give  way,  and  after  the  os  uteri  is  fully 
dilated ;  and  then,  if  energetic  contractions  have  been  uselessly  exerted  during 
all  this  time  to  overcome  the  obstacle,  it  will  be  necessary  to  interfere,  and  to 
apply  the  instrument ;  though  it  will  be  advisable  to  act  a  little  more  promptly 
where  the  head,  after  having  been  engaged  for  some  time  in  the  excavation,  is 
arrested  by  a  contraction  of  the  inferior  strait ;  and  the  same  would  be  true,  if 
this  strait  were  regularly  formed,  and  the  arrest  of  the  head  were  dependent  on  a 
feebleness  of  the  uterine  contractions  occasioned  by  the  previous  efforts  on  the 
part  of  the  organ  to  force  it  through  the  contracted  superior  strait.  It  is  un- 
necessary to  add,  that  if  any  accident  whatever,  grave  enough  to  endanger  the 
health  of  the  mother  or  the  life  of  the  child,  should  occur  during  the  labor,  it 

'  I  am  happy  to  state,  that  most  of  the  following  considerations  and  practical  views  are 
deduced  from  the  excellent  thesis  which  M.  P.  Dubois  sustained  with  so  much  credit  in  the 
concowrs,  at  the  close  of  which  he  was  nominated.  I  congratulate  myself  on  being  the  first 
to  give  publicity  to  a  work  that  is,  unfortunately,  but  too  little  known. 

*  It  is  highly  important  not  to  confound  in  practice  the  constantly-increasing  tumefaction 
of  the  hairy  scalp  with  an  actual  descent  of  the  head.  For,  when  the  labor  is  retarded,  the 
sero-sanguineous  tumor,  formed  by  the  soft  parts,  continually  augments  in  volume,  and  its 
summit  gets  nearer  and  nearer  to  the  vulva;  and,  therefore,  unless  the  precaution  is  taken  to 
get  an  osseous  portion  of  this  region,  as  a  point  of  departure,  the  accoucheur  might  suppose 
that  the  head  was  traversing  the  excavation,  and  approaching  the  inferior  strait,  when,  in 
reality,  it  did  not  move. 


684  DYSTOCIA. 

would  demand  a  more  prompt  intervention  of  art.  Most  generally,  the  frequently- 
repeated  auscultation  of  the  pulsations  of  the  heart  would  be  satisfactory  as  to 
the  child's  condition,  though  even  here  only  a  certain  degree  of  confidence  can 
be  reposed  in  this  sign. 

.  B.  Where  the  Child  Presents  hy  the  Pelvic  Extremity. — When  describing  the 
mechanism  of  natural  labor,  we  expressly  recommended  that  no  traction  should  be 
made  on  the  pelvic  extremity  in  breech  presentations,  with  the  view  of  avoiding 
the  straightening  out  of  the  arms  and  an  extension  of  the  head ;  and  we  still 
insist  on  the  same  precept  here.  Nevertheless,  in  the  case  before  us,  if  the 
largest  part  of  the  trunk  is  delivered,  and  the  expulsion  of  the  head  is  unusually 
delayed,  it  would  be  proper  to  hasten  the  termination  of  the  labor  by  a  moderate 
traction  on  the  body;  for  such  attempts,  if  well  conceived  and  well  directed  in 
the  line  of  the  pelvic  axis,  would  prove  sufficient  in  most  cases  to  accomplish  the 
delivery.  If,  however,  they  are  ineffectual,  it  will  then  be  necessary  to  apply 
the  forceps. 

C.  TF/icre  the  Child  Presents  hy  the  Pace. — Although  face  presentations  may 
terminate  naturally  in  the  majority  of  cases  where  the  pelvis  is  well  formed,  it 
is  not  the  less  true,  as  elsewhere  demonstrated  (pp.  442  and  478),  that  the  labor  is 
somewhat  more  painful  to  the  mother,  and  is  besides  more  dangerous  for  the 
child  than  in  others.  If,  therefore,  these  difficulties,  resulting  from  the  position 
itself,  are  superadded  to  those  which  exist  as  a  necessary  consequence  of  the  con- 
traction, there  can  be  no  doubt  that  a  delivery  left  entirely  to  nature,  would  be 
attended  with  a  very  considerable  risk  to  the  fcetus.  Under  such  circumstances, 
M.  P.  Dubois  recommends  the  conversion  of  the  face  position  into  one  of  the  vertex, 
by  flexing  the  head,  and  then  the  application  of  the  forceps,  if  the  uterine  eflForts 
remain  fruitless  after  the  change.  It  appears  to  us  that  this  cephalic  version 
would  be  quite  as  difficult  as  the  pelvic,  if  attempted  long  after  the  membranes 
are  ruptured,  and  we  should  give  preference  to  the  latter,  which,  generally,  would 
enable  us  to  dispense  with  the  use  of  the  forceps.     (See  Forceps.) 

D.  Where  the  Child  Presents  hy  the  Trunk. — If  the  contraction  is  discovered 
before  the  membranes  are  ruptured  or  very  shortly  after,  and  the  foetus  is  very 
movable,  we  should  endeavor  to  convert  the  presentation  of  the  shoulder  into  one 
of  the  vertex,  and  then  leave  the  expulsion  to  the  efforts  of  the  womb;  but  after 
the  waters  are  discharged,  the  contraction  of  the  organ  renders  the  introduction 
of  the  hand  and  the  cephalic  version  so  difficult,  that  I  consider  turning  by  the 
feet  much  easier  and  less  dangerous. 

The  pelvic  version,  in  the  case  before  us,  is  attended  with  some  peculiarities 
that  ought  to  be  mentioned.  For  instance,  where  an  undue  development  of  the 
sacro-vertebral  angle  is  the  cause  of  the  narrowing,  it  often  happens,  as  before 
shown,  that  the  base  of  the  sacrum  is  turned  a  little  to  the  one  or  the  other  side 
at  the  same  time  that  it  is  projected  forward,  thereby  constricting  one  half  of 
the  pelvis  much  more  than  the  other ;  and  hence,  in  performing  the  evolution  of 
the  fujtus,  and  drawing  on  its  pelvic  extremity,  under  such  circumstances,  it 
would  evidently  be  requisite  to  turn  its  posterior  plane  towards  the  larger  half  of 


MALFORMATIONS     OF    THE     PELVIS. 


5k 


the  pelvic,  so  that,  when  the  head  presented  at  the  superior  strait,  its  large  occi- 
pital extremity  would  correspond  to  the  non-retracted  side. 

It  was  stated  above  that  when  the  foetus  presented  by  its  flexed  cephalic  ex- 
tremity, it  would  be  necessary  to  apply  the  forceps,  if  the  uterine  efforts  were 
incapable  of  terminating  the  labor;  but  the  particular  variety  of  malformation 
that  we  are  now  treating  of  may  modify  the  rule  laid  down,  which  was  perhaps 
a  little  too  absolute ;  for,  in  this  case,  the  position  of  the  head  must  greatly  in- 
fluence the  accoucheur's  determination.  Let  us  take,  for  example,  a  pelvis  whose 
sacro-vertebral  angle  while  projecting  forward  is  turned  to  the  right,  so  as  to 
diminish  the  sacro-cotyloid  interval  very  considerably  on  this  side ;  now,  the 
intervention  of  art  being  judged  necessary,  if  the  head  is  placed  in  the  left 
occipito-iliac  position,  an  application  of  the  forceps  will  be  the  only  practicable 
measure  j  whereas,  on  the  contrary,  if  the  occiput  is  directed  to  the  mother's 
right,  we  should  preferably  resort  to  the  pelvic  version.  This  last  operation,  by 
converting  a  second  vertex  position  into  the  first  of  the  feet,  would  haye  the  ad- 
vantage of  bringing  the  great  occipital  extremity  of  the  head  to  the  largest  side 
of  the  pelvis,  and  would  thus  place  the  ftetus  in  a  much  more  favorable  position. 
The  delivery  has  frequently  been  rendered  comparatively  easy  by  the  pelvic 
version  when  resorted  to  under  such  conditions ;  and  M.  Velpeau  relates  a  case 
which  he  terminated  successfully  by  this  manojuvre,  though  other  practitioners 
had  deemed  craniotomy  to  be  indispensable  in  a  former  labor  of  the  same  woman. 

The  recommendations  just  made  have  the  double  object  of  sparing  the  mother 
from  useless  suffering,  and  more  particularly  of  relieving  the  foetus  from  the 
danger  it  would  incur  from  a  prolonged  labor.  Whence,  it  is  evident,  that  the 
accoucheur's  course  will  be  somewhat  diff'erent  in  those  cases  where  there  is  a 
cei'tainty  that  the  child  is  not  living ;  for,  having  nothing  to  fear  on  its  account, 
he  might  accord  a  much  longer  time  to  the  uterine  contractions,  especially  as  the 
head,  which  is  then  softened  and  reducible,  contributes  far  more  to  an  easy  ex- 
pulsion than  under  other  circumstances.  Consequently,  he  ought  not  to  interfere 
in  such  cases,  until  he  has  ascertained  positively,  by  a  proper  delay,  the  absolute 
inefiiciency  of  the  natural  forces. 

The  child's  death  may  also  modify  the  precept  above  given,  in  the  trunk  pre- 
sentations, since  the  cephalic  version  was  only  recommended  because  it  is  more 
advantageous  for  the  infant;  therefore,  after  its  death,  the  pelvic  version  would 
be  preferred  as  being  less  painful  to  the  mother. 

§  2.  What  is  to  be  done  when  the  Degree  of  Contraction  is  such 

THAT  THE  PeLVIS  MEASURES  THREE  AND  THREE-QUARTER  INCHES  AT  THE 
MOST,  AND  TWO  AND  A  HALF  InCIIES  AT  THE  LEAST,  IN  ITS  SMALLEST  DIA- 
METER ? 

If  the  foetus  dies  before  or  during  the  labor,  and  the  uterine  contractions  are 
ineffectually  prolonged,  we  should,  doubtless,  prevent  the  dangers  the  mother 
might  undergo  from  the  delay,  by  resorting  to  embryotomy,  and  the  application 
of  the  ordinary  forceps,  or  even  of  the  embryotomy  forceps. 

Again,  if,  when  the  accoucheur  is  summoned  to  the  patient,  the  membranes 


586  DYSTOCIA. 

have  been  ruptured  for  some  time,  and  the  waters  are  partially  or  -wholly  evacu- 
ated; if  the  uterine  contractions  are  exerted  on  the  child's  body  alone,  or  re- 
peated attempts  at  extraction  have  been  made  without  success ;  if,  in  a  word, 
the  child's  life  has  been  compromised,  either  by  the  length  of  the  labor  or  the 
useless  intervention  of  art,  in  all  such  cases  it  may  be  regarded,  though  still 
living,  as  non-viable,  and  embryotomy  is  considered  .by  most  modern  accoucheurs 
to  be  the  only  proposable  measure.  We,  ourselves,  held  this  opinion  for  a  long 
time,  but  being  rather  less  fearful  of  the  probable  consequences  of  pelvic  version 
in  contractions  of  the  pelvis,  we  now  think,  that  so  long  as  any  chance  remains 
in  favor  of  the  child,  the  latter  operation  should  first  be  attempted.  Craniotomy 
can  always  be  had  recourse  to,  if,  after  the  disengagement  of  the  trunk,  it  should 
be  found  impossible  to  extract  the  head. 

But  where  the  degree  of  contraction  alluded  to  is  detected  at  the  commence- 
ment of  the  labor,  before  the  membranes  are  ruptured,  and  consequently  at  a 
time  when  there  is  no  reason  for  supposing  that  the  viability  of  the  foetus  has 
been  compromised,  what  ought  to  be  done  ? 

Following  the  example  of  M.  P.  Dubois,  we  shall  here  admit  a  further  sub- 
division into  two  classes,  namely,  one,  where  the  pelvis  has  an  extent  of  three 
and  three-quarter  inches  at  the  most,  and  three  inches  at  the  least;  and  the 
other,  where  it  has  but  three  inches  at  the  most,  and  two  and  a  half  inches  at 
the  least,  in  its  smallest  diameter. 

In  the  former  case,  after  having  waited  for  all  that  can  reasonably  be  expected 
from  the  uterine  contractions,  the  forceps  are  to  be  applied  when  the  vertex  pre- 
sents favorably,  and  if  moderate  tractions  are  found  to  be  insufficient,  the  instru- 
ment should  be  withdrawn,  and  pelvic  version  attempted,  in  the  hope  of  extract- 
ing a  living  child.  (See  Art.  Forceps,  Appreciation.)  Should  this  attempt  prove 
fruitless,  the  contractions  may  be  allowed  to  continue  for  an  hour  or  two  longer, 
and  if  these  are  ineffectual,  the  instrument  is  again  to  be  had  recourse  to.  If  no 
favorable  result  follows  this  second  application  of  the  forceps,  we  are  in  the  con- 
ditions above  mentioned,  and  the  life  of  the  child  being  certainly  compromised, 
we  are  authorized  in  preferring  craniotomy  to  an  operation  which  might  prove 
disastrous  to  the  mother ;  I  allude  to  symphyseotomy  or  the  Csesarean  operation. 

But  should  the  presentation  of  the  vertex  be  an  inclined  one,  or  should  the 
child  present  by  the  face,  trunk,  or  breech,  turning  is  to  be  preferred.  (See  Ap- 
preciation of  the  Forceps.) 

When  the  pelvic  diameters  afford  but  from  two  and  three-quarters  to  three 
and  a  quarter  inches,  the  indications  to  be  fulfilled  remain  the  same ;  but  the 
difficulty  experienced  in  executing  the  manoeuvres,  leaves  no  alternative  but  a 
bloody  operation. 

The  various  degrees  of  contraction,  when  ascertained  long  before  the  termina- 
tion of  pregnancy,  present  new  indications  to  the  practitioner;  these,  in  fact,  are 
the  cases  in  which  the  induction  of  premature  labor  is  to  be  resorted  to.  The 
recommendation  to  subject  pregnant  women  with  contracted  pelves  to  a  restricted 
diet  and  repeated  bloodletting  during  gestation,  applies  also  to  the  degree  of 
narrowing  under  consideration,  and  more  especially,  to  those  cases  in  which  the 


MALFORMATIONS     OF    THE    PELVIS.  587 

smallest  diameter  amounts  to  at  least  three  and  a  quarter  inches.     The  value  of 
these  two  methods  will  be  discussed  hereafter. 

§  3.  What  is  to  be  done  when  the  Dimensions  of  the  Pelvis  are 
under  two  and  a  half  inches? 

If  the  child  is  living,  we  have,  evidently,  only  to  choose  between  the  Caesarean 
operation  and  the  mutilation  of  the  fcetus,  for  its  spontaneous  or  artificial  expul- 
sion is  here  physically  impossible.  (See  Caesarean  Operation.)  But  if  it  is  dead, 
or  if,  in  con.sequence  of  the  duration  of  the  labor,  and  the  repeated  attempts  at 
extraction  which  have  been  made,  there  is  reason  to  believe  that  its  viability  is 
so  compromised  that  it  might  be  considered  as  incapable  of  surviving  after  its 
birth,  the  indications  will  vary  according  to  the  degree  of  contraction. 

Where,  under  these  latter  circumstances,  the  pelvis  offers  two  inches  at  least 
in  its  smallest  diameter,  and  it  is  yet  possible  to  hope,  that,  by  reducing  the  size 
of  the  parts  by  craniotomy,  the  delivery  can  be  accomplished  without  subjecting 
the  mother  to  any  very  serious  dangers,  the  mutilation  of  the  foetus  should  be 
resolved  on,  and  its  extraction  effected  by  aid  of  the  embryotomy  forceps.  But 
when  the  diameters  are  less  than  two  inches,  we  can  no  longer  think  of  extracting 
the  child  by  the  natural  passages ;  and  the  Caasarean  operation  is  then  alone  ad- 
missible. The  extraction  of  the  base  of  the  cranium,  after  the  perforation  of  its 
vault,  and  the  evacuation  of  its  cavity,  requires  such  numberless  gropings  and 
violent  efforts,  such  repeated  and  grievous  pressures  and  distensions,  that  the 
chances  for  the  mother's  safety  after  these  painful  attempts,  which  are  sometimes 
made  without  any  benefit,  are  not  more  favorable  than  those  which  follow  the 
Caesarean  operation. 

In  our  remarks,  thus  far,  we  have  supposed  that  the  child  always  presented  by 
its  cephalic  extremity  j  but,  in  order  to  fill  up  the  outline  we  have  traced,  it  is 
now  necessary  to  point  out  what  must  be  done  when  the  pelvic  extremity  pre- 
sents, the  pelvis  affording  two  and  a  half  inches  at  the  most.  Under  such  cir- 
cumstances, the  head  still  adhering  to  the  trunk  after  the  escape  of  the  latter,  or 
entirely  separated  from  it  by  decapitation,  may  become  arrested  above  the  supe- 
rior strait.  If,  then,  the  least  diameter  of  the  pelvis  amounts  to  two  inches, 
craniotomy,  and  the  application  of  the  embryotomy  forceps,  will  evidently  be 
indicated.  But  if  the  contraction  be  still  greater,  it  would  be  necessary,  after 
having  diminished  the  volume  of  the  parts,  and  attempted  in  vain  every  effort  at 
extraction  compatible  with  the  mother's  safety,  it  would  be  necessary,  I  repeat, 
to  separate  the  head  from  the  trunk,  by  dividing  the  neck,  and  to  abandon  its 
expulsion  entirely  to  nature ;  for,  notwithstanding  all  the  dangers  to  which  the 
woman  would  then  be  exposed,  this  would  be  better  than  the  Caesarean  operation, 
performed  after  the  almost  total  contraction  of  the  womb. 

If  nothing  has  hitherto  been  said  concerning  a  faulty  direction  of  the  axis  of 
the  pelvis,  it  was  only  because,  like  Professor  Naegele,  we  do  not  attach  to  this 
particular  variety  of  defective  conformation  all  the  importance  that  Lobstcin  and 
many  other  accoucheurs  have  attributed  to  it.  The  degree  of  inclination  of  the 
superior  and  the  inferior  straits  may  depart  widely  from  the  figure  before  given 


588  DYSTOCIA. 

as  expressing  tlie  average  normal  condition.  Thus,  the  plane  of  the  abdominal 
strait  may  be  so  inclined  downwards  as  to  be  sometimes  quite  vertical,  as  in  a 
woman  described  by  M.  Nasgele ;  while,  at  others,  there  is  no  inclination  at  all, 
being  then  almost  horizontal;  finally,  the  upper  part  of  the  symphysis  pubis  may 
be  more  elevated  than  the  sacro-vertebral  angle,  the  plane  being  inclined  from 
above  downwards,  and  from  before  backwards,  as  in  the  case  reported  by  M. 
Bello.  (^Transactions  Medicales,  t.  xiii,  p.  285.)  The  plane  of  the  inferior  strait 
may  present  the  same  ii-regularities  of  inclination ;  indeed,  the  direction  of  both 
straits  is  most  frequently  changed  at  the  same  time. 

But  excepting  some  inconveniences  which  the  woman  suffers  during  gestation, 
that  are  more  particularly  dependent  on  the  wrong  direction  of  the  uterus,  whose 
displacement  is  often  a  consequence  of  the  faulty  direction  of  the  axis  of  the 
superior  strait,  the  puerperal  functions  are  scarcely  troubled  by  the  anomaly  men- 
tioned ;  for,  although  this  abnormal  direction  of  the  pelvis  has  appeared  in  some 
few  cases  to  present  a  serious  obstacle  to  the  delivery,  it  was  only  because  it 
happened  to  coincide  with  a  deformity  of  the  bones,  and  a  contraction  of  the 
cavity.  The  facts  reported  by  Moreau  and  Bello,  when  carefully  examined,  fully 
confirm  the  second  part  of  this  proposition,  while  the  first  is  proved  by  the  curious 
observations  of  M.  Naes-ele. 


CHAPTER  11. 

OF  MALFORMATIONS  OF  THE  VULVA  AND  VAGINA. 

The  malformations  of  the  genital  parts  maybe  either  congenital  or  accidental ; 
but,  as  both  offer  very  similar  indications  for  treatment,  I  shall  include  them  in 
the  same  description.  In  treating  of  these,  we  shall  successively  take  up  the 
congenital  or  accidental  adhesion  of  the  labia  externa  and  interna;  the  persist- 
ence of  the  hymen  ;  contraction  and  rigidity  of  the  vulva  ;  the  partitions,  bands, 
and  cicatrices  that  may  exist  in  the  vagina;  and  the  narrowness  of  this  canal. 

§  1.  Adhesion  op  the  Greater  and  the  Lesser  Labia. 

This  may  exist  at  birth,  or  it  may  result  from  some  wound  or  ulceration,  the 
healing  up  of  which  has  not  been  properly  attended  to.  Denman  has  remarked 
that  .this  abnormal  union  is  quite  frequent  in  little  girls,  though  it  is  rarely  ob- 
served at  the  age  of  puberty,  as  the  free  and  constant  use  made  of  their  limbs, 
when  they  begin  to  walk,  most  probably  causes  a  spontaneous  separation.  This 
union,  when  congenital,  may  be  more  or  less  complete,  intimate,  or  resistant. 
When  resulting  from  an  accident,  it  is  never  perfect,  because  the  frecjuent  pas- 
sage of  the  urine  prevents  adhesion  from  taking  place  at  the  point  corresponding 
to  the  meatus  urinarius ;  and  the  discharge  of  the  menstrual  fluid,  when  the 


MALFORMATIONS     OF    THE    VULVA    AND    VAGINA.        589 

courses  come  on  before  the  cicatrization  is  completed,  likewise  prevents  the  adhe- 
sion of  the  labia  for  a  considerable  extent. 

§  2.  Persistence  of  the  Hymen. 

The  hj'nien  may  occasionally  persist  even  after  copulation,  and  thus  consti- 
tute an  obstacle  to  the  expulsion  of  the  child.  The  varieties  of  form  it  may 
exhibit  under  such  circumstances  were  pointed  out  in  the  anatomical  description 
of  this  membrane.  A  persistence  of  the  hymen  does  not  always  prevent  concep- 
tion, since  most  authors  relate  instances  in  which  they  were  obliged  to  divide  it 
at  the  time  of  labor  in  order  to  make  a  free  passage  for  the  child.  They  have 
even  detailed  examples  of  pregnant  women,  in  whom  a  second  hymen  was  found 
some  distance  above  the  first.  Again,  this  membrane  has  persisted  after  the 
delivery,  as  proved  in  a  case  observed  by  Meckel,  Sr.,  and  reported  by  Tolberg. 
A  woman,  after  having  expelled  a  foetus  of  five  months,  surrounded  by  all  its 
membranes,  still  preserved  her  hymen  intact,  circular,  and  tense. 

§  3.  Contraction  and  Rigidity  of  the  Vulva. 

The  rigidity  of  the  external  parts  of  generation,  which  is  frequently  observed 
in  women  who  do  not  become  pregnant  until  an  advanced  period  of  life,  as  also 
in  very  young,  muscular  girls,  who  are  somewhat  fat  and  of  a  plethoric  habit, 
often  causes  a  considerable  delay  in  the  progress  of  the  head  during  the  first 
labor.  Most  commonly,  however,  this  narrowness  and  natural  rigidity  give  way, 
and  the  parts  become  distended ;  but  this  distension  is  not  always  so  complete  as 
the  volume  ofrthe  head  demands ;  and  then  the  latter,  being  urged  on  by  the  vio- 
lence of  the  uterine  contractions,  breaks  down  the  resistance  before  it,  and  a 
laceration  of  the  posterior  vulvar  commissure  and  of  a  more  or  less  considerable 
portion  of  the  perineum  results.  In  certain  cases,  as  elsewhere  described,  the 
contraction  is  vainly  exerted  for  a  long  time  against  the  resistance  of  the  soft 
parts,  and  it  becomes  enfeebled  or  ceases  altogether ;  the  intervention  of  artificial 
measures  is  then  indicated,  at  first  to  restore  the  contraction  if  possible,  and  after- 
wards to  replace  it  by  moderate  tractions  with  the  forceps. 

In  cases  of  this  nature,  where  the  labor  had  been  abandoned  for  too  long  a 
time  to  the  resources  of  the  organism,  the  fourchette,  being  too  firm  to  yield,  has 
been  known  to  remain  intact;  while  the  perineum,  distended  beyond  measure, 
and  thereby  rendered  thinner,  was  perforated  at  its  centre,  and  the  child  ex- 
pelled through  an  accidental  opening,  bounded  in  front  by  the  posterior  commis- 
sure of  the  vulva,  and  behind  by  the  sphincter  ani  muscle.  At  the  present  day, 
this  fact  is  well  determined.  But  it  may  happen  that  the  perineum  is  perforated 
at  its  middle,  and  yet,  notwithstanding  this  accident,  the  foetus  pass  out  through 
the  natural  passage  :  this  is  particularly  apt  to  occur  when  the  accoucheur's  hand, 
being  forcibly  applied  on  these  parts,  endeavors  to  press  back  the  head  in  its 
normal  direction,  and  thus  replace  the  accustomed  resistance  of  the  pelvic  floor. 
Therefore,  it  does  not  follow  that  the  child  has  escaped  through  the  central  lace- 
ration of  the  perineum,  simply  because  such  an  opening  is  met  with  after  the 
delivery. 


590  DYSTOCIA. 

Even  when  every  precaution  is  taken,  there  are,  as  we  see,  cases  in  which 
extreme  smalhiess  of  the  vulva,  and  rigidity  of  the  soft  parts,  make  it  impossible 
for  the  head  to  be  expelled  without  greater  or  less  rupture  of  the  perineum.  In 
order  to  prevent  it,  Michaelis  advised,  in  1810,  incision  of  the  posterior  commis- 
sure. The  example  of  Eichelbery  might,  however,  be  followed,  and  the  incision 
be  made  on  one  or  both  sides  of  the  vulvar  orifice.  This  operation  should  be 
performed  only  when  the  head  is  at  the  vulva,  and  rupture  of  the  perineum 
seems  imminent.  The  blade  of  Pott's  bistoury  is  to  be  glided  on  its  side  between 
the  head  of  the  child  and  the  margin  of  the  vulva,  and  an  effort  made  to  limit 
the  incision  to  the  extent  just  necessary  to  allow  the  head  to  pass.  Eichelbery 
mentions  a  rapid  and  safe  cicatrization  of  the  wound,  in  recommendation  of  this 
incision  of  the  thickest  part  of  the  vulva. 

The  contraction  and  rigidity  of  the  external  parts  may  likewise  be  owing  either 
to  abnormal  bands,  or  to  resistant  and  inextensible  cicatrices,  which  have  resulted 
in  consequence  of  the  wounds  or  lacerations  that  often  occur  in  the  course  of  slow 
or  difficult  labors.^ 

'  To  the  numerous  examples  reconled  in  the  books,  I  may  add  the  following  from  my 
own  experience:  In  the  beginning  of  January,  18.3S,  while  I  performed  the  duties  of  Chef 
de  Clinique  at  the  hospital  of  the  Faculte,  a  woman  of  about  thirty  years  of  age  was  brought 
there,  who  was  pregnant  for  the  second  time,  and  had  reached  her  full  term.  She  had  been 
in  labor  since  the  previous  Friday  evening,  and  it  was  then  Sunday  morning.  The  patient 
informed  us  that  the  membranes  were  ruptured  on  Saturday  at  eight,  a.m.,  and  that  the 
head  appeared  to  descend  rapidly  in  the  excavation,  but  was  arrested  in  the  passage.  The 
accoucheur  in  attendance  called  one  of  his  brethren  in  consultation,  and  they  attempted  an 
aj;plication  of  the  forceps  at  two  o'clock  in  the  afternoon,  without  any  benefit.  At  eight  in 
the  evening,  everything  being  in  the  same  condition,  they  renewed  the  use  of  the  instrument, 
which  still  proved  ineffectual.  They  then  waited  until  Sunday  morning,  and  had  the  patient 
transported  to  the  hospital.  As  Professor  P.  Dubois  was  absent  on  her  arrival,  I  examined 
the  woman,  and  found  that  the  head  had  entered  the  excavation  and  was  resting  on  the 
floor  of  the  pelvis,  the  inferior  strait  of  which  appeared  to  be  slightly  contracted.  A  trans- 
verse band,  about  the  thickness  of  a  large  goose-quill,  and  composed  of  a  very  bard  and  ap- 
parently cartilaginous  tissue,  existed  at  the  posterior  commissure  of  the  vulva.  (The  woman 
then  told  us  that  her  former  labor  could  not  be  terminated  without  resorting  to  the  forceps, 
and  that  a  considerable  laceration  of  the  perineum  had  resulted  in  consequence  of  its  use.) 
At  every  contraction,  which,  however,  was  feeble  and  infrequent,  the  child's  head  pressed 
strongly  against  this  bridle,  but  the  latter  did  not  yield  in  the  least;  and  for  two  hours,  during 
which  we  watched  the  progress  of  the  labor  before  taking  any  part,  the  head  did  not  ad- 
vance a  single  line;  besides,  the  vulva  did  not  dilate,  and  the  band  remained  as  hard,  resis- 
tant, and  inelastic  as  ever.  I  was  about  to  make  an  incision  on  the  anterior  commissure  of 
the  perineum  ;  but  a  new  examination  of  the  parts  having  satisfied  me  that  the  lower  strait 
was  somewhat  contracted,  that  the  pains  were  very  feeble,  and  consequently  that  the  head's 
arrest  might  be  dependent  on  these  two  circumstances,  as  well  as  upon  the  resistance  of  the 
band,  I  resolved  to  attempt  a  new  application  of  the  forceps.  The  head  was  then  in  an  oc- 
cipito-pubic  position,  or  nearly  so,  though  the  occiput  was  still  a  little  to  the  left;  the  blades 
were  applied  and  locked  without  difficulty,  but  the  first  tractive  efforts  proved  to  be  wholly 
abortive;  after  trying  for  a  quarter  of  an  hour,  I  succeeded  in  fairly  engaging  the  head  in 
the  osseous  strait;  the  posterior  part  of  the  perineum  began  to  bulge  out,  though  the  commis- 
sure still  resisted,  and  the  pressure  thus  made  on  the  soft  parts  seemed  to  arouse  the  uterine 


MALFORMATIONS    OF    THE    VULVA    AND    VAGINA.         591 

It  must  not  be  supposed  that  all  women,  in  whom  the  fourchette  had  been 
destroyed  in  a  former  labor,  and  in  whom  the  band  resulting  from  the  vicious 
cicatrix  had  constituted  the  obstacle  to  delivery,  are  as  fortunate  as  she  whose 
history  I  have  just  given ;  for  sometimes  a  fresh  laceration  has  occurred,  and  at 
others  the  resisting  band  has  not  yielded,  and  the  child  has  been  expelled  through 
a  central  rupture  of  the  perineum. 

§  4.  Resistance  of  the  Perineum. 

It  is  not  at  all  unusual,  particularly  in  strong  and  muscular  primiparae,  and  in 
those  possessing  a  considerable  embonpoint,  to  find  the  labor  progressing  very 
regularly  at  first,  the  head  clearing  the  cervix  and  descending  into  the  excava- 
tion as  far  as  the  pelvic  floor,  and  then  its  further  progress  to  be  entirely  arrested; 
the  uterus  struggles  energetically  for  a  time  against  this  obstacle,  but,  notwith- 
standing the  force  of  its  efforts,  the  head  may  remain  there  for  several  hours 
without  advancing  a  single  line.  This  resistance  on  the  part  of  the  perineum  is 
evidently  owing  either  to  an  excessive  contraction  of  the  muscular  fibres  that 
enter  into  its  composition,  or  else  to  the  presence  of  so  great  a  quantity  of  adipose 
tissue,  as  to  render  this  portion  of  the  pelvic  wall  too  inextensible  to  permit  the 
escape  of  the  head. 

But  whatever  may  be  the  cause  of  the  resistance,  it  affects  the  ulterior  course 
of  the  labor  in  two  widely  different  ways,  which  it  is  highly  important  to  distin- 
guish in  practice,  for  they  require  the  employment  of  opposite  means.  For  in- 
stance, it  may  happen  that  the  uterine  contraction,  which  was  originally  strong 
and  energetic,  is  sustained  in  the  same  degree  during  several  hours,  but  then, 
being  overcome  by  the  resistance  which  it  cannot  surmount,  it  grows  weaker,  is 
exhausted,  and  finally  disappears  altogether.  The  indications  here  are  obvious : 
to  endeavor  to  arouse  the  pains  again,  by  making  the  patient  walk  about  her 
chamber,  by  rubbing  the  abdomen  or  titillating  the  cervix  uteri,  and  by  adminis- 
tering the  ergot ;  and,  if  all  these  prove  ineffectual,  to  apply  the  forceps.  But  a 
very  different  case  is  occasionally  met  with,  in  which  the  contractions,  so  far  from 
being  exhausted,  are  kept  up  as  strong  and  vigorous  as  at  the  commencement  of 
the  labor;  and  yet,  notwithstanding  their  energy,  they  are  incapable  of  effecting 
the  dilatation  of  the  soft  parts  in  the  perineum;  this  proving  an  insurmountable 
resistance  against  which  the  most  powerful  efforts  are  spent  in  vain.  Here 
the  accoucheur  should  evidently  avoid  the  "use  of  means  calculated  to  arouse 
the  contractions — the  ergot  in  particular  would  be  exceedingly  dangerous — 
since  the  tetanic  and  irregular  contractions  that  result  from  its  use,  and  which 
have  so  often  been  followed  by  the  death  of  the  child,  and  even  by  a  rupture 
of  the  womb  that  has  almost  uniformly  proved  fatal  to  the   mothei',  are  then 

contractions,  for  the  woman,  from  that  moment,  aided  my  efforts  witli  all  her  powers.  Under 
the  conjoint  influence  of  these  two  forces,  the  head  constrained  the  vulva  to  dilate,  the  band 
gradually  yielded,  it  became  thinner  and  more  distended,  and  finally,  after  three  quarters  of 
an  hour  of  constant  tractions  and  almost  continual  pains,  the  head  succeeded  in  clearing  the 
vulva.  Tlie  perineum  was  well  sustained  by  an  assistant,  and  did  not  exhibit  the  smallest 
trace  of  a  laceration. 


592  DYSTOCIA. 

peculiarly  apt  to  occur.  The  uterus  is  certainly  doing  all  that  it  can,  and  the 
physician  should  not  attempt  to  arouse  any  more  energetic  contractions,  but 
should  rather  aid  its  expulsive  efforts  by  tractions  carefully  performed  on  the 
child ;  and  an  application  of  the  forceps  is  clearlj'  the  only  resource.  Our  view 
of  its  particular  mode  of  action  in  the  case  before  us  will  be  studied  hereafter  in 
the  article  on  Forceps. 

Xow,  in  order  to  illustrate  this  distinction,  which  we  believe  very  important 
in  practice,  we  will  suppose  two  women  in  labor,  in  both  of  whom  the  child's 
head  is  properly  situated,  and  has  rested  on  the  pelvic  floor  for  six  or  seven 
hours;  but,  in  one  of  them,  the  contractions,  that  were  at  first  strong  and  frequent, 
have  gradually  become  more  feeble  and  rare,  or  even  have  almost  entirely  disap- 
peared ;  while,  in  the  other,  on  the  contrary,  they  still  maintain  all  their  original 
power.  In  the  latter  case,  we  would  apply  the  forceps  immediately ;  whilst,  in 
the  foi'mer,  we  should  first  have  recourse  to  the  various  measures  calculated  to 
restore  the  pains,  and  we  would  only  resort  to  the  forceps  when  these  excitations 
had  proved  inefiectual,  or  the  pains  caused  by  the  ergot  still  appeared  to  be  insuf- 
ficient. 

It  is  also  important  to  remember  that  the  life  of  the  foetus  may  be  greatly 
endangered  by  the  ergotic  contractions.  These,  therefore,  should  not  be  allowed 
to  continue  too  long.  If  the  head  is  not  expelled  after  the  lapse  of  half  or  three 
quarters  of  an  hour  from  the  commencement  of  the  ergotic  contractions,  I  should 
think  it  prudent  to  terminate  the  labor  by  the  forceps. 

This  inefficiency  of  the  pains  brought  on  by  the  ergot  is  not  very  unusual  in 
the  case  before  us;  but,  even  then,  the  administration  of  this  article  will  have 
been  useful,  though  an  application  of  the  forceps  be  afterwards  deemed  neces- 
sary; because  the  instrument  will  then  be  applied  under  much  more  favorable 
conditions;  for  the  contractions  produced  by  the  secale  cornutum  will  aid  the 
artificial  tractions;  and,  moreover,  will  prevent  the  consecutive  inertia  of  the 
womb,  to  which  the  woman  would  have  been  exposed,  if  the  instrument  had 
been  applied  without  previously  exciting  its  contractility  of  tissue. 

§  5.  Malformations  of  the  Vagina. 

This  canal  may  be  wanting  altogether,  or  only  in  its  upper  half;  we  have 
already  mentioned  a  case  (page  88)  in  which  the  lower  fourth  only  of  the  vagina 
was  present.  This  malformation  Often  coincides  with  an  absence  of  the  womb, 
but  the  care  of  the  accoucheur  in  such  a  case  is  evidently  unnecessary. 

Again,  it  may  be  obliterated  wholly  or  in  part  in  one  portion  of  its  extent, 
either  by  the  partial  or  the  complete  agglutination  of  its  walls,  or  by  actual  par- 
titions, passing  from  one  side  to  the  other.  This  cohesion  may  be  congenital, 
and  the  vagina  exist  as  a  dense,  solid  cord,  not  traversed  by  a  canal,  but,  on  the 
contrary,  reduced  to  a  simple  cellular  tract ;  or  it  may  be  accidental,  resulting 
most  usually  from  lacerations  or  lesions  during  former  labors,  or  else  from  wounds 
or  injuries.  Thus,  in  the  case  of  a  woman,  reported  by  M.  Lombart,  of  Geneva, 
who  used  a  pint  of  sulphuric  acid  as  an  injection,  with  the  culpable  design  of 
procuring  an  abortion,  the  bladder  was  found  to  be  fused  immediately  into  the 


MALFORMATIONS    OF    TUE    VULVA    AND    VAGINA.         593 

rectum,  the  vagina  having  been  destroyed  at  the  corresponding  part;  and  M. 
Cruveilhier  has  known  the  vulvo-uterine  canal  to  terminate  in  a  cul-de-sac,  about 
an  inch  from  the  meatus  urinarius,  in  consequence  of  vaginal  injections  made 
•with  a  solution  of  corrosive  sublimate. 

The  partitions  spoken  of  as  existing  in  the  vagina  may  be  transverse  or  longi- 
tudinal ;  and  most  of  the  cases  of  double  or  triple  hymen  mentioned  by  authors 
can  probably  be  referred  to  the  former.  These  may  be  complete,  that  is,  they 
may  divide  this  canal  into  two  distinct  cavities,  though  more  frequently  they 
exhibit  a  small  opening  through  which  the  liquids  ooze ;'  or  incomplete,  only 
obliterating  it  in  part;  consequently,  their  form  is  very  variable  in  different  cases. 

Where  the  septa  are  longitudinal,  ai;  times  they  only  divide  the  vagina  in  a 
part  of  its  extent ;  but,  at  others,  they  separate  it  throughout.  In  the  latter 
case,  the  continuity  of  the  partition  may  be  interrupted  at  some  part,  and  then 
the  two  canals  which  it  forms  will  communicate  through  this  opening.  The  sep- 
tum, when  complete,  is  occasionally  prolonged  into  the  uterus,  which  it  likewise 
divides  into  two  cavities,  although  this  does  not  always  happen. 

The  vagina  may  have  been  originally  very  small,  or  it  may  have  undergone  a 
remarkable  diminution  or  contraction.  This,  in  some  cases,  has  been  carried  so 
far  as  scarcely  to  permit  the  introduction  of  the  female  catheter.  M.  Moreau 
observed  a  young  woman  in  the  fourth  or  fifth  month  of  her  pregnancy,  in  whom 
this  canal  was  so  contracted  that  it  barely  admitted  the  barrel  of  an  ordinary 
writing  quill.  Such  a  disposition,  which  gives  rise  to  much  uneasiness,  nearly 
always  yields  to  the  natural  progress  of  the  gestation. '^ 

'  In  the  course  of  the  year  1837,  a  young  woman,  who  was  advanced  to  the  last  month 
of  gestation,  presented  herself  at  the  clinic  of  the  Faculte.  When  the  vaginal  touch  was 
resorted  to,  the  finger  was  arrested,  at  the  depth  of  one  inch  and  a  half  or  two  inches,  by  a 
perfectly  smooth  septum,  in  which  it  could  detect  no  sensible  opening.  By  a  resort  to  the 
speculum,  it  became  evident  that  the  obstacle  to  the  entrance  of  the  finger  consisted  of  a 
membrane,  which  adhered  to  the  walls  of  the  vagina,  and  completely  blocked  up  its  cavity 
at  this  point.  Its  surface  appeared  to  be  nearly  an  inch  in  diameter;  and,  by  pushing  and 
distending  it  with  the  extremity  of  the  instrument,  a  small  opening  was  detected  towards 
the  upper  third  and  right  portion  of  this  partition,  through  which  a  few  drops  of  a  sero- 
purulent  liquid  were  oozing. 

The  extremity  of  a  blunt  probe  could  scarcely  be  made  to  penetrate  the  little  orifice, 
which  was  directed  obliquely  from  below  upwards,  and  from  before  backwards  ;  the  instru- 
ment then  entered  a  kind  of  posterior  chamber,  formed  by  the  upper  wall  of  the  vagina. 
Thus  far,  no  accident  had  impeded  the  course  of  the  gestation,  but  some  difficulty  was 
thenceforth  anticipated  at  the  time  of  labor.  This  patient  was  taken  during  the  night  with 
pains,  but  they  were  so  feeble  that  a  commencement  of  the  labor  was  not  suspected  ;  though 
about  five  o'clock  in  the  morning  very  strong  and  frequent  ones  came  on,  which  efl"ected  the 
expulsion  of  the  foetus.  The  lying-in  was  very  favorable,  and  two  weeks  afterwards  I 
found  that  the  septum  had  been  split  into  three  distinct  pieces;  one  inferior  and  two  supe- 
rior. I  have  examined  this  woman  several  times  since,  and  am  satisfied  that  the  flaps  still 
remain  isolated. 

2  Plenck  states  that,  being  summoned  to  a  woman  in  labor,  he  found  the  vagina  so  con- 
tracted that  the  little  finger  could  not  be  introduced  at  all.  Nevertheless,  this  canal  was 
sufficiently  dilated  by  the  end  of  eighteen  hours,  and  the  child's  expulsion  took  place  with- 

38 


594  DYSTOCIA. 

Again,  tlie  vulvo-uterine  canal  may  be  deviated  from  its  usual  course,  and  pre- 
sent no  natural  openings  at  the  parts  of  generation.  The  points  at  which  it  then 
terminates  are  very  various ;  thus,  it  has  been  known  to  open  below  the  navel  by 
two  small  orifices,  separated  from  each  other  by  a  strong  membi'ane,  one  of  which 
gave  passage  to  the  urine,  and  the  other  to  the  menstrual  fluids ;  frequently,  it 
discharges  into  the  rectum.  Portal  states  that  a  young  girl,  in  whose  vulva  there 
was  only  a  small  opening  for  the  passage  of  the  urine,  and  whose  menses  were 
always  discharged  by  the  anus,  became  pregnant;  yet  the  small  opening  enlarged 
sufilciontly  during  the  latter  stages  of  gestation,  and  more  particularly  during 
the  travail,  to  permit  a  spontaneous  termination  of  the  labor.  M.  Rossi  re- 
ports that,  having  been  called  to  a  woman  in  labor,  he  discovered  a  total  ab- 
sence of  the  external  genital  organs.  At  first,  he  supposed  there  was  a  retention 
of  the  menses,  and,  under  this  impression,  made  an  incision  about  two  inches 
long  in  the  direction  of  the  vagina;  when,  instead  of  the  menstrual  blood,  he 
encountered  a  male  child,  which  escaped  through  this  opening,  and  lived  but 
seven  hours  after  its  birth.  Whilst  searching  where  the  fecundation  could  have 
taken  place,  he  discovered,  after  having  interrogated  the  husband,  a  small  orifice, 
near  the  sphincter  ani  and  at  the  internal  part,  which  would  scarcely  admit  a  fine 
probe. 

The  various  obstacles  just  studied  are  most  frequently  surmounted  by  the 
efforts  of  nature  alone ;  and,  therefore,  as  a  general  rule,  there  is  no  necessity 
for  an  early  resort  to  cutting  instruments.  If,  however,  it  be  deemed  advisable 
to  have  recourse  to  an  operation  before  the  labor,  for  separating  the  agglutinated 
parts,  incising  the  hymen,  or  for  destroying  an  abnormal  septum  or  vaginal  ad- 
hesion, it  would  be  better  to  wait  until  the  first  four  or  five  months  of  the  gesta- 
tion had  passed  over;  because,  after  this  period,  there  would  be  less  reason  to 
fear  the  unfavorable  influence  which  the  shock  caused  by  the  operation  might 
have  over  its  progress.  As  the  hymen  and  the  vaginal  septum  are  nearly  always 
perforated  by  an  opening,  a  director  might  be  introduced  into  it,  along  which  a 
bistoury  should  be  passed,  so  as  to  incise  the  parts ;  where  it  is  necessary  to 
divide  the  adherent  labia,  we  might  use  the  scissors,  as  their  agglutination  is 
always  incomplete ;  but,  in  all  cases,  the  incision  must  be  carried  as  luw  down  as 
possible,  so  as  to  open  a  free  passage  for  the  lochia.  When  it  is  desirable  to 
destroy  the  hymen  or  a  septum,  it  is  usually  recommended  to  make  a  crucial 
incision,  and  even  to  excise  the  flaps  to  prevent  them  from  afterwards  reuniting. 
A  similar  plan  would  be  resorted  to,  at  the  time  of  parturition,  excepting  that 
the  same  importance  does  not  attach  to  the  excision  of  the  flaps,  as  the  dis- 
charges of  the  lochia  would  prevent  their  reunion. 

As  to  the  bands  and  partial  contractions  found  at  some  part  or  other  of  the 

out  producing  any  laceration  of  it  or  of  the  external  genital  parts.     (Elementa  artis  Obstetri- 
cia,  p.  113.) 

Merriman  states  that  the  labor  terminated  spontaneously  in  thirty-six  hours,  in  a  case 
where  the  introduction  of  the  finger  was  barely  possible;  but  the  patient  died  on  the  third 
day,  and  a  small  laceration  of  the  vagina  was  found  at  the  post-viortem  examination.  (Sy7iop- 
sis,  p.  59.) 


TUMORS  OF  THE  EXCAVATION.  595 

canal,  wo  should  delay  our  operation,  for  they  most  generally  become  softened, 
and  ultimately  permit  the  delivery  to  take  place;  in  the  contrary  case,  they  must 
evidently  be  incised. 

Finally,  an  accidental  and  complete  obliteration  of  the  vulva,  occurring  during 
the  course  of  gestation,  would  require  the  creation  of  a  new  passage  for  the  head, 
as  soon  as  the  latter  distends  the  perineum ;  and  it  is  advisable  to  make  the  in- 
cision in  the  place  usually  occupied  by  the  vulvar  orifice. 

§  6.  Inversion  of  the  Vagina. 

An  inversion  of  the  vagina  occasionally  takes  place  during  parturition ;  that 
is,  the  mucous  membrane  of  this  canal  being  pressed  down  by  the  child's  head, 
and  consequently  being  more  or  less  inverted,  forms  a  livid  and  fungous  cushion 
of  considerable  size  between  the  labia,  or  beyond  the  vulva,  which  opposes  the 
passage  of  the  head.  The  pressure  made  by  this  part  on  the  inverted  mem- 
brane, often  gives  rise  to  gangrene ;  and,  therefore,  with  a  view  of  preventing 
this  unfortunate  result,  the  forceps  ought  to  be  applied  at  once.  The  causes 
that  predispose  the  "[patient  to  an  inversion  of  the  vagina,  are,  a  long  and  difficult 
labor,  a  large  head,  and  a  marked  relaxation  of  the  mucous  membrane.  If  this 
affection  is  detected  before  the  head  is  engaged,  the  accident  might  be  prevented 
by  pushing  up  the  membrane  at  the  commencement  of  the  labor,  and  maiutain- 
ins;  it  there  until  its  close. 


CHAPTER  III. 


OF  TUMORS    OF   THE   EXCAVATION. 


The  tumors  that  may  obstruct  the  excavation  are  extremely  numerous  and 
varied ;  and,  where  they  have  acquired  a  considerable  volume,  they  constitute 
one  of  the  most  serious  difficulties  in  the  practice  of  midwifery.  It  will  not  be 
in  our  power,  in  this  work,  to  enter  into  all  the  details  which  the  importance  of 
the  subject  demands;  besides,  all  that  relates  to  the  etiology,  the  pathological 
anatomy,  and  the  symptomatology  of  these  tumors,  rather  belongs  to  surgery 
than  to  the  obstetrical  art ;  and  we  must  confine  ourselves  more  particularly  to 
pointing  out  to  the  practitioner  those  signs  by  means  of  which  their  diagnosis  is 
established,  as  also  to  bringing  into  view  the  different  indications  they  present 
for  treatment.  It  is  proper  to  state  at  the  outset  that,  in  compiling  this  article, 
we  have  freely  extracted  from  the  learned  dissertation  of  M.  Puchelt  on  this 
subject,  whose  classification  we  retain. 

The  tumors,  whose  influence  over  parturition  is  about  to  claim  our  attention, 
may  have  their  origin  either  in  the  walls  of  the  canal  which  the  foetus  has  to 
traverse,  and  therefore  appertain  to  the  soft  parts  or  to  the  osseous  parietes,  or 
they  may  be  a  dependency  of  the  neighboring  organs. 


596  DYSTOCIA. 

ARTICLE   I. 

OP   THE   TUMORS   DEVELOPED   IN   THE   BONY   WALLS. 

The  ossific  tumors,  large  enough  to  constitute  an  obstacle  to  natural  labor,  are 
the  exostoses,  osteo-sarcoma,  and  those  that  result  from  old  and  badly  consoli- 
dated fractures. 

§  1.  Exostosis. 

If  we  lay  aside,  says  M.  Danyau,  all  those  cases  in  which  an  unusual  promi- 
nence of  the  sacro-vertebral  angle  has  been  mistaken  for  a  true  ossific  tumor,  as 
well  as  those  where  there  is  an  uncertainty  with  regard  to  their  character,  from 
the  insufficiency  of  the  details  in  the  written  account,  there  positively  remain 
but  two  examples  of  exostosis,  the  authenticity  of  which  is  incontestable,  namely, 
those  reported  by  Leydig  and  Mackibbin.  Though  some  doubts  may  still  exist, 
as  to  the  value  of  many  assertions  that  have  not  been  subsequently  confirmed  by 
the  autopsy,  yet,  I  do  not  believe  that  we  can  thus  strike  out,  by  a  dash  of  the 
pen,  most  of  the  observations  recorded  in  our  science.  For  example,  it  would 
really  be  difficult  not  to  admit  the  authenticity  of  the  one  reported  by  Gardien, 
since  Duret  preserved  the  pelvis  of  the  female  who  was  the  subject  of  it  for  a 
long  time  in  his  cabinet. 

The  facts  reported  by  JM.  Puchelt,  prove  that  most  pelvic  exostoses  arise  from 
the  anterior  face  of  the  sacrum.  Nevertheless,  several  other  points  of  the  pelvis 
have  likewise  been  their  seat;  thus  they  have  been  known  to  spring  from  the 
sacro-vertebral  articulation,  from  the  last  lumbar  vertebra,  or  the  first  bone  of 
the  sacrum,  and  from  the  posterior  face  of  the  pubis,  either  from  its  middle  part, 
or  on  one  of  the  sides,  as  also  from  the  internal  face  of  one  of  the  ischia. 

What  has  been  stated  respecting  the  uncertainty  of  the  published  observations, 
forewarns  us  of  the  difficulty  that  is  at  times  experienced  in  diagnosticating  the 
pelvic  exostoses,  and  in  distinguishing  them  from  the  various  prominences  caused 
by  the  deformities  of  the  pelvis.  The  hardness  of  the  tumor,  and  its  original 
adhesion  to  the  osseous  parietes,  are  given  as  characteristic  signs;  its  unevenness 
and  immobility  are  also  important  to  be  ascertained.  Being  always  covered  by 
the  vaginal  wall,  it  projects  into  the  interior  of  this  canal,  by  pi'cssing  aside  the 
organs  situated  before  it.  When  arising  from  the  anterior  face  of  the  sacrum,  it 
impinges  on  the  posterior  wall  particularly ;  and,  if  the  rectum  be  then  explored, 
the  latter  will  be  found  slightly  pressed  forward  by  the  tumor,  which  is  itself 
located  behind.  This  last  sign  is  very  important,  for  nearly  all  the  other  tumors 
are  situated  in  front  of  the  gut. 

The  prognosis  is  necessarily  dependent  on  the  size  and  situation  of  the  tumor, 
and  on  the  earlier  or  later  period  of  gestation,  at  which  the  labor  takes  place.  It 
is  evidently  more  serious  when  the  abnormal  growth  is  very  voluminous;  when 
it  is  so  placed  as  to  diminish  one  of  the  small  diameters  of  the  straits,  and  when 
the  child's  head  is  very  large. 


TUMORS    OF    THE    EXCAVATION.  597 

The  indications  for  treatment,  -whicli  were  so  fully  described  in  studying  the 
deformities  of  the  pelvis,  present  themselves  anew,  and  demand  the  employment 
of  the  same  means,  namely,  to  abandon  the  labor  to  nature  when  the  tumor  is 
small,  and  so  situated  as  only  to  diminish  the  large  diameters ;  or  to  apply  the 
forceps,  resort  to  symphyseotomy,  to  the  Caesarean  operation,  or  to  embryotomy, 
according  to  the  degree  of  contraction.     (See  page  582,  et  seq.) 

§  2.  Of  Osteo-sarcoma. 

Osteo-sarcoma  of  the  pelvis  is  a  very  rare  disease ;  two  instances,  however,  are 
recorded,  in  which  the  contraction  produced  by  it  was  extensive  enough  to 
require  the  Ccesarean  operation. 

The  tumor  can  -scarcely  be  distinguished  from  that  of  exostosis,  unless,  per- 
haps, by  the  inequalities  it  presents,  and  more  particularly  by  the  depressibility, 
the  semi-cartilaginous  softness,  and  the  crepitation  that  it  may  oiFer  at  certain 
portions  of  its  surface. 

It  is  evident  that  this  depressibility  of  the  tumor  will  render  the  prognosis  less 
serious  than  in  cases  of  exostosis  :  since  we  may  indulge  a  hope  that  the  head 
being  urged  on  by  the  uterine  contractions,  will  flatten  it  down,  and  make  it 
disappear  in  part.  Consequently,  it  is  here  permissible  to  wait  a  longer  time ; 
but  as  soon  as  the  inefficiency  of  the  effi)rts  of  nature  becomes  apparent,  we  must 
resort  at  once  to  the  same  measures  as  in  cases  of  pelvic  contraction. 

§  3.  Bony  Tumors  resulting  from  Deformities. 

The  ossific  protuberances  in  the  pelvis  may  likewise  depend  on  the  irregular 
consolidation  of  an  old  fracture  in  this  part;  or  may  be  formed  by  the  head  of 
the  femur,  which,  in  consequence  of  coxalgia,  has  traversed  the  bottom  of  the 
carious  and  perforated  acetabulum,  and  projects  into  the  pelvic  cavity.  I  recol- 
lect having  read  in  a  medical  journal  (which  I  cannot  now  find)  an  account  of 
the  Cassarean  operation  having  been  performed  in  a  case  where  the  sole  obstacle 
to  delivery  was  thus  formed  by  the  head  of  the  thigh  bone. 

A  representation  of  a  fracture  is  given  in  the  atlas  of  Professor  Moreau,  taken 
from  the  Musee  Dupui/tren,  in  which  the  bottom  of  the  right  cotyloid  cavity  has 
been  driven  in,  the  internal  wall  forming  a  rounded  tumor  that  projects  nearly 
an  inch  and  a  half  inwards ;  the  ilium  was  at  the  same  time  divided  beyond  the 
right  sacro-iliac  symphysis;  but,  in  consolidating,  the  exterior  part  of  the  iliac 
fossa  has  been  carried  inwards  in  such  a  manner  as  to  approach  towards  the 
sacrum,  whereby  the  tumor  formed  by  the  cotyloid  wall  is  brought  near  to  the 
sacro-vertebral  angle. 

The  Journal  des  Progrhs,  t.  xv,  1828,  contains  another  curious  instance  of  a 
fracture  of  the  pelvis,  with  a  consecutive  deformity  in  the  excavation  followed  by 
mortal  symptoms;  this  woman  had  previously  had  five  fortunate  deliveries.  The 
Cresarean  operation  has  frequently  been  performed  for  obstacles  of  this  nature ; 
thus  Burns,  Lever,  and  Barlow,  have  each  reported  a  case  of  the  kind. 

In  conclusion,  it  is  evident  that,  from  whatever  point  the  osseous  tumors  of 
the  pelvis  may  arise,  this  cause  of  dystocia  will  still  present  the  same  indications 
for  treatment. 


598  DYSTOCIA. 


ARTICLE   II. 

TUMORS   APPERTAINING   TO    THE    SOFT   PARTS. 

The  tumors  appertaining  to  the  soft  parts  may  either  be  attached  to  the  vulva 
or  vao-ina,  or  they  may  arise  from  the  neck  and  body  of  the  uterus.  Those 
which  are  seated  in  the  vulva  or  the  vagina  are  very  variable  in  their  character; 
thus  we  may  enumerate  an  cedema  of  the  labia  externa,  a  thrombus  of  these  parts, 
cysts,  abscesses,  fibrous  tumors  with  or  without  pedicles,  together  with  cancerous 
degenerations  and  vegetations  of  every  kind ;  while  those  appertaining  to  the 
neck  and  body  of  the  womb  are  caused  by  an  induration  of  the  os  tincJB,  an  elon- 
gation, hypertrophy,  and  tumefxction  of  the  anterior  lip,  abscesses,  cancers,  or 
other  degenerations  with  which  they  may  be  affected ;  or  lastly,  on  polypous 
masses,  arising  from  the  cervix  or  body  of  the  womb,  and  projecting  into  the 
excavation. 

§  1.  CEdema  op  the  Labia  Externa. 

The  cedema  of  the  greater  labia,  already  alluded  to,  when  treating  of  the  com- 
plications of  pregnancy,  is  sometimes  so  considerable  at  the  time  of  labor  as  to 
obliterate  the  entrance  of  the  vagina  almost  completely;  and,  by  opposing  the 
necessary  distension  of  the  vulva,  it  may  render  the  parturition  very  difficult,  as 
well  as  exceedingly  painful.  The  child's  head  may  produce  a  gangrene  in  the 
parts  thus  tumefied,  by  the  pressure  on  them  during  its  passage,  or,  at  least,  it 
may  cause  an  extensive  rupture.  These  accidents  are  to  be  prevented  by  making 
punctures  with  the  lancet  in  all  the  swollen  tissues;  the  number  of  the  punctures 
will  necessarily  vary  with  the  extent  of  the  swollen  parts,  and  the  degree  of  their 
engorgement. 

§  2.  Sanguineous  Tumors,  or  Thrombus. 

The  tissue  that  constitutes  the  lips  of  the  vulva,  and  lines  the  entrance  of  the 
vagina,  is  composed  of  venules,  arterioles,  cellular  filaments,  and  fatty  masses,  so 
interlaced  and  held  together,  that  an  effusion  of  blood  there  is  almost  always 
abundant;  besides  which,  the  stagnation  of  the  fluids  in  the  external  genital 
parts,  and  the  varicose  state  of  the  vaginal  veins,  so  frequent  in  pregnant  women, 
predispose  all  these  organs  to  what  is  denominated  thrombus.  In  fact,  during 
gestation,  and  more  particularly  in  the  course  of  its  latter  months,  these  large 
veins  are  apt  to  give  way,  either  spontaneously,  or  in  consequence  of  some  exter- 
nal violence,  and  the  blood  is  extravasatcd  into  the  cellular  tissue,  whereby  a 
considerable  tumor  is  developed ;  and,  in  the  course  of  a  variable  period,  gan- 
grene attacks  the  distended  parts,  and  a  hemorrhage,  which  is  occasionally  very 
profuse  and  sometimes  even  fatal,  takes  place.' 

'  This  accident  was  ilescribed  quite  accurately,  in  1G47,  by  Veslingius.  "  I  liave  twice," 
says  he,  "witnessed  an  effusion  of  blood  between  the  vajjinal  tunics,  in  cases  of  difficult 
labor.  The  labia  presented  a  considerable  tumor,  which,  when  opened,  discharged  quite  a 
large  auiount  of  blood." 


TUMORS  OF  THE  EXCAVATION.  699 

Thrombus  of  the  vulva  does  not  appertain  to  pregnant  women  exclusively, 
since  it  may  also  appear  in  the  non-gravid  condition ;  indeed,  according  to  Vel- 
peau,  it  is  even  more  frequent  then  than  during  gestation.  However,  it  must 
be  acknowledged  that  the  obstruction  to  the  circulation  in  the  lower  extremities, 
caused  by  the  development  of  the  womb,  must  necessarily  favor  the  production 
of  this  tumor ;  and,  consequently,  that,  in  the  non-pregnant  state,  a  thrombus  of 
the  vulva  is  far  less  dangerous  than  in  the  opposite  condition. 

This  tumefaction  most  generally  affects  the  greater  labia,  though  it  has  also 
been  observed  in  the  lesser;  in  most  cases,  a  single  lip  only  is  involved,  though 
at  times  there  is  a  double  tumor,  caused  by  a  simultaneous  effusion  into  both  of 
the  labia  externa.  Wherefore,  Boer  was  wrong  in  supposing  that  the  right  one 
was  its  exclusive  scat,  for  it  may  appear  indifferently  on  either  side. 

It  is  rarely  present  in  the  earlier  months  of  gestation,  but  it  is  more  frequent 
in  the  latter  periods,  and  particularly  so  during  the  labor,  or  after  the  delivery. 
The  most  common  causes  of  thrombus  during  pregnancy,  are  blows,  falls,  violent 
concussions,  &c.  &c.  In  some  cases  it  can  be  traced  to  no  external  violence,  and 
then  the  spontaneous  rupture  must  evidently  be  referred  to  an  excessive  disten- 
sion of  one  of  the  vaginal  veins.  When  occurring  during  labor,  this  affection  is 
nearly  always  manifested  just  as  the  head  or  breech  endeavors  to  clear  the  vulva, 
after  having  reached  the  inferior  strait.  The  rupture  of  the  veins  is  then  cer- 
tainly caused  by  the  distension,  which  they,  like  all  the  othe"r  parts,  are  subjected 
to  (a  distension  to  which  they  yield  with  more  difficulty),  and  by  the  great  accu- 
mulation of  blood  produced  by  the  obstruction  to  the  circulation  from  the  pre- 
sence of  the  child's  head.  Therefore,  an  excessive  size  of  the  latter,  or  its  un- 
usual delay  at  the  inferior  strait,  a  narrowing  of  the  pelvis,  and  the  consequent 
immoderate  efforts  on  the  part  of  the  patient  to  overcome  the  resistance,  are  its 
most  common  causes.  Certain  authors  have  likewise  supposed  that  the  obliqui- 
ties of  the  womb,  and  the  frequent  rough  examinations  of  the  parts  of  genera- 
tion, might  produce  them ;  but  it  is  evident  that  such  circumstances  cannot  have 
the  attributed  effect,  unless  a  varicose  predisposition  exists  at  the  same  time. 
Ordinarily,  these  tumors  only  appear  after  the  delivery,  when,  indeed,  they  are 
the  more  dangerous ;  first,  because  they  may  the  more  readily  escape  unperccived, 
and  then,  because  the  relaxation  of  the  parts  permits  them  to  acquire  a  very  con- 
siderable volume. 

The  remark  of  M.  Deneux  should  be  borne  in  mind,  that  most  of  the  cases  of 
thrombus  which  are  not  detected  until  after  delivery,  really  commence  during  the 
labor,  or,  at  least,  that  the  rupture  of  the  vessels,  if  not  the  effusion,  takes  place 
during  the  first  expulsive  pains.  Often,  indeed,  when  a  vein  is  ruptured,  it  is 
so  compressed  by  the  head  in  the  excavation  as  to  prevent  any  effusion,  a  free 
escape  of  blood  taking  place  only  after  the  labor  is  terminated.  It  being  rarely 
necessary  to  introduce  the  hand  into  the  vagina  after  the  deliveiy  of  the  placenta, 
the  tumor  will  not  be  discovered  until  it  has  become  so  large  as  to  incommode 
the  patient,  or  the  physician  is  alarmed  by  the  general  symptoms  of  hemorrhage. 
Therefore,  considerable  time  may  elapse  between  the  commencement  of  the  acci- 
dent and  its  detection. 


600  DYSTOCIA. 

Still  another  condition  may  postpone  the  appearance  of  the  thrombus,  namely, 
the  stoppage  of  the  small  opening  in  the  vein  by  a  coagulum. 

Finally,  it  may  happen,  as  supposed  by  M.  Dubois,  that  the  badly  contused, 
and,  perhaps,  even  mortified  vi^alls  of  the  vessels,  do  not  give  way  until  when,  at 
a  later  period,  the  part  which  has  suffered  the  pressure  becomes  detached.  The 
mucous  membrane,  being  more  extensible  than  the  walls  of  the  veins,  recedes,  so 
to  speak,  before  the  violence  which  aflfects  the  distended  vessel,  and  is  not,  there- 
fore, so  much  injured  by  it.  Thus  is  explained  the  late  effusion  of  the  blood 
into  the  submucous  cellular  tissue,  and  the  consequent  formation  of  a  tumor. 

Such,  doubtless,  is  the  usual  way  in  which  a  thrombus  is  formed  after  delivery, 
the  effusion  only  being  consecutive  to  the  expulsion  of  the  foetus.  We  can 
imagine,  however,  that  the  phenomena  may  take  place  differently ;  for,  as  the 
walls  of  the  veins  are  often  very  much  weakened,  either  by  extreme  distension  or 
the  stretching  to  which  they  are  subjected  during  the  labor,  it  is  possible  that  a 
sudden  movement,  a  violent  inspiratory  effort,  or  a  fit  of  coughing,  might  sud- 
denly cause  such  an  afflux  of  fluid  into  them,  as  to  produce  their  spontaneous 
rupture  even  after  the  lapse  of  several  hours  from  delivery. 

The  development  of  a  sanguineous  tumor  is  generally  announced  by  a  severe 
pain  in  the  affected  part,  caused,  doubtless,  by  the  rupture  of  some  of  its  vessels; 
then  one,  or  sometimes  both  of  the  greater  labia,  or,  perhaps,  only  the  nymphoe, 
soon  swells  up,  becomes  rapidly  distended,  and  forms  a  more  or  less  voluminous 
tumor.  This  tumor  may  acquire  a  considerable  size,  and  the  quantity  of  effused 
blood  be  great  enough  to  debilitate  the  patient,  and,  possibly,  to  produce  syn- 
cope. In  some  instances  it  acquires  its  full  volume  at  once,  while  in  others  it 
goes  on  augmenting  for  twenty-four  hours;  it  maybe  limited  to  the  external 
parts,  or  it  may  extend  deeply  into  the  pelvis,  and,  possibly,  as  far  as  the  iliac 
fossae. 

In  1846,  I  had  occasion  to  witness  a  case  in  which  the  effusion  had  extended 
much  farther.  The  autopsy  revealed  a  layer  of  coagulated  blood  between  the 
muscles  and  peritoneum,  spread  over  the  whole  lower  half  of  the  anterior  walls 
of  the  abdomen  on  the  right  side.  The  layer  was  nearly  a  quarter  of  an  inch 
thick,  and  extended  from  below  upward  to  about  two  fingers'  breadth  below  the 
umbilicus,  besides  occupying  transversely  the  entire  space  between  the  linea  alba 
and  the  crest  of  the  ilium. 

At  the  latter  point,  the  layer  of  blood  was  continuous  with  a  clot  about  three- 
eighths  of  an  inch  thick,  also  situated  beneath  the  peritoneum,  and  lining  the 
entire  iliac  fossa.  Below  and  inward,  it  turned  over  the  edge  of  the  superior 
strait,  and  was  lost  in  a  large  collection  of  coagulated  blood,  which  formed  the 
tumor  that  during  life  had  especially  attracted  our  attention.  The  clot  in  this 
place  was  at  least  five-eighths  of  an  inch  thick  at  the  centre,  but  it  grew  thinner 
as  it  spread  out  over  the  entire  right  side  of  the  excavation  :  the  remaining  cel- 
lular tissue  of  the  pelvis  was  highly  colored  by  infiltrated  blood. 

The  disaster  was  not,  however,  limited  to  what  we  have  described,  for  in  as- 
cending, and  separating  the  peritoneum  upon  the  right  position  and  lateral  side 
of  the  abdomen,  the  coagulated  blood  was  found  to  extend  as  far  23  the  right 


TUMORS  OF  THE  EXCAVATION.  GOl 

hypochondrium,  and  to  imbue  the  entire  cellular  tissue  surrounding  the  kidney; 
it  also  passed  between  the  folds  of  the  peritoneum  forming  the  origin  of  the 
mesentery,  and  finally  extended  to  the  attachments  of  the  diaphragm  to  the  false 
ribs  of  the  right  side,  which  connections  seemed  to  have  been  the  only  barrier 
to  its  further  progress.  The  thickness  of  this  large  coagulated  layer  varied  from 
one  to  two-eighths  of  an  inch.  The  total  amount  of  efi"used  blood  was  estimated 
at  two  pounds  by  those  who  witnessed  the  autopsy.^ 

Again,  it  not  unfrequently  happens  that  the  effusion  commences  within  the 
pelvis,  and  subsequently  approaches  the  exterior.  The  tumor  shortly  assumes  a 
violet  or  livid  hue ;  and  when  the  thrombus  is  seated  high  up,  this  discoloration 
of  the  skin  rarely  permits  it  to  be  mistaken ;  when  lower,  and  in  the  substance 
of  the  greater  labia,  on  the  contrary,  it  may  neither  be  accompanied  by  ecohy- 
mosis,  pulsation,  nor  throbbing.  Where  the  blood  infiltrates  into  the  meshes  of 
the  cellular  tissue  only,  the  tumor  is  hard ;  but  it  becomes  soft  and  fluctuating 
when  this  texture  is  torn,  and  there  is  an  abnormal  cavity  formed.  Again,  it  is 
not  unusual  for  the  skin,  or  mucous  membrane  covering  it,  to  give  way  in  con- 
sequence of  being  gradually  rendered  thinner;  thereby  giving  vent  to  a  consi- 
derable discharge  of  blood,  with  an  instantaneous  ces.sation  of  the  pain ;  and  this 
hemorrhage  may  be  so  profuse  as  to  speedily  terminate  in  death,  especially  if  the 
tumor  be  voluminous,  and  the  rupture  occurs  during  the  efforts  of  parturition. 
Cases  have  been  known  in  which  the  rupture  was  followed  by  the  projection  of  a 
jet  of  blood  with  such  force  and  abundance,  as  to  fall  at  a  distance  of  several 
feet  from  the  patient,  and  to  be  mistaken  by  the  attendants  for  a  rupture  of  the 
membranes,  and  discharge  of  a  large  amount  of  water.  Whenever  the  nature  of 
the  accident  was  mistaken  and  the  proper  measures  were  not  employed,  the 
patient  succumbed  in  a  few  minutes. 

A  copious  bleeding  has  occasionally  taken  place  during  the  formation  of  a 
thrombus.  In  fact,  this  circumstance  may  occur  whenever  the  mucous  mem- 
brane and  one  or  more  of  the  veins  are  lacerated  at  the  same  time.  Should  the 
two  openings  not  correspond  with  each  other,  one  part  of  the  blood  will  escape 
into  the  vagina,  and  the  other  be  infiltrated  into  the  cellular  tissue. 

Where  the  thrombus  has  acquired  a  considerable  size,  it  may  evidently  impede 
the  passage  of  the  head,  and  after  the  delivery,  that  of  the  placenta  and  lochia. 

Madame  Lachapelle  relates  a  very  curious  instance,  in  which  a  thrombus,  that 
had  first  commenced  during  the  labor,  underwent  a  rapid  development  after  the 
child's  expulsion.  The  tumor  obstructed  the  vagina  so  much,  that  it  prevented 
the  escape  of  the  lochia,  whence  the  latter  accumulated  in  the  womb,  and  be- 
came, somewhat  later,  the  source  of  a  profuse  hemorrhage.  Fortunately,  she 
continues,  in  the  attempts  to  introduce  my  hand  into  the  uterus,  for  the  purpose 
of  extracting  the  clotted  blood,  I  ruptured  the  tumor  involuntarily,  near  the 
entrance  of  the  vagina,  when  a  large  quantity  of  coagulated  blood  immediately 
escaped,  its  size  diminished,  and  all  the  attendant  symptoms  disappeared  without 
any  particular  treatment. 

*  For  the  details  of  this  case,  see  the  Gazette  Mcdico-Chirurgicale  (February  28th,  1846). 


602  DYSTOCIA. 

Finally,  the  pressure  of  the  tumor  on  the  neck  of  the  bladder,  may  cause  re- 
tention of  the  urine  and  fecal  matters. 

When  the  thrombus  appears  early  in  pregnancy  and  has  been  emptied  by 
incision  and  the  patient  cured,  it  may  reappear  some  time  after  and  at  the  same 
place.  A  relapse  of  the  kind  is  reported  by  Monttromery.  The  tumor,  which 
showed  itself  in  the  left  labium  in  the  seventh  month  of  gestation,  cau.scd  so 
much  pain  as  to  induce  the  author  to  puncture  and  empty  it  on  the  18th  of  June. 
He  was  sent  for  again  on  the  13th  of  July,  and  discovered  a  much  larger  tumor 
than  the  preceding,  and  was  again  obliged  to  puncture  it  in  order  to  relieve  the 
patient.  It  did  not  return  until  the  24th  of  August,  at  which  time  the  young 
woman  was  delivered. 

The  diagnosis  of  these  tumors  is,  in  general,  quite  easy;  for  their  sudden 
appearance,  their  rapid  development,  their  hardness  when  the  blood  is  simply 
infiltrated,  and  fluctuation  when  it  is  collected  in  an  abscess ;  the  violent  pains 
they  give  rise  to,  and  the  bluish  discoloration  of  the  skin,  are  always  sufficient  to 
detect  them.  Nevertheless,  they  have  sometimes  been  confounded  with  certain 
other  tumefactions,  such  as  the  simple  varicose  ones,  an  inversion  of  the  vagina, 
the  descent  or  inversion  of  the  womb,  and  with  the  vaginal  hernife  formed  either 
by  the  intestine,  the  omentum,  or  the"  bladder ;  but  as  we  shall  have  occasion 
hereafter  to  treat  of  each  of  these  tumors,  and  their  peculiar  signs,  it  seems  use- 
less to  enter  here  into  their  differential  diagnosis. 

The  prognosis  is  usually  unfavorable ;  thus,  "  in  sixty-two  cases  brought  to  my 
knowledge,"  says  M.  Deneux,  "the  mother  died  in  twenty-two  of  them,  either 
during  the  gestation,  or  else  during  or  after  delivery ;  and,  with  the  exception  of 
a  single  instance,  all  the  children  of  these  twenty-two  females  were  likewise  lost. 
The  profuse  hemorrhage  is  the  most  frequent  cause  of  the  patient's  death,  though 
the  latter  may  also  be  occasioned  by  the  gangrene  and  suppuration  which  often 
follow  the  primary  symptoms. 

These  tumors  may  terminate  either  by  resolution,  suppuration,  rupture,  or 
gangrene,  but  as  the  progress  of  the  disease  exhibits  nothing  peculiar  in  any  of 
those  cases,  we  shall  merely  mention  them  in  passing. 

The  treatment  of  thrombus  necessarily  varies  according  to  its  size,  and  the 
sufferings  thereby  occasioned  to  the  female,  as  also  to  the  period  at  which  it  is 
manifested.  If  the  patient  be  in  labor  when  the  tumor  is  developed,  and  the 
latter  be  large  enough  to  seriously  impede  the  passage  of  the  head,  the  effused 
liquid  should  evidently  be  evacuated  by  a  free  incision,  made  on  the  most  de- 
pendent part  of  the  swelling,  the  extent  of  which  must  be  proportioned  to  its 
volume.  If  this  operation  is  performed  some  time  before  the  head  engages  in 
the  excavation,  it  would  be  advisable,  after  having  emptied  the  sac,  to  make  use 
of  the  tampon  in  order  to  prevent  hemorrhage ;  but  if,  on  the  contrary,  the  tumor 
is  only  opened  when  the  head  is  fully  engaged,  the  application  of  the  tampon 
maybe  dispensed  with,  for  the  child's  head  will  sufficiently  compress  the  divided 
vessels  to  prevent  a  further  discharge  of  blood.  In  the  latter  case,  it  would  bo 
requisite  to  attend  to  the  precautions  described  below,  after  the  delivery. 

The  question  is  not,  however,  so  easily  decided  when  the  thrombus  appears 


TUMORS    OF    THE    EXCAVATION.  603 

during  pregnancy  or  after  delivery,  and  authors  are  far  from  being  unanimous  as 
respects  the  course  to  be  pursued.  To  give  greater  precision  to  our  therapeutic 
recommendation,  we  shall  distinguish  the  eases  in  which  it  is  necessary,  1,  to 
incise  immediately ;  2,  to  incise  at  a  later  period ;  and,  3,  to  omit  incision  alto- 
gether. 

1.  Wheii  it  is  necessary  to  Incise  immediateli/. — The  tumor  is  sometimes  so 
large  as  to  fill  a  great  part  of  the  excavation,  and  seems  capable  of  obstructing 
the  discharge  of  the  lochia.  Careful  examination  then  shows  the  skin  or  the 
mucous  membrane  covering  its  internal  surface,  to  be  so  greatly  thinned  by  dis- 
tension and  to  present  so  deep  a  violet  hue  that  gangrene  or  spontaneous  rupture 
seems  likely  to  occur  at  any  moment.  On  the  other  hand,  the  quantity  of  fluid 
effused,  and  the  disorder  which  it  necessarily  produces  in  the  cellular  tissue  in 
which  it  has  formed  a  large  cavity,  renders  its  absorption  very  improbable ;  the 
evident  fluctuation  discoverable  over  the  greater  part  of  the  tumor  induces  the 
reasonable  belief  that  it  does  not  contain  a  large  clot,  and  that  there  is  nothing, 
therefore,  to  prevent  a  continuance  of  the  internal  discharge.  The  patient  ex- 
periences acute  pain,  and,  lastly,  her  increasing  weakness,  the  feebleness  of  pulse, 
pallor  of  the  skin,  &c.,  lead  to  the  opinion  that  the  disorder  is  not  limited  to  the 
tumor  of  the  excavation,  but  that  in  all  probability  the  blood  is  making  its  way 
to  the  upper  part  of  the  abdomen.  Under  these  circumstances,  it  would  cer- 
tainly be  nothing  short  of  folly  to  depend  upon  the  efforts  "of  nature  alone,  and 
immediate  incision  appears  to  us  indispensable. 

2.  Postponement  of  Incision. — If,  however,  the  tumor  is  small,  being  no 
larger,  for  example,  than  an  egg;  if  the  walls  are  of  considerable  thickness  and 
of  a  natural  color;  if  it  is  but  slightly  painful,  and  does  not  appear  to  increase  in 
size ;  if,  from  the  coagulation  of  the  effused  fluid,  fluctuation  becomes  more  and 
more  obscure;  if,  in  a  word,  there  is  every  reason  to  hope  that  the  internal 
hemorrhage  is  not  only  arrested,  but  its  recurrence  rendered  impossible  through 
the  compression  of  the  ruptured  vessels  by  the  coagulum,  I  have  no  hesitation  in 
believing  that  everything  should  be  done  to  assist  resolution,  and,  consequently, 
that  the  instrument  should  not  be  used,  unless  rendered  necessary  by  certain 
accidents,  which  may  occur  under  the  circumstances. 

This  method,  I  am  aware,  has  both  its  advantages  and  disadvantages ;  still  I 
regard  the  former  as  of  greater  importance  than  the  latter.  As  advantages,  I 
would  mention  :  1,  the  possibility  of  absorption,  which  we  certainly  have  occa- 
sion frequently  to  observe  as  taking  place  with  much  larger  effusions ;  2,  the 
rarity  of  consecutive  hemorrhages.     This  latter  point  we  shall  discuss  hereafter. 

The  partisans  of  immediate  incision  reproach  expectation  with  exposing  the 
tumor  to  suppuration  and  gangrene,  besides  thinking  that  a  late  incision  does 
not  always  protect  against  hemorrhage.  Let  us  examine  the  worth  of  these  ob- 
jections. 

The  attempt  to  bring  about  resolution  docs  not  dispense  with  the  necessity  of 
a  careful  oversight  of  the  case  :  now,  before  becoming  affected  with  gangrene, 
the  walls  of  the  tumor  present  to  the  attentive  eye  of  the  surgeon  certain  changes 
which  forewarn  him  of  the  danger.     On  the  other  hand,  when  the  blood,  which, 


604  DYSTOCIA. 

extravasated  in  tlie  tissues,  acts  as  a  foreign  body,  and  excites  around  it  first  an 
irritation  and  then  an  intense  inflammation,  suppuration  does  not  take  place 
without  having  been  preceded  by  heat,  redness,  greater  or  less  tension  of  the 
tumor,  and  more  or  less  pain  to  the  patient  :  now  we  can  hardly  expect  the  phy- 
sician to  be  so  negligent  as  to  allow  all  the  phenomena  of  a  suppurative  inflam- 
mation to  pass  undiscovered.  Therefore,  as  soon  as  the  tumor,  so  far  from 
progressing  toward  complete  resolution,  presents  some  of  these  preliminary  symp- 
toms, it  will  be  time  enough  to  have  recourse  to  the  operation.  But,  would  it 
not  have  been  better  to  have  practised  it  at  once?  Certainly  not;  for,  indepen- 
dently of  the  chances  of  obtaining  resolution,  you  have  now  the  advantage  of 
performing  incision  under  circumstances  the  best  calculated  to  prevent  consecu- 
tive hemorrhage. 

Indeed,  it  seems  to  me  vindeniable,  that,  when  the  hemorrhage  has  ceased  for 
several  days,  and  the  greater  part  of  the  blood  is  converted  into  a  solid  clot, 
which,  either  by  direct  compression,  or  by  extending  into  the  opening  of  the 
ruptured  vessel  shall  have  obliterated  the  latter,  the  cavity  may  be  incised  with- 
out probability  of  hemorrhage.  I  am  acquainted  with  the  observations  relied  on 
by  M.  Deneux  and  others,  as  showing  that  secondary  hemorrhage  is  not  an 
impossible  occurrence ;  but,  in  my  opinion,  they  are  far  from  being  conclusive 
against  the  opinion  which  I  hold. 

If  hemorrhage  is  ever  to  be  feared  as  a  consequence  of  opening  sanguineous 
tumors  of  the  vulva  and  vagina,  I  certainly  maintain  that  it  is  especially  so  when 
practised  immediately;  for,  as  the  rupture  of  the  varicose  veins  is  then  recent, 
there  is  nothing  to  prevent  the  blood  from  flowing  externally :  the  determination 
of  blood  to  the  parts,  which  may  have  contributed  to  the  production  of  the  rup- 
ture, still  exists,  and,  during  pregnancy,  the  obstruction  to  the  return  of  the 
circulating  fluid  by  the  large  venous  trunks,  in  consequence  of  the  pressure  of 
the  uterus,  highly  developed  as  it  is,  and  situated  above  the  superior  strait,  is 
remarkably  well  calculated  to  produce  venous  hemorrhage.  I  am  well  aware  that 
the  tampon  may  be  applied,  as  also  that  the  partisans  of  immediate  incision  rely 
chiefly  upon  it;  but  whoever  has  used  the  tampon,  knows  what  suffering  it  occa- 
sions when  it  has  to  be  left  in  its  place  for  several  days,  and  how  difficult  it  is, 
notwithstanding  all  the  means  proposed  for  the  purpose,  to  maintain  a  free  dis- 
charge of  the  lochia. 

It  appears  to  me  that  M.  Velpeau,  who  treats  the  fears  of  some  authors  on  the 
subject  of  hemorrhage  as  chimerical,  has  had  reference  rather  to  cases  of  throm- 
bus frequently  witnessed  by  him  in  non-pregnant  women,  than  to  those  which 
appear  in  the  puerperal  state ;  for,  according  to  him,  there  is  no  vessel  in  this 
region  large  enough  to  become  a  source  of  anxiety.  This  last  proposition  I 
esteem  erroneous,  if  it  be  intended  to  apply  to  pregnant  females ;  it  is  well  known 
that  the  arteries  and  veins  of  the  vagina  share  in  the  development  of  the  entire 
generative  apparatus,  and  all  practitioners  have  felt  the  varicose  veins  projecting 
beneath  the  vaginal  mucous  membrane  during  pregnancy,  and  also  the  pulsations 
of  large  arteries.  The  latter  sensation  is  so  evident  as  to  have  been  styled,  by 
Osiander,  the  vaginal  pulse. 


TUMORS    OF    THE    EXCAVATION.  605 

Finally,  it  may  be  said  that  by  deferring  the  incision  of  the  tumor,  we  incur 
the  risk  of  an  extension  of  the  effusion,  and  a  separation  of  the  peritoneum  over 
a  large  surface,  all  of  which  would  have  been  avoided  by  providing  a  free  exit 
externally.  This,  doubtless,  is  possible ;  but  when  we  come  to  reflect  upon  the 
conditions  by  which  we  would  limit  the  expectant  method,  and  the  attempts  to 
obtain  resolution,  it  will  be  seen  that  we  are  protected  from  any  such  danger. 
Besides,  if  it  is  necessary  to  apply  the  tampon  after  immediate  incision,  may  not 
this  have  the  same  effect  by  obstructing  the  discharge  of  blood  outwardly? 
Unfortunately,  this  is  no  hypothesis,  for  it  is  supported  by  one  of  M.  Deneux's 
own  observations. 

3.  The  Omission  of  Incision  altogether. — It  is  evident  that  whenever  the 
means  employed  to  assist  nature  in  effecting  resolution  seem  to  affect  favorably 
the  size  of  the  tumor,  and  its  consistency,  by  which  we  mean  its  becoming  more 
compact  and  solid,  their  employment  should  be  continued,  and  cutting  instru- 
ments abstained  from. 

At  whatever  period  the  incision  is  practised,  it  is  best  not  to  insist  upon  the 
removal  of  all  the  clots ;  but,  at  the  first  dressing,  to  respect  all  that  seem  to 
adhere  to  the  surrounding  parts ;  for  while  their  immediate  detachment  would 
risk  a  return  of  the  hemorrhage,  they  would  come  away  gradually  at  the  subse- 
quent dressings.  If  necessary,  their  separation  might  be  assisted  by  daily 
injections. 

Another  question  has  reference  to  the  part  of  the  tumor  to  be  operated  upon. 
Most  authors  agree  to  make  the  incision  external,  that  is,  through  the  integu- 
ments; for  they  find  that  the  dressing  is  thereby  rendered  easier,  that  it  does 
not  require  the  introduction  into  the  vagina  of  foreign  bodies,  which  might  ob- 
struct the  discharge  of  the  lochia,  and  that  the  wound  is  not  subject  to  irritation 
from  the  uterine  fluids.  I  would  add  that  the  cicatrix  would  be  less  dragged 
upon  in  future  labors,  and,  therefore,  less  exposed  to  rupture  when  the  external 
parts  are  greatly  distended  by  the  foetal  head.  I  therefore  adopt  the  external 
incision,  but  upou  one  condition,  namely,  that  it  shall  be  possible,  which  is  not 
always  the  case ;  for  when  the  tumor  is  situated  in  the  greater  or  lesser  labia,  it 
presents  two  surfaces,  one  mucous  and  the  other  cutaneous,  and  unless  there 
exists  a  very  thin  and  altered  point,*  which  of  itself  deprives  the  surgeon  of  the 
power  of  choosing,  it  may  be  incised  either  outwards  or  inwards.  But  the 
thrombus  is  not  always  situated  so  low  down  :  in  such  cases,  and  I  would  recall 
the  one  the  details  of  which  I  have  already  related,  the  tumor  being  altogether 
within  the  excavation,  and  limited  outwardly  by  the  bony  walls  of  the  pelvis, 
presents  none  other  than  a  mucous  surface  to  the  instrument.  Therefore,  should 
incision  be  deemed  necessary,  it  can  then  only  be  practised  upon  the  wall  of  the 
vagina. 

I  make  this  remark,  because  it  forms,  in  my  opinion,  an  additional  reason  for 
recommending  late  incisions.     A  large  wound  in  the  walls  of  the  vagina  is  not, 

'  It  were  useless  to  state  that  if  the  integuments  upon  any  point  of  the  tumor  are  exceed- 
ingly thin,  or  affected  with  gangrene,  the  incision  should  be  through  the  affected  parts. 


60G  DYSTOCIA. 

under  ordinary  circumstances,  a  serious  affair;  but,  in  the  case  of  a  newly-deli- 
vered female,  it  would  be  attended  witb  great  inconvenience ;  for,  not  to  speak 
of  the  serious  consequences  which  might  result  from  the  introduction  of  the 
uterine  fluids  into  the  cavity,  it  is  evident  that  a  dressing  which  should  be  at 
once  sufficiently  protective  and  suitable,  and  at  the  same  time  permit  the  free 
discharge  of  the  lochia,  would  be  of  very  difficult  performance. 

When  incision  is  decided  upon,  it  should  be  practised  freely ;  for  a  simple 
puncture  would  allow  only  the  fluid  blood  to  discharge,  whilst  clots  of  consider- 
able size  would  certainly  be  left  in  the  cavity.  A  too  small  incision  would  have 
the  same  inconveniences,  in  part;  therefore,  the  opening  should  be  large,  and 
made  upon  the  part  most  favorable  to  the  discharge  of  the  fluids.  Though  the 
incision  be  very  extensive  at  the  moment  it  is  practised,  on  account  of  the  great 
distension  of  the  integuments,  it  diminishes  much  by  the  retraction  of  the  walls 
of  the  tumor  after  its  contents  are  discharged.  It  will,  besides,  have  the  very 
great  advantage  of  facilitating  the  extraction  of  the  clots. 

After  the  incision  and  the  partial  evacuation  of  the  clots,  it  is  very  common 
for  inflammation  to  be  set  up  in  the  cellular  tissue  in  which  the  effusion  had 
taken  place.  This  inflammation  is  to  be  opposed  by  the  appropriate  means ;  but, 
like  M.  Deneux,  we  should  place  in  the  first  rank  attentions  to  cleanliness,  fre- 
quent washings,  and  injections,  at  first  emollient,  and  afterwards  containing  a 
small  amount  of  chlorine,  to  be  thrown  gently  within  the  cavity. 

§  3.  Sanguineous  Tumors  or  Thrombus  of  the  Lips  or  the  Xeck  of 
THE  Uterus. 

We  shall  learn  hereafter  that  the  anterior  lip  of  the  cervix  sometimes  becomes 
considerably  swelled  during  labor,  and  that  the  swelling  may  sometimes  be  occa- 
sioned by  an  infiltration  of  blood.  This  infiltration,  which  may  become  a  mecha- 
nical obstacle  to  the  expulsion  of  the  head,  is  certainly  the  first  degree  of  a  much 
more  serious  accident ;  for  the  blood,  which  is  merely  infiltrated  at  the  outset, 
may,  by  separating  the  meshes  of  the  tissues  of  the  neck,  collect  in  a  cavity, 
which,  by  opening  afterward  in  the  same  way  as  the  thrombus  of  the  vulva,  may 
give  rise  to  mortal  hemorrhage.  A  case  of  this  kind  was  communicated  to  the 
Obstetrical  Society  of  Dublin  by  Dr.  Johnston,  and  its  character  was  so  remark- 
able as  to  justify  our  giving  a  short  analysis  of  it. 

A  woman,  who  had  already  given  birth  to  six  children,  was  delivered  for  the 
seventh  time,  after  four  hours  of  easy  labor.  The  child  presented  by  the  breech. 
The  after-birth  came  away  without  difficulty,  and  the  patient  was  perfectly  well 
for  the  three  first  days ;  about  the  fifth  day,  however,  she  was  seized  suddenly, 
and  without  apparent  cause,  with  profuse  flooding. 

The  uterus  was  thoroughly  contracted,  and  yet,  notwithstanding  the  employ- 
ment of  the  most  appropriate  means,  she  died  in  about  an  hour  and  a  half  All 
the  abdominal  and  thoracic  organs  were  found,  at  the  autopsy,  to  be  perfectly 
healthy.  The  uterus  was  well  contracted,  but  upon  the  left  side  of  its  neck,  at 
about  an  inch  from  its  orifice,  there  was  discovered  a  rupture,  with  irregular  and 
blackened  edges.  This  opening,  which  was  large  enough  to  permit  the  easy  in- 
troduction of  two  fingers,  conducted  into  a  cavity  formed  in  the  substance  of  the 


TUMORS     OF    THE    EXCAVATION.  607 

neck,  large  eiiougli  to  contain  a  small  orange.  Five  or  six  open  vessels,  of  a  size 
sufficient  to  admit  tlie  introduction  of  a  small  bougie,  were  observed  upon  the 
internal  surflice  of  the  cavity,  and  were  proved  by  insufflation  to  communicate 
with  the  uterine  sinuses.  "A  careful  examination  of  the  specimen,"  says  Mr. 
Montgomery,  ''  convinced  me  that  it  was  a  case  of  thrombus,  whose  external 
envelope  formed  a  thin  layer  of  the  uterine  tissue,  became  gradually  thinner,  and 
finally  ruptured.  The  fluid  and  coagulated  blood  escaped  through  the  rupture, 
and  the  hemorrhage  continued."     (^Dublin  Quarterly  Journal,  1851.) 

The  thrombus  is,  in  all  probability,  developed  during  labor,  under  the  follow- 
ing circumstances.  When  the  neck  is  half  dilated  and  the  waters  discharged, 
the  anterior  lip  is  found  to  swell,  thicken,  project,  and  descend  beneath  the  pre- 
senting part,  usually  the  head,  to  the  disengagement  of  which  it  sometimes  pre- 
sents an  insurmountable  obstacle.  An  infiltration  of  blood,  which  may  become 
converted  into  a  sanguineous  collection,  is  soon  formed  in  the  substance  of  the 
lip.  The  cavity  increases  in  size,  until  its  walls  rupture  and  give  rise  to  hemor- 
rhage. The  discharge  may  then  take  place  during  the  labor  itself,  though  far 
more  frequently  it  does  not  appear  until  some  time  after  delivery.  In  the  latter 
case,  it  is  more  likely  to  prove  dangerous,  as  the  complete  retraction  of  the  uterus 
makes  it  difficult  for  the  accoucheur  to  divine  the  true  cause. 

The  introduction  of  a  tampon  into  the  vagina  is  certainly  the  most  useful 
measure  that  can  be  employed. 

§  4.  Various  other  Tumors. 

The  other  tumors  met  with  on  the  external  parts  of  generation,  are  cancers, 
phlegmons,  cysts  in  the  thickness  of  the  labia  externa,  together  with  various  ex- 
crescences and  syphilitic  vegetations.  But  whatever  may  be  the  nature  of  these 
tumors,  the  course  of  the  practitioner  is  always  the  same ;  that  is,  to  do  nothing, 
so  long  as,  by  their  size  and  character,  they  do  not  oppose  the  dilatation  of  the 
vulva;  but,  in  the  contrary  case,  to  puncture  the  cysts,  to  open  the  abscesses, 
and  to  extirpate  the  vegetations  or  degenerated  parts.  As  to  the  modus  operandi 
in  these  cases,  it  is  too  simple  to  require  a  particular  description. 

Prompt  action  is  not  requisite  in  cases  of  polypus,  for,  unless  it  be  very  large, 
it  will  seldom  offer  an  insurmountable  obstacle  to  the  expulsory  efforts  of  the 
womb ;  because,  when  adherent  to  the  vagina,  these  abnormal  growths  are  often 
pressed  beyond  the  vulva.  But  if  their  size  should  be  deemed  too  great  to  per- 
mit delivery,  the  tumor  might  be  removed. 

In  a  case  where  M.  Gensoul  was  obliged  to  apply  the  forceps,  he  seized  the 
head  and  the  fibrous  body,  whose  pedicle  adhered  to  the  upper  part  of  the  vagina, 
at  the  same  time,  and  brought  them  away  together.  The  polypus  weighed 
twenty-two  ounces  after  it  was  extracted. 

§  5.  Tumors  appertaining  to  the  Neck  or  Body  op  the  Uterus. 

Besides  the  indurations,  the  oederaatous  swellings,  and  the  cancerous  degene- 
rations affecting  the  cervix  uteri,  which  will  be  described  in  the  following  chap- 
ter, there  are  certain  tumors,  which,  though  filling  up  the  excavation,  really  have 
their  origin  or  seat  in  the  proper  tissue  of  the  neck ;  others,  that  arise  from  the 


608  DYSTOCIA. 

body  of  the  womb,  to  which  they  still  adhere  by  a  long  pedicle,  are  found  liang- 
ing  down  in  the  lesser  pelvis. 

A.  Fibrous  Tumors  of  the  Cervix  Uteri. — These  tumors  may  be  developed  in 
the  neck  as  well  as  in  the  tissue  of  the  uterine  walls.  In  a  case  described  by 
Madame  Lachapelle,  the  pelvic  excavation  was  almost  entirely  occupied  by  a 
tumor  that  seemed  enclosed  in  the  lateral  and  posterior  portions  of  the  neck ;  it 
was  as  large,  she  states,  as  the  head  of  a  foetus  at  term,  and  would  have  been  the 
more  likely  to  deceive  an  inattentive  person,  from  the  fact  of  its  presenting  a 
depression  similar  to  a  fontanelle.  The  child  was  very  small,  and  had  been  dead 
for  a  long  time;  so  that,  notwithstanding  the  size  of  the  swelling,  it  was  enabled 
to  flatten  it  down  and  pass  through  the  narrow  passage  that  still  remained  free. 
Madame  Boivin  and  M.  Duges  found,  when  making  a  post-mortem  examination 
of  a  woman  who  died  of  peritonitis,  after  a  very  painful  though  natural  labor,  a 
fibrous  body  about  the  size  of  the  fist  in  the  substance  of  the  neck ;  the  child 
had  a  fractured  cranium,  and  was  stillborn.  In  another  case  of  the  kind,  Rams- 
botham  was  obliged  to  resort  to  embryotomy ;  but  the  woman  recovered. 

M.  Danyau  reported  to  the  Academy  (1851),  a  case  in  which  he  was  much 
more  fortunate,  for  he  succeeded  in  enucleating  a  tumor  of  considerable  size 
which  had  been  developed  in  the  posterior  lip  of  the  cervix.  Encouraged  by 
the  idea  that  although  he  might  not  be  able  to  remove  it  altogether,  he  might, 
at  least,  extirpate  a  portion  large  enough  to  give  passage  to  the  foetus,  he  deter- 
mined to  operate,  and  was  successful  in  bringing  it  away  completely.  The 
appearance  of  the  tumor  was  precisely  that  of  a  fibrous  tumor  of  the  uterus ;  it 
weighed  about  20  ounces,  and  its  greatest  diameter  was  six  inches.  When  enu- 
cleated completely,  the  tumor  was  drawn  down,  but  could  not  be  extracted  until 
after  it  was  divided  into  two  parts. 

I  was  called,  in  February,  1853,  to  take  charge  of  a  young  woman  at  term  in 
her  third  pregnancy,  and  whose  waters  had  been  discharged  four  days  previously. 
Upon  practising  the  touch,  I  was  astonished  to  find  the  excavation  filled  by  a 
tumor  apparently  of  the  size  of  a  full-grown  foetal  head.  At  first,  I  was  unable 
to  discover  the  orifice  of  the  womb,  and  it  was  only  by  carrying  the  finger  very 
high  up  in  front  and  to  the  left,  that  I  succeeded  in  introducing  the  index  into 
something  like  the  finger  of  a  glove,  which  appeared  to  me  to  be  the  cervix 
retainin<T  its  full  length.  Penetrating  still  deeper,  I  at  last  reached  the  internal 
orifice,  above  which,  I  distinguished  the  foetal  head. 

"What,  now,  was  the  nature  of  the  great  tumor  which  had  thus  turned  the  neck 
aside,  and  prevented  the  effacement  that  it  should  have  undergone  during  the 
last  few  weeks  of  gestation  ?     Where,  also,  was  it  situated  ? 

My  first  hope  was,  that  it  would  prove  to  be  merely  an  exaggerated  anterior 
obliquity  of  the  neck,  and  I  asked  myself,  whether  what  sometimes  happens  to 
the  anterior  lip,  had  not  occurred  in  the  present  instance  to  the  posterior  one, 
and  whether  the  latter,  forcibly  depressed  by  the  foetal  head,  did  not  alone  form 
the  tumor  which  filled  the  excavation.  But  the  tumor  had  a  peculiar  consistence 
and  an  apparent  fluctuation,  by  no  means  resembling  the  hardness  of  the  head, 
besides  which,  the  hypothesis  did  not  explain  the  persistence  of,  and  the  increased 


TUMORS    OF    THE    EXCAVATION.  609 

length  of  the  neck.  A  fresh  examination  induced  me  to  conclude  that  a  solid 
tumor  had  become  developed  in  the  substance  of  the  neck. 

The  waters  had  continued  to  discharge  for  the  past  four  days  without  any  pain, 
and  I  resolved  to  wait.  The  next  day,  the  condition  of  things  remaining  the 
same,  I  requested  M.  Dubois  to  examine  the  patient. 

A  long  investigation  induced  M.  Dubois  to  suppose  that  a  cyst  containing 
fluid  had  formed  in  one  of  the  lips  of  the  orifice,  and  therefore  he  recommended 
waiting,  and  finally  puncture,  if  the  tumor  should  appear  to  present  an  insur- 
mountable obstacle,  after  labor  had  continued  for  a  certain  time. 

At  first  I  did  not  coincide  with  this  diagnosis,  but  it  also  seemed  to  me  wisest 
to  wait  for  the  pains.  The  latter  appeared  decidedly  on  the  evening  of  the  next 
day,  five  days  after  the  membranes  were  ruptured ;  they  continued  all  night  with- 
out effecting  any  change  either  in  the  tumor,  or  in  the  situation  or  length  of  the 
neck.  To  clear  up  the  diagnosis,  I  introduced  the  entire  hand  into  the  excava- 
tion, and  grasping  the  whole  tumor,  I  declared  joyfully  to  my  friend,  M.  Par- 
chappe,  that  I  had  been  deceived,  that  M.  Dubois  was  right,  and  that,  most 
happily,  we  had  to  deal  with  a  cyst. 

With  a  long  trocar,  of  at  least  an  eighth  of  an  inch  in  diameter,  I  made  a 
puncture,  but,  to  my  great  surprise,  nothing  escaped.  I  endeavored  to  remove 
obstructions  from  the  tube,  if  there  were  any,  but  in  vain ;  nothing  appeared. 

My  sensations  were  so  decided,  and  so  convinced  was  I  that  I  had  to  deal  with 
a  cyst,  that  I  had  no  hesitation  in  puncturing  anew;  but  the  same  result  fol- 
lowed, and  I  was  obliged  to  relinquish  the  idea. 

M.  Dubois  being  absent,  I  requested  my  professional  brother  and  friend,  M. 
Danyau,  to  assist  me  with  his  advice.  I  related  to  him  all  that  had  passed,  and 
insisted  especially  upon  the  result  of  my  two  punctures,  but  notwithstanding  all 
this,  M.  Danyau,  after  examining  the  patient,  was  convinced  of  the  existence  of 
a  cyst.  He  made  two  successive  punctures,  but  not  a  drop  of  fluid  escaped. 
There  was  no  avoiding  the  conclusion ;  it  was  not  a  cyst. 

What,  then,  was  to  be  done  ?  We  could  no  longer  hear  the  pulsations  of  the 
foetal  heart.  After  proving  our  incapacity  of  making  an  exact  diagnosis  of  the 
nature  of  the  tumor,  we  thought  that  its  soft  and  apparently  fungous  character 
would  enable  us  to  incise  it  throughout  its  extent,  and  thus  create  a  passage  to 
the  foetus,  which  we  then  might  extranet.  The  tumor  was  therefore  divided  into 
two  lateral  parts,  and  we  were  able  to  reach  the  head. 

The  forceps  were  at  first  applied  with  much  difficulty,  but  notwithstanding  the 
diminution  that  the  tumor  had  undergone,  it  obstructed  the  entire  excavation, 
and  rendered  the  extraction  of  the  head  impossible.  Craniotomy  and  the  appli- 
cation of  the  cephalotribe  forceps  were  equally  unsuccessful. 

Blood  flowed  freely  from  the  incised  tumor,  the  patient  was  pale  and  pros- 
trated, and  the  uterine  contractions  became  weaker  and  weaker.  But  a  single 
feeble  hope  remained,  namely,  pelvic  version.  It  was  performed  immediately, 
and  the  trunk  of  the  foetus,  bringing  with  it  the  entire  tumor  externally,  enabled 
us  at  last  to  extract  the  child. 

The  operation  had  lasted  two  hours,  and  the  unfortunate  lady  was  exhausted. 

39 


61^  DYSTOCIA. 

Before  extracting  the  placenta,  ergot  was  administered,  the  uterus  rubbed,  and 
the  after-birth  was  expelled  almost  spontaneously.  Notwithstanding  all  our 
precautions,  and  the  use  of  all  kinds  of  tonics  and  stimulants,  some  blood  still 
escaped  from  the  womb,  which  in  a  patient  already  exhausted  by  the  hemorrhage 
from  the  operation,  was  sufficient  to  cause  a  fatal  termination.  She  died  about 
half  an  hour  after  her  delivery. 

The  autopsy  showed  that  the  tumor,  which  was  larger  than  the  head  of  a  child 
at  term,  had  formed  in  the  anterior  lip  of  the  cervix.  By  its  weight,  which  was 
considerable,  it  had  during  life  so  twisted  the  neck  around,  as  to  bring  the  pos- 
terior lip  in  front,  which  explains  the  situation  of  the  orifice,  as  the  seat  of  the 
tumor  accounts  for  the  persistence  of  the  length  of  the  neck,  notwithstanding 
the  progress  of  gestation. 

The  tumor  was  constituted  of  a  soft  and  spongy  tissue,  resembling  rarified 
placental  tissue,  the  meshes  of  which  circumscribed  numerous  cavities,  in  which 
no  fluid  was  to  be  found.  No  abnormal  element  could  be  discovered  by  the  most 
careful  examination,  no  newly-formed  pathological  product;  it  was  simply  an 
enormous  hypertrophy  of  the  tissue  of  the  neck.  Such  was  the  opinion  of  several 
professors  who  examined  the  specimen  at  the  School  of  Medicine. 

There  is  every  reason  to  believe  that  this  tumor  was  developed  during  the  last 
pregnancy,  for,  eighteen  months  before  this  last  delivery,  I  attended  her  on 
account  of  a  miscarriage,  and  did  not  at  that  time  detect  any  anomaly  either  of 
structure  or  form  affecting  the  neck. 

These  examples  show  what  may  he  feared  or  hoped  for  in  such  cases.  Thus, 
we  should  wait  when  the  tumor  is  very  small  and  so  situated  as  to  correspond 
with  one  of  the  large  diameters  of  the  pelvis,  or  extirpate  it,  if  the  bistoury  can 
reach  it  without  danger,  which  seldom  happens ;  on  the  other  hand,  where  its 
size  no  longer  permits  us  to  attempt  the  extraction  of  a  living  infant,  to  resort  to 
embryotomy;  and,  if  the  excavation  is  completely  obstructed,  to  open  a  passage 
for  the  child  by  the  C^esarean  operation. 

B.  The  polypous,  or  pediculated  fibrous  tumors  that  arise  from  the  body  or  neck 
of  the  womb  are  seldom  very  serious ;  for,  when  their  size  appears  to  constitute 
an  insurmountable  obstacle  to  the  delivery,  an  extirpation  of  them  is  nearly 
always  feasible. 

As  a  general  rule  their  diagnosis  is  readily  made  out,  though  several  singular 
errors  on  this  head  are  recorded  by  authors;  for  example,  Dr.  Merriman  relates 
a  case  in  which  an  experienced  physician  mistook  a  polypus  for  the  head  of  a 
child ;  and  Smellie  furnishes  two  similar  instances ;  consequently,  we  must  not 
trust  to  a  superficial  examination. 

The  influence  of  uterine  polypi  over  the  progress  of  labor  will  be  modified  by 
a  number  of  circumstances  ;  thus,  when  the  tumor  is  small,  it  may  be  compressed 
against  one  of  the  walls  of  the  excavation  by  the  child's  head,  and  the  latter 
then  passes  before  it ;  or,  where  the  pedicle  is  very  long,  the  fibrous  mass  is 
pushed  by  the  head  entirely  out  of  the  vulva,  and  therefore  only  retards  the 
foetal  expulsion  in  a  slight  degree.     This  occurred  in  a  case  reported  by  Dr.  F. 


TUMORS    OF    THE    EXCAVATION. 


611 


Fig.  93. 


H.  Ramsbothara ;  who  says,  "  I  was  summoned  to  a  woman  in  labor,  and  found  a 
tumor  of  the  size  of  a  goose's  egg  hanging  in  the  vagina. 

*'  I  had  no  difficulty  in  determining  it  to  be  a  polypus,  whose  pedicle  was  at- 
tached to  the  internal  wall  of  the  organ  above  the  neck.  Dilatation  took  place 
rapidly,  and  the  membranes  ruptured ;  then,  in  less  than  an  hour,  the  head, 
urged  on  by  powerful  contractions,  forced  the  body  of  the  polypus  outside  of  the 
vulva  and  became  disengaged."    (^Obstetric.  Med.  and  Surg.,  p.  237.) 

After  having  consulted  with  his  father,  whether  it 
■was  advisable  to  remove  the  polypus  at  once,  the  ques- 
tion was  determined  in  the  negative. 

In  many  cases,  therefore,  we  may  trust  to  the  re- 
sources of  the  organism,  remembering,  at  the  same  time, 
that  too  great  a  delay  is  not  without  danger  both  to  the 
mother  and  child ;  and,  where  the  inefficiency  of  the 
uterine  contractions  has  been  fully  ascertained,  a  divi- 
sion of  the  pedicle  appears  to  us  to  be  the  only  resource. 
If  the  subsequent  extraction  of  the  tumor  is  rendered 
very  difficult  by  its  volume,  it  might  be  cut  up  into 
several  pieces,  as  I  have  seen  done  on  two  occasions,  or 
be  firmly  grasped  with  a  small  serrated  forceps.  Pelvic 
version,  which  is  recommended  by  some  authors,  could  This  figure,  taken  from 
be  performed  in  those  cases  only  in  which  the  length  of   R^^m^i^o'i'^m's   work,  shows 

.  1  •!•  1  1     1-1  '''^   silualion    of  ihe    polypus 

the  pedicle  gives  great  mobility  to  the  tumor,  and  allows    described  by  him. 
it  to  be  pushed  above  the  superior  strait.     It  is  unne- 
cessary to  add  that,  if  the  existence  of  this  tumor  in  the  canal  be  ascertained 
during  the  latter  months  of  gestation,  it  should  be  excised  immediately,  if  it  be 
of  a  sufficient  size  to  render  the  parturition  difficult  or  tedious. 

C.  Fungous,  or  Caidljloioer  Tumors,  &c. — These  tumors,  which  resemble  a 
cauliflower  in  their  appearance,  may  arise  from  either  lip  of  the  womb  ;  and  then, 
by  acquiring  a  considerable  size,  they  mask  the  orifice  and  render  it  nearly  in- 
accessible. As  they  often  give  rise  to  hemorrhage,  and  as  the  spongy  tissue  that 
constitutes  them  has  some  analogy  with  the  placental  structure,  they  have  occa- 
sionally been  mistaken  for  a  placenta  praevia.  Both  Madame  Lachapelle  and 
Denman  relate  errors  of  this  character ;  and  I  witnessed  the  following  still  more 
singular  case.  The  internes  of  the  Hospital  de  I'Oursine  sent  for  M.  Nelaton, 
who  was  surgeon  to  the  establishment,  to  turn  in  a  supposed  case  of  hand  pre- 
sentation. M.  Nelaton  desired  me  to  accompany  him ;  and,  on  our  arrival,  we 
ascertained  that  these  young  gentlemen  had  mistaken  an  enormous  cauliflower 
excrescence,  that  sprung  from  the  anterior  lip  of  the  cervix  uteri,  for  the  hand ; 
its  pedicle  was  at  least  an  inch  and  a  half  long,  and  its  base  presented  five  or  six 
little  vegetations  that  had  been  mistaken  for  the  fingers. 

It  frequently  happens  that  these  tumors  are  small  enough  to  admit  of  the 
child's  spontaneous  delivery;  indeed,  such  was  the  fact  in  the  case  just  men- 
tioned ;  but  there  are  many  others  where  the  accoucheur  is  less  fortunate.  Take, 
for  instance,  the  seven  cases  reported  by  Puchelt ;  in  one  of  which  it  was  neces- 


612  DYSTOCIA. 

sary  to  make  incisions  upon  another  part  of  the  hard  and  scirrhous  neck,  so  as 
to  secure  the  introduction  of  the  hand,  and  in  a  second,  to  remove  the  tumor, 
that  was  attached  to  the  anterior  lip  and  occupied  all  the  vagina,  by  the  scissors; 
gastrotomy  was  resorted  to  in  a  third,  on  account  of  a  rupture  of  the  womb,  and 
not  even  the  child  was  saved ;  in  another,  the  extraction  of  the  child  was  im- 
possible, notwithstanding  the  perforation  of  the  cranium,  and  the  woman  died 
before  delivery.     Only  a  single  mother  survived. 

D.  Encysted  tumors,  adhering  to  the  cervix  uteri,  or  to  the  vaginal  walls,  may 
also  exist  in  the  excavation.  As  a  general  rule,  they  are  rounded,  well-defined, 
movable,  elastic,  yielding  a  little  under  a  moderate  pressure,  and  sometimes 
fluctuating;  the  mucous  membrane  covering  them  remains  unaltered.  A  small 
puncture,  in  the  way  of  exploration,  will  always  dissipate  any  doubts  concerning 
their  true  nature,  especially  if  containing  a  liquid ;  and  where  they  enclose  a 
solid,  cheesy,  or  fatty  matter,  some  portions  of  it  will  adhere  to  the  canula. 

An  attempt  should  be  made  to  push  the  tumor  above  the  superior  strait,  before 
the  head  becomes  engaged ;  and  the  membranes  must  be  ruptured  early,  so  as  to 
determine  the  engagement  of  the  foetus.  In  the  opposite  case,  it  will  be  requi- 
site to  evacuate  the  liquid  by  a  simple  puncture,  or  even  to  make  an  incision 
large  enough  to  allow  the  contents  to  be  pressed  out. 

ARTICLE   III. 

OF  TUMORS   IN   THE   NEIGHBORINa  PARTS. 

These  are  very  variable,  both  in  character  and  location ;  and  may  appertain 
either  to  the  ovary,  the  Fallopian  tube,  the  rectum,  the  bladder,  or  to  the  cellular 
tissue  of  the  pelvis. 

§  1.  Tumors  of  the  Ovary. 

This  organ  may  be  affected  with  a  number  of  diseases,  nearly  all  of  which 
have  the  effect  of  singularly  augmenting  its  volume ;  thus  cysts,  distended  with 
solid  or  liquid  matters,  are  frequently  observed  there,  and  abscesses  have  also 
been  met  with ;  or  this  body  itself  may  become  hypertrophied,  or  be  affected 
with  scirrhous  or  encephaloid  cancer.  But  we  shall  not  treat  of  these  latter 
affections,  further  than  to  examine  the  influence  they  may  have  over  the  puer- 
peral functions.  In  this  respect,  it  is  highly  important  to  ascertain  the  exact 
seat  of  the  tumor;  for  sometimes  the  diseased  ovary  remains  in  the  abdominal 
cavity  above  the  superior  strait ;  and,  again,  it  is  very  often  displaced,  and  falls 
into  the  pelvic  excavation.  In  the  former  case  it  may,  doubtless,  obstruct  the 
development  of  the  uterus,  by  its  bulk,  and  thus  bring  on  a  premature  labor;  or 
it  may  produce  an  obliquity  of  the  womb  by  pressing  the  latter  to  the  opposite 
side,  and  thus  prove  a  source  of  dystocia;  but  it  particularly  claims  the  attention 
of  the  accoucheur  when  situated  in  the  lesser  pelvis ;  for  it  may  then  so  obstruct 
the  passages,  'that  a  natural  delivery  of  the  child  becomes  wholly  impossible. 

The  tumors,  constituted  by  the  displaced  ovary,  nearly  always  fall  down  into 


TUMORS  OF  THE  EXCAVATION.  613 

the  cul-de-sac,  formed  by  the  peritoneum,  in  being  reflected  from  the  posterior 
surface  of  the  uterus  to  the  anterior  one  of  the  rectum.  In  a  single  case  only, 
reported  by  Jackson,  has  it  been  found  behind  the  rectum,  which  latter  was  then 
pressed  forward.     This  singular  anomaly  merits  attention. 

The  ovarian  tumors  vary  greatly,  both  in  their  volume  and  form — from  the 
size  of  a  small  orange  up  to  that  of  a  child's  head ;  sometimes  they  only  occupy 
a  part  of  the  excavation,  while,  at  others,  they  fill  it  up  so  completely  that  the 
finger  can  scarcely  be  introduced  between  them  and  the  pelvic  walls.  It  is  im- 
portant in  practice  to  ascertain  these  differences  of  size  and  location,  and  equally 
so  to  detect  the  nature  of  the  tumor,  and  the  kind  of  material  that  forms  it.  In 
some  cases  of  ovarian  dropsy,  the  fluctuation  is  so  evident  that  no  possible  doubt 
can  exist  concerning  its  character,  but,  in  others,  this  sensation  is  not  so  clearly 
recognized ;  though  here  the  smooth  and  polished  surface  of  the  tumor,  and  its 
rounded  form,  compared  with  the  irregularities,  and  the  nodules  exhibited  by 
cancerous  degenerations  of  this  organ,  will  facilitate  the  diagnosis.  The  density 
of  the  fluid  tumor,  its  elastic  resistance  and  fluctuation,  are  singularly  modified 
during  the  contraction ;  because,  being  then  strongly  compressed  by  the  child's 
head,  the  sac,  that  was  at  first  soft  and  yielding,  becomes  hard,  tense,  and  resis- 
tant ;  consequently,  it  is  advisable  to  examine  both  during  and  after  the  pain, 
for  the  difi"erences  then  presented  will  likewise  aid  in  making  out  the  diagnosis. 
The  exploration  should  be  made  both  by  the  vagina  and  rectum,  since  this  is  the 
best  method  of  distinguishing  the  enlargements  of  the  ovary,  from  those  belong- 
ing to  the  uterus  or  the  vagina.  This  double  exploration  only  admits  of  their 
being  confounded  with  the  tumors  existing  in  the  recto-vaginal  septum ;  but  this 
error  would  be  of  little  consequence,  since  the  two  cases  present  the  same  indi- 
cations for  treatment. 

The  presence  of  such  tumors  is  always  a  very  unfavorable  complication  of  the 
labor ;  but  the  prognosis  will  necessarily  vary  with  their  volume,  seat,  nature,  and 
mobility,  as  also  according  to  the  period  at  which  the  physician  is  summoned. 
Thus,  in  thirty-one  cases  recorded  by  Puchelt,  fifteen  were  fatal  to  the  mother 
and  twenty-three  to  the  child.  Twenty-one  children  and  one  woman  died  during 
the  labor. 

As  regards  the  treatment,  the  same  course  is  not  always  to  be  pursued  in  the 
cases  under  consideration.  There  is  evidently  nothing  to  be  done  where  the  size 
and  locality  of  the  tumor  afi"ord  a  well-grounded  hope  of  a  spontaneous  delivery ; 
but  when  it  is  movable,  and  the  head  has  not  yet  engaged,  it  is  recommended 
to  attempt  to  press  up  the  former  above  the  abdominal  strait;  and,  should  the 
tumor  still  have  a  tendency  to  fall  back,  after  having  been  carried  up,  it  ought 
to  be  supported,  while  the  feet  are  sought  after,  or  an  application  of  the  forceps 
is  resorted  to. 

But,  in  some  grave  cases,  the  engagement  of  the  head  or  the  adhesions  of  the 
tumor  render  a  return  of  the  latter  impossible ;  here  it  is  particularly  important 
to  be  certain  of  its  nature ;  and  if  the  signs  above  indicated  have  not  proved 
sufiicient  to  settle  the  diagnosis,  a  puncture  should  be  made  in  it,  which  would 
determine  the  question  of  its  fluidity  or  solidity.     If  it  proves  to  be  an  ovarian 


614  DYSTOCIA. 

dropsy,  it  is  to  be  evacuated  by  a  trocar  somewhat  larger  than  the  one  used  for 
the  exploratory  puncture ;  but  if  the  cyst  be  multilocular,  or  if  it  contain  a  cheesy 
matter  that  cannot  escape  through  the  canula  of  the  trocar,  a  free  incision  will 
evidently  be  requisite. 

By  allowing  the  fluid  to  escape,  the  incision  would  have  the  double  advantage 
of  facilitating  the  labor  when  the  tumor  is  very  large,  and  of  preventing  conse- 
cutive inflammation  of  the  cyst,  when  the  latter,  though  too  small  absolutely  to 
prevent  the  expulsion  of  the  foetus,  is  yet  large  enough  to  delay  it  greatly. 
Under  the  latter  circumstances,  indeed,  the  compression  it  undergoes  during 
labor  may  excite  in  it  a  violent  inflammation,  and,  in  some  cases,  even  produce 
a  rupture.  As  a  consequence  of  this  rupture,  the  fluid  may  be  discharged  ex- 
ternally through  a  perforation  of  the  vagina,  or  be  effused  into  the  cavity  of  the 
peritoneum. 

The  incision  or  the  puncture  is  usually  made  by  the  vagina,  as  the  evacuation 
of  its  contents  is  more  easily  effected  through  this  canal.  Some  persons,  how- 
ever, fearing  lest  an  incision  made  through  the  vaginal  wall  might  become  en- 
larged at  the  moment  of  the  passage  of  the  head,  have  recommended  the  intro- 
duction of  the  instrument  through  the  rectum;  and  although  this  mode  of 
operating  ought,  in  general,  to  be  rejected,  it  should  certainly  be  followed  in 
those  cases  in  which  the  tumor  is  located  between  the  posterior  part  of  the  rectum 
and  the  anterior  surface  of  the  sacrum. 

Again,  the  tumor  is  solid,  it  cannot  be  pushed  up,  and  its  size  is  so  great  as  to 
render  an  extraction  of  the  foetus  altogether  impossible.  The  case  is  then  most 
serious,  and  we  have  only  to  choose  between  an  extirpation  of  the  tumor,  or  a 
resort  to  embryotomy  or  to  the  Caesarean  operation.  Under  such  circumstances, 
if  it  were  possible  to  ascertain  that  the  abnormal  growth  had  not  contracted  inti- 
mate adhesions  to  the  neighboring  parts,  I  would  willingly  adopt  the  views  of 
Merriman,  who  recommends  its  extirpation ;  but  if  this  latter  be  deemed  im- 
practicable, a  mutilation  of  the  child  might  be  resorted  to,  when  there  is  room 
enough  between  the  tumor  and  the  pelvic  wall  to  afford  a  passage  to  the  foetus 
grasped  by  the  embryotomy  forceps ;  otherwise,  the  Caesarean  operation  seems  to 
be  the  only  resource. 

The  following  summary,  which  will  serve  to  illustrate  the  danger  of  the  opera- 
tions just  recommended,  is  extracted  from  M.  Puchelt's  statistics :  in  five  cases, 
where  the  delivery  was  abandoned  to  the  resources  of  the  organism,  four  of  the 
mothers  died,  and  but  two  children  were  born  living.  The  simple  pushing  up 
of  the  tumor  was  only  followed  by  the  safety  of  both  individuals  in  a  single  in- 
stance, while  in  another  case  the  infant  was  stillborn.  Version  was  performed 
twice,  after  having  previously  pushed  up  the  tumor,  but  this  double  operation 
was  only  once  successful  for  the  woman ;  the  child,  though  born  living,  died 
immediately  afterwards ;  but  in  the  other,  both  mother  and  child  perished.  A 
simple  puncture  of  the  tumor  was  attended  with  success  in  one  case,  though  in 
two  others  it  did  not  obviate  the  necessity  for  embryotomy,  and  both  women  died. 
The  incision  of  the  mass,  which  was  practised  in  three  instances,  was  favorable 
to  both  individuals  in  a  single  case  only,  while  in  the  other  two  the  children 


TUMORS    OF    THE    EXCAVATION".  615 

perished ;  in  a  fourth,  version  was  effected  after  the  incision,  but  both  mother 
and  child  were  lost;  the  same  result  attended  the  application  of  the  forceps  in 
one  case  j  a  perforation  of  the  cranium  was  found  necessary  in  six,  and  only 
three  of  the  women  recovered ;  and,  finally,  both  parties  survived  in  those  in- 
stances where  the  blunt  hook  could  be  employed. 

§  2.  Tumors  appertaining  to  the  Fallopian  Tube. 

As  the  tumors  of  the  tube  are  much  more  rare  than  those  of  the  ovary,  they 
very  seldom  constitute  a  mechanical  obstacle  to  the  delivery.  In  fact,  only  one 
case  of  the  kind  is  on  record,  that  related  by  Chambry  of  Boulaye,  in  the  old 
Journal  de  31edecine,  Chirurgic,  et  Pharmacie.  It  appeared  as  a  round,  hard, 
irregular,  and  partly  osseous  tumor,  the  true  seat  of  which  was  subsequently 
ascertained  by  the  post-mortem  examination.  If  a  similar  case  should  be  met 
with,  it  would  offer  the  same  indications  for  treatment  as  the  ovarian  tumors. 

§  3.  Tumors  of  the  Rectum. 

a.  Fecal  matters  may  accumulate  and  harden  in  the  rectum,  and  give  rise  to  un- 
pleasant symptoms,  which  sometimes  simulate  a  regular  disease  of  the  intestine ; 
and  if  such  an  accumulation  takes  place  towards  the  end  of  pregnancy,  it  may 
render  delivery  difficult  or  even  impossible,  by  obstructing  the  passages  the  foetus 
has  to  traverse.  In  several  of  the  reported  cases,  injections  could  not  be  made, 
and  laxatives  given  by  the  mouth  proved  ineffectual.  For  instance.  Guillemot 
says,  "  We  were  constrained,  before  delivering  her,  to  extract  all  the  excrements 
which  distended  the  said  large  bowel;"  and  Lauverjat  likewise  remarks,  "I 
introduced  my  finger  into  the  vagina,  and  pressed  on  the  matters,  with  the  view 
of  diminishing  their  solidity;  I  then  gave  two  injections,  which  soon  emptied 
the  intestine ;  the  pains,  which  had  been  completely  suspended  for  six  hours, 
reappeared,  and  the  labor  was  terminated  in  less  than  fifteen  minutes."  Under 
like  circumstances,  I  know  of  nothing  better  than  to  follow  the  example  of  these 
practitioners. 

A  curious  case,  in  many  respects,  is  reported  by  Fournier,  who  says :  "  I  was 
sent  for  by  three  surgical  students,  who  had  been  ineffectually  attempting  to  de- 
liver a  woman  for  five  days.  Having  ascertained,  on  my  arrival,  that  she  was 
costive,  and  had  not  had  a  passage  for  a  week,  I  immediately  directed  an  injec- 
tion. The  student,  charged  with  this  duty,  endeavored  in  vain  to  find  the  anus; 
and,  on  going  to  his  aid,  I  discovered  that  it  was  imperforate,  and  that  no  ves- 
tige whatever  of  an  orifice  remained;  but,  in.stead,  a  line  similar  to  the  raphe, 
extended  from  the  coccyx  to  the  vulva.  I  introduced  my  finger  into  the  vagina, 
where  I  found  the  rectum  floating,  and  as  it  was  filled  with  excrement,  compress- 
ing the  womb,  the  canula  was  introduced  there,  and  the  injection  penetrated  into 
the  intestine,  from  whence  a  prodigious  quantity  of  cherry-stones,  mixed  up  with 
fecal  matters,  came  away  at  once ;  and  after  this  evacuation,  I  terminated  the 
labor."     (^Dict.  Sci.  Med.,  torn,  iv,  p.  155.      Cas  rares.) 

B.  Scirrhus. — Dr.  Lever  relates  having  met  with  a  case  where  the  labor  was 
rendered  difficult  by  the  presence  of  a  cancerous  tumor  situated  three  inches 


616  DYSTOCIA. 

above  the  anus.     But  such  tumors  rarely  acquire  a  large  size,  and  the  application 
of  the  forceps  would  nearly  always  prove  suflSicient  to  overcome  the  obstacle. 

§  4.  Tumors  of  the  Bladder. 

The  tumors  in  the  pelvic  cavity,  dependent  on  the  bladder,  may  be  caused 
either  by  a  procidentia  vesicae,  a  cancer  of  this  organ,  or  a  urinary  calculus. 
In  addition  to  which,  we  have  elsewhere  spoken  of  the  unfavorable  influence 
that  an  excessive  distension  of  the  bladder  might  have  over  the  puerperal 
functions. 

A.  Procidentia  Vesicce  (Falling  of  the  Bladder). — Under  this  title,  certain 
authors  have  described  an  inconsiderable  displacement  of  the  bladder,  but  which 
does  not  the  less  constitute  a  true  hernia  of  the  organ ;  and  we  shall,  therefore, 
refer  our  remarks  on  this  subject  to  the  article  in  which  hernial  tumors  are 
treated  of  in  detail. 

B.  Cancer  of  the  Bladder. — Puchelt  extracts  one  case  of  this  disease  from 
Herteufer,  and  Dr.  Lever  reports  another ;  both  of  which  would  seem  to  prove 
that  the  vesical  walls,  when  attacked  by  cancer,  may  form  a  tumor  in  the  exca- 
vation large  enough  to  obstruct  the  course  of  parturition.  As  to  its  treatment, 
this  tumor  evidently  presents  the  same  indications  as  all  the  other  solid  ones 
before  described. 

C.  Urinary  Calculi. — Instances  of  a  stone  in  the  bladder  descending  into  the 
excavation,  and  thereby  obstructing  the  free  passage  of  the  head,  are  not  very 
unusual.  The  numerous  cases  of  the  kind  on  record,  prove  that  they  are  always 
situated  below  the  head,  or  else  are  placed  between  it  and  the  symphysis  pubis. 
In  a  single  instance  only,  reported  by  Lauverjat,  the  calculus  was  above  the 
pelvis,  though,  as  M.  Velpeau  remarks,  it  is  difficult  to  understand  how  it  could 
then  arrest  the  expulsion  of  the  foetus. 

Calculi  vary  very  much  in  their  size,  and  the  same  is  true  of  their  shape, 
•which  fact  modifies  the  prognosis.  The  diagnosis  iS  not  always  an  easy  matter, 
thouo-h,  if  the  tumor  felt  behind  the  symphysis  pubis  is  hard,  circumscribed, 
and  gives  rise  to  pain  when  pressed  upon  by  the  finger  or  the  child's  head,  if  it 
is  situated  without  the  vagina,  and  if  it  is  firmly  fixed  during  the  contraction, 
but  is  movable  during  the  relaxation  of  the  womb,  there  is  every  reason  to  sus- 
pect the  existence  of  a  calculus  ;  which  suspicions  would  naturally  lead  us  to  the 
use  of  the  catheter,  whereby  the  foreign  body  can  nearly  always  be  detected. 

Treatment. — An  attempt  should  be  made  to  press  up  the  stone  above  the 
superior  strait,  before  or  even  during  the  labor,  and  prior  to  the  engagement  of 
the  head;  or,  if  the  latter  is  still  movable — although  it  may  be  engaged — it 
should  be  raised  up  from  the  strait,  and  the  calculus  be  pushed  above  it.  But, 
unfortunately,  it  is  not  always  possible  to  do  this,  either  because  the  head  has 
descended  too  far  to  be  pressed  back  (the  stone  being  below  it),  or  because  this 
latter  is  forcibly  wedged  in  between  it  and  the  symphysis.  In  such  cases,  an 
extraction  of  the  calculus  seems  to  be  the  only  resource;  however,  this  need  not 
be  attempted  at  once,  for  some  of  the  reported  facts  would  seem  to  prove  that  its 
spontaneous  expulsion  may  take  place,  even  where  its  great  size  might  preclude 


TUMORS    OF    THE    EXCAVATION.  617 

all  hope  of  such  an  event,  as  occurred  in  the  following  case  reported  by  Smellie. 
The  wife  of  a  coal-porter,  who  had  long  been  suffering  from  the  presence  of  a 
stone  in  the  bladder,  became  pregnant.  The  midwife,  summoned  at  the  time  of 
labor,  was  surprised  to  find  a  hard  resistant  body  lying  before  the  head,  but,  as 
the  means  of  the  patient  did  not  admit  of  her  sending  for  a  physician  in  consul- 
tation, the  midwife  could  only  keep  up  the  spirits  of  her  patient  during  the  long 
and  painful  parturition.  At  last,  she  felt  something  coming  away,  which  proved 
to  be  a  stone  about  the  size  and  shape  of  a  goose's  gizzard,  and  which  weighed 
from  five  to  six  ounces.  Immediately  after  its  escape,  the  child  was  expelled, 
and  the  woman  recovered  in  due  time,  but  she  afterwards  suffered  from  inconti- 
nence of  urine.  Some  surgeons  have  been  encouraged,  probably  by  facts  of  this 
kind,  to  attempt  an  extraction  of  the  calculus  through  the  previously-dilated 
urethra ;  but  this  operation  requires  too  much  time  to  admit  of  being  performed 
during  the  progress  of  parturition.  If  there  should  be  no  hope  of  succeeding  by 
the  forceps  or  pelvic  version,  on  account  of  its  large  size,  it  would  be  necessary 
to  resort  to  the  operation  of  vaginal  lithotomy,  and  incise  the  urethra  directly  on 
the  stone  through  the  anterior  vaginal  wall. 

§  5.  Of  Tumors  developed  in  the  Cellular  Tissue  of  the  Pelvis. 

We  have  yet  to  treat  of  the  fatty,  the  fibrous,  and  the  cancerous  masses,  and 
of  the  abscesses,  or  encysted  tumors,  that  may  be  developed  in  the  cellular  tissue 
of  the  lesser  pelvis,  nearly  all  of  which  are  situated  in  the  substance  of  the  recto- 
vaginal septum,  though  they  are  occasionally  found  on  the  sides  of  the  vagina. 
In  one  instance,  reported  by  Ed.  Meier,  the  delivery  was  rendered  impossible  by 
the  existence  of  a  cyst,  about  the  size  of  a  child's  head,  between  the  uterus  and 
the  bladder.  The  steatomatous  and  cancerous  tumors  are  usually  found  in  con- 
tact with  the  osseous  or  ligamentous  walls  of  the  pelvis,  to  which  they  seem  to 
appertain. 

It  must  be  apparent  that  there  is  an  identity  of  nature  and  seat  between  the 
tumors  of  the  cellular  tissue  and  those  of  the  ovary;  the  reducibility  of  the  one, 
when  non-adherent,  and  the  irreducibility  of  the  others,  constitute  the  only 
marked  difference  between  the  two.  Consequently,  the  diagnosis  is  not  easily 
made  out  after  the  engagement  of  the  head,  or  when  the  ovarian  tumor  is  re- 
tained in  place  by  old  adhesions ;  but,  fortunately,  that  would  be  an  error  of  little 
importance,  since  both  present  the  same  indications  for  treatment.  It  is  more 
easy  to  distinguish  the  tumors  of  the  cellular  tissue  from  those  appertaining  to 
the  organs  before  spoken  of,  and  we  refer  to  the  signs  already  given,  as  charac- 
teristic of  each  of  them. 

The  reader  will  understand  that  the  prognosis  varies  according  to  the  size, 
nature,  density,  and  seat  of  the  tumors.  "When  small,  compressible,  and  situated 
in  the  direction  of  one  of  the  long  pelvic  diameters,  it  will  most  frequently  per- 
mit a  spontaneous  termination  of  the  labor;  and  this  may  also  take  place,  if,  not- 
withstanding its  hardness  and  size,  it  still  retains  a  certain  degree  of  mobility. 
Even  in  those  cases  where  it  is  impossible  to  push  it  above  the  superior  strait, 
we  may  still  hope  that,  being  forcibly  compressed  by  the  child's  head,  it  will 


618  DYSTOCIA. 

permit  the  latter  to  pass.  During  my  sojourn  at  the  Cliuique,  I  saw  a  woman, 
in  whom  the  child's  head  was  arrested  at  the  superior  strait  for  a  long  time,  by 
a  tumor,  which  was  probably  fibrous  in  its  character,  and  was  situated  in  front  of 
and  on  a  level  with  the  sacro-iliac  symphysis.  An  application  of  the  forceps  had 
been  seriously  thought  of,  but  the  tumor,  located  in  the  recto-vaginal  septum, 
was  gradually  forced  down  by  the  head,  under  the  influence  of  strong  contrac- 
tions, as  far  as  the  floor  of  the  pelvis,  where  it  was  pressed  backward,  at  the  same 
time  distending  the  perineum,  and  the  labor  terminated  by  the  birth  of  a  living 
child. 

In  many  cases,  the  volume  and  permanence  of  these  tumors  do  not  permit  us 
to  anticipate  so  happy  a  result,  and  it  will  then  be  necessary  to  interpose.  The 
indications  to  be  fulfilled  will  vary  according  to  the  particular  case;  that  is,  where 
an  abscess  or  an  encysted  tumor  is  detected,  it  is  to  be  punctured,  so  as  to  eva- 
cuate the  liquid,  or  it  is  to  be  incised  when  the  contents  cannot  be  removed 
by  a  simple  puncture ;  but  where  the  tumor  is  solid,  is  easily  accessible,  and 
has  contracted  no  intimate  adhesions  with  the  vagina  or  rectum,  it  ought  to  be 
extirpated.  Two  modes  of  operating  have  been  recommended  for  this  purpose ; 
in  the  one,  the  vaginal  wall  only  is  incised,  while  in  the  other  the  tumor  is 
reached  by  making  an  opening  in  the  perineum.  The  success  obtained  by  Drew 
and  Burns  pleads  in  favor  of  the  latter  procedure.  In  the  worst  cases,  where  the 
situation  of  the  tumor,  or  the  numerous  and  firm  adhesions  which  it  has  formed, 
render  its  extirpation  impracticable,  our  only  resources  are  in  the  obstetrical 
manipulations,  properly  so  called ;  namely,  the  application  of  the  forceps,  or 
tractions  on  the  feet,  if  the  tumor  is  not  very  large,  and  the  Cassarean  operation, 
or  embryotomy,  if  the  excavation  be  so  obstructed  that  the  extraction  of  a  living 
child  is  impossible. 

§  6.  Of  Hernial  Tumors. 

A  considerable  portion  of  the  intestine,  omentum,  or  bladder,  may  become 
engaged  in  one  of  the  culs-de-sac  formed  by  the  peritoneum,  in  being  reflected 
from  the  bladder  to  the  womb,  and  from  the  latter  to  the  rectum,  and  thus  con- 
stitute a  true  vaginal  hernia.  But  when  the  parts  that  are  displaced  and  engaged 
between  the  I'ectum  and  the  vagina  descend  still  more,  and  cause  a  prominence 
in  the  perineum,  the  term  perineal  hernia  is  applied. 

Under  the  title  of  vajino-lahial  hernia,  a  tumor  has  been  described,  which  is 
situated  in  the  substance  of  the  labia,  or  in  the  lowest  and  most  projecting  part 
of  the  fold  which  it  forms  with  the  skin. 

A.  Intestinal  or  Omental  Hernia. — The  seat  of  a  vaginal  enterocele,  or  epiplo- 
cele,  is  sometimes  between  the  vagina  and  bladder,  but  oftener  between  the  rec- 
tum and  the  posterior  wall  of  the  vulvo-uterine  canal,  and  always  on  one  side  of 
it,  in  consequence  of  the  vaginal  adhesions  both  behind  and  in  front.  The  mis- 
placed organ  forms  a  tumor  there  which  is  very  variable  in  its  size,  and  which 
either  presents  the  clammy  softness  of  epiplocele,  or  the  elasticity  and  rumbling 
of  an  enterocele.  Though  easily  recognized,  these  tumors  have,  in  some  in- 
stances, given  rise  to  serious  mistakes,  which  might  have  proved  disastrous  to  the 


TUMORS  OF  THE  EXCAVATION.  619 

patient.  I  was  summoned,  says  Levret,  to  a  case  of  this  kind,  where  the  question 
was  actually  discussed  whether  a  large  portion  of  the  tumor  should  be  removed  or 
not;  but  I  demonstrated,  in  a  satisfactory  manner,  that  some  part  of  the  intestine 
had  slipped  down  into  the  substance  of  the  septum,  through  the  bottom  of  the 
cul-de-sac  that  is  found  between  the  neck  of  the  womb  and  the  upper  part  of  the 
rectum.     (Levret,  Abus  des  rhfjles.) 

The  prognosis  is  unfavorable,  not  only  from  the  obstacle  thereby  created  to  the 
expulsion  of  the  child,  but  also  from  the  pressure  of  the  head  on  the  hernial  sac; 
because  an  inflammation,  that  is  always  serious,  and  which  might  sometimes  even 
terminate  in  gangrene,  may  result  in  consequence.  All  authors  have,  therefore, 
recommended  the  reduction  of  the  hernia  as  soon  as  possible. 

To  accomplish  this,  it  is  better  to  place  the  woman  on  her  knees  and  elbows, 
so  as  to  facilitate  the  return  of  the  intestine  and  the  engagement  of  the  head; 
this  position  was  followed  by  the  happiest  results  in  the  case  above  reported.  In 
another  instance,  Stubbs,  by  compressing  the  hernial  tumor,  succeeded  in  redu- 
cing it,  and  the  head  then  engaged.  In  my  estimation,  the  taxis  should  be  pre- 
ferred to  Levret's  method,  taking  care  to  sustain  the  head  at  the  same  time  with 
the  other  hand,  if  the  hernia  be  voluminous.  Where  the  reduction  is  impossible, 
it  is  necessary  to  terminate  the  labor  as  soon  as  possible  by  the  aid  of  the  forceps, 
or  by  turning. 

B.  Vulvar  or  Perineal  Hernia. — We  may  be  allowed  to  speak  in  this  place  of 
vulvar  or  perineal  hernias,  which,  although  they  do  not  present  a  mechanical 
obstacle  to  parturition,  may  give  rise  to  special  indications  during  pregnancy  and 
labor.  These  tumors,  which  are  situated  in  the  lowest  and  most  posterior  part  of 
the  greater  labia,  may  be  formed  by  the  escape  of  a  loop  of  intestine,  and  some- 
times of  a  portion  of  the  bladder.  They  have  been  oftener  observed  during 
pregnancy  than  at  any  other  period,  and  may  ultimately  acquire  a  very  consider- 
able size.  Papus  mentions  having  dissected  one  which  had  the  form  of  a  large 
bottle,  hanging  to  the  right  of  the  anus,  and  descending  as  far  as  the  leg.  In 
one  of  the  cases  observed  by  Smellie,  the  tumor,  which  toward  the  end  of  gesta- 
tion was  as  large  as  the  fist,  became  strangulated  and  gangrenous. 

The  seat  of  the  tumor,  which  is  always  situated  in  the  lower  part  of  the 
greater  labia,  between  the  edge  of  the  anus  and  the  tuberosity  of  the  ischium, 
the  ease  with  which  it  is  reduced  in  the  horizontal  position,  and  its  sudden  re- 
appearance when  the  patient  rises  or  makes  the  least  exertion,  serve  to  indicate 
its  nature.  Enterocele  may  be  distinguished  from  cystocele  by  the  gurgling 
which  accompanies  the  reduction  of  the  former.  The  latter  often  diminishes  in 
size  after  urinating,  or  using  the  catheter,  and  desires  to  urinate  are  produced  by 
pressing  upon  the  tumor. 

It  is  evident  that  the  exertions  of  labor  have  a  tendency  to  increase  the  size 
of  the  hernia  greatly,  and  even  to  produce  strangulation.  It  should  be  kept 
reduced  by  pressure  properly  applied. 

C.  Vesical  Hernia,  or  Cysiocele. — It  sometimes  happens  during  labor  that  the 
fundus  of  the  bladder  descends  below  the  head,  and  constitutes  a  tumor  of  vari- 
able size  at  the  anterior  superior  part  of  the  vagina ;  the  descent  being  probably 


620  DYSTOCIA. 

caused  by  the  pressure  made  by  the  child's  head  or 
^^°-  ^'*-  the  inferior  part  of  the  womb,  on  the  fundus  of  this 

organ.  The  patient  has  a  feeling  of  weight  or  fulness 
in  the  pelvis,  and  a  dragging  sensation  about  the  um- 
bilicus ;  she  has  a  constant  desire  to  urinate,  without 
the  power  of  emptying  her  bladder,  though,  some- 
times, each  uterine  contraction  is  followed  by  the 
emission  of  a  small  quantity  of  urine ;  besides  which, 
a  more  or  less  oval  tumor,  that  is  smooth,  soft,  and 
fluctuating  between  the  pains,  but  hard  and  tense 
whilst  they  last,  is  detected  by  the  touch  at  the  upper 
front  part  of  the  vagina ;  and  above  this  the  head  can 
Vaginal  eystoceie,  taken  from     ofjen  be  distincjuished ;  indeed,  the  finger  may  easily 

Ramsbotham.  ,.      ,     i  •     ,     ,  ,  ,      ,  .  •      , 

slip  behind  the  tumor,  and  reach  the  cervix  uteri ;  but 
it  cannot  pass  between  the  former  and  the  pubic  symphysis. 

The  tumor  formed  by  a  eystoceie  is  occasionally  quite  large.  Madame  Lacha- 
pelle  says,  "  The  first  thing  that  attracted  our  attention  was  a  pediculated  tumor, 
about  the  size  of  an  egg,  which  projected  a  little  from  the  vulva,  and  seemed  to 
be  attached  to  the  right  anterior  wall  of  the  vagina  near  its  middle.  The  pedicle 
was  about  an  inch  and  a  half  in  thickness,  and  the  tumor  contained  a  liquid,  all 
of  which  could  be  pressed  back  through  the  pedicle ;  an  opening  with  a  thick 
margin  was  then  detected,  which  appeared  to  communicate  with  the  bladder. 
In  fact,  according  to  the  woman's  account,  the  tumor  augmented  in  size  in  the 
erect  position,  though  it  often  disappeared  after  the  emission  of  urine,  and  always 
when  using  the  cold  bath.  The  uterine  pains  increased  the  size  of  the  hernia, 
and  the  head  in  descending  compressed,  and  rendered  it  very  tense;  after  having 
emptied  the  bladder,  I  reduced  it,  and  recommended  the  students  to  support  it 
with  two  fingers  during  each  contraction  of  the  womb.  The  head  soon  cleared 
the  passage,  sustaining  the  hernia  itself,  and  the  labor  terminated  favorably." 

The  tumor  is  nearly  always  seated  at  the  anterior  part  of  the  vagina ;  but,  in  a 
case  reported  by  Sandiford,  it  was  located  between  this  canal  and  the  rectum. 

There  is  one  variety  of  tumor,  formed  in  the  pelvic  cavity,  which  is  the  more 
worthy  of  attention,  as  its  true  nature  might  be  misunderstood  from  its  singular 
situation.  It  depends  on  a  lateral  displacement  of  the  bladder,  and  M.  Christian 
assigns  to  it  the  following  characters,  namely,  a  remarkable  fulness  on  one  side  of 
the  pelvis,  more  especially  during  the  uterine  contractions,  which  give  to  the 
tumor  an  evident  elasticity  and  tension ;  it  is  generally  circumscribed,  though  its 
base  is  somewhat  spread  out,  and  extends  along  the  side  of  the  pelvis  as  far  as 
the  sacrum ;  its  volume  varies,  of  course,  with  the  quantity  of  fluid  contained  in 
the  sac,  occasionally  equalling  one-third  of  the  transverse  diameter  of  the  pelvis. 

The  tumefaction  completely  disappears  after  the  use  of  the  catheter ;  and,  by 
directing  the  concavity  of  the  instrument  downwards,  its  point  can  be  felt  through 
the  walls,  and  can  readily  be  moved  from  before  backwards  in  a  horizontal  direc- 
tion. As  the  tumor  is  covered  by  the  vagina,  and  its  base  is  diff"use,  there  is  no 
danger  of  mistaking  it  for  the  bag  of  waters,  since  it  does  not  prevent  the  finger 


OBSTACLES     PRESENTED     BY    THE     UTERUS.  621 

from  reaching  the  uterine  orifice.  Cystocele  may  sometimes  be  removed  by 
pressure,  and  almost  always  by  the  catheter;  its  size  will  vary  with  the  extent  of 
displacement,  and  with  the  quantity  of  urine  contained  in  it. 

Cases  of  this  kind  merit  serious  attention,  for  they  may  be  confounded  with 
other  tumors ;  and  such  an  error  of  diagnosis  might  lead  to  the  performance  of  a 
useless  and  perhaps  dangerous  operation.  Dr.  Merriman  (Si/nopsis,  page  202) 
speaks  of  a  surgeon,  who,  supposing  he  had  to  treat  a  case  of  hydrocephalic  head, 
thrust  a  sharp  instrument  into  the  bladder;  and  a  similar  mistake,  according  to 
Hamilton,  was  committed  by  another  practitioner,  who  imagined  he  was  opening 
the  bag  of  waters. 

In  all  these  obscure  cases,  a  resort  to  the  catheter  is  the  best  possible  means  of 
diagnosis ;  nevertheless,  it  must  be  observed,  that,  for  this  measure  to  be  conclu- 
sive, it  should  be  done  in  such  a  manner  as  to  plunge  the  beak  of  the  instrument 
into  the  liquid  contained  in  the  cavity  of  the  tumor;  that  is,  after  the  instrument 
has  once  entered,  it  should  be  turned  over,  so  as  to  make  its  concavity  look  down- 
wards and  backwards.  As  a  remedy,  this  is  the  only  one  requisite,  and  the 
instrument  ought  to  be  left  in  the  bladder  until  after  the  head  is  engaged. 

Unfortunately,  its  introduction  is  not  always  an  easy  matter,  particularly  where 
the  head  has  been  wedged  in  the  pelvis  for  a  long  time ;  under  such  circum- 
stances, an  attempt  should  be  made  to  press  up  the  former  during  the  intervals; 
but  if  this  is  impracticable,  and  there  is  reason  to  fear  a  rupture  of  the  bladder 
from  its  over- distension,  I  know  of  no  other  resource  than  to  puncture  the  organ 
with  a  very  delicate  trocar. 


CHAPTER  IV. 

OBSTACLES   PRESENTED   BY   THE   NECK   AND   BODY   OF   THE   UTERUS. 
ARTICLE   I. 

OBSTACLES   DEPENDENT   ON   THE   NECK. 

The  obstacles  to  delivery  which  the  cervix  uteri  may  present,  are  due  either 
to  a  rigidity  or  spasmodic  contraction  of  the  orifice,  or  to  its  obliquity,  to  an 
agglutination  or  complete  obliteration  of  the  lips,  or  to  a  scirrhous  or  other  dege- 
neration of  its  tissue. 

§  1.  Rigidity  of  the  Neck. 

Under  certain  circumstances,  the  fibres  of  the  uterine  neck  seem  to  possess  an 
extraordinary  degree  of  resistance ;  and  although  they  have  none  of  the  charac- 
ters we  are  about  to  indicate  as  appertaining  to  an  inflammatory  or  spasmodic 
contraction,  yet  their  dilatation  is  not  effected.  According  to  Dewees,  this  resis- 
tance of  the  cervix  uteri  is  particularly  apt  to  be  met  with  in  very  young  girls,  or 


622  DYSTOCIA. 

in  middle-aged  women  in  their  first  labors,  and  also  in  those  cases  in  which  par- 
turition takes  place  prematurely. 

There  is  one  symptom  that  would  lead  us  to  suspect  a  rigidity  of  the  os  uteri, 
even  before  an  examination ;  we  allude  to  what  is  ordinarily  termed  the  pains  in 
the  loins.  These  have  always  appeared  to  Madame  Lachapelle  to  be  a  conse- 
quence of  the  rigidity  of  the  external  orifice,  either  from  its  experiencing  a  kind 
of  cramp,  or  that  because  of  its  having  to  sustain  the  whole  force  of  the  uterine 
contractions  in  consequence  of  its  firmness,  it  sufi'ers  more  than  when  soft  and 
yielding. 

Prolonged  baths,  employed  from  the  beginning  of  the  labor,  and  bleeding  from 
the  arm,  if  not  contraindicated  by  the  general  condition  of  the  patient,  are  the 
only  measures  which  need  be  used  under  these  circumstances. 

However,  as  this  extreme  slowness  appears  from  the  beginning  of  the  labor, 
that  is  to  say,  at  a  period  in  which  the  membranes  are  still  intact,  the  life  of  the 
foetus  is  by  no  means  endangered  thereby,  and  its  only  eifect  is  to  fatigue  the 
mother  greatly.  Therefore,  unless  some  dangerous  complication  should  super- 
vene, there  is  nothing  to  do  but  recommend  patience.  Still,  if  the  labor  should 
be  extremely  prolonged,  and,  by  its  duration,  seem  likely  to  endanger  the  life  of 
the  mother,  it  would  be  right  to  make  a  few  incisions  upon  the  lateral  parts  of 
the  cervix. 

§  2.  Spasmodic  Contraction  or  the  Neck. 

Again,  it  may  happen  that  after  having  attained  a  considerable  degree  of  dila- 
tation, the  cervix  becomes  affected  with  spasmodic  contraction,  whereby  its 
subsequent  expansion  is  retarded,  or  suspended  altogether  for  several  hours. 
The  orifice  then  presents  a  thin,  cutting  edge,  and  is  warmer,  drier,  and  more 
sensitive  to  pressure  of  the  finger;  in  short,  is  much  more  irritable  than  usual. 

This  condition,  which  has  been  designated  as  spasmodic  contraction  of  the 
external  orifice,  may  be  confounded  with  the  simple  rigidity  just  spoken  of,  and 
with  the  natural  retraction  of  the  neck,  when  the  presenting  part  of  the  child 
does  not  engage  in  its  opening  immediately  after  the  rupture  of  the  membranes. 
In  the  latter  case,  however,  the  thick,  soft,  and  easily  dilatable  edges  of  the  ori- 
fice, will  always  enable  us  to  avoid  error.  In  the  former  case,  the  diagnosis  is 
often  more  difficult  if  all  the  phenomena  of  the  labor  have  not  been  watched,  and 
the  extreme  sensibility  of  the  neck,  which  is  not  generally  met  with  in  rigidity, 
will  be  the  only  evidence  that  we  have  a  case  of  spasmodic  contraction  to  deal 
with.^ 

This  state  of  spasm  does  not  generally  last  for  a  great  while ;  but  so  long  as  it 
exists,  the  dilatation  is  extremely  slow,  and  sometimes  hardly  takes  place  at  all. 
Usually,  however,  the  efibrts  of  the  body  of  the  womb  overcome  the  resistance 
at  last,  and  the  head  of  the  foetus  clears  the  orifice ;  but,  in  some  cases,  it  happens 

'  Rigidity  is  a  passive  force,  by  which  the  fibres  of  the  orifice  resist  the  dilatation  they 
have  to  undergo.  Spasmodic  contraction  is  an  active  force,  by  which  the  fibres  contract  and 
diminish  the  size  of  the  opening  previously  exhibited  by  the  mouth  of  the  womb. 


OBSTACLES    PRESENTED    BY    THE    UTERUS.  623 

that  being  no  longer  supported,  the  neck  retracts  immediately,  and  grasps  the 
neck  of  the  foetus  more  or  less  forcibly,  so  that  a  new  dilatation  is  required  to 
allow  the  shoulders  to  pass ;  nor  is  this  second  dilatation  as  easy  as  might  be 
expected. 

This  spasm  of  the  external  orifice  may  be  met  with  in  strong  and  plethoric 
women,  but  also  in  lymphatic,  nervous,  and  very  irritable  individuals,  of  a  pale 
and  relaxed  fibre.  In  the  former  case,  general  bleeding  is  one  of  the  first  mea- 
sures to  be  had  recourse  to,  but  in  the  latter  it  might  prove  hurtful.  Under 
both  circumstances,  however,  recourse  may  be  had  with  advantage  to  emollient 
injections,  fumigations,  baths,  and  the  administration  of  laudanum  by  clysters, 
or,  preferably,  the  application  of  belladonna  to  the  uterine  neck  itself.  Chaus- 
sier,  who  has  particularly  recommended  the  use  of  this  latter  remedy,  was  in  the 
habit  of  using  an  ointment  prepared  by  mixing  and  triturating  one  drachm  of 
the  extract  or  juice  of  belladonna  with  an  ounce  of  lard.  But  as  the  application 
of  this  ointment  is  quite  difficult,  Professor  P.  Dubois  prefers  the  ordinary  dry 
extract.  He  places  a  little  pellet  of  it,  about  the  size  of  a  pea,  on  the  nail  ot 
the  index  finger,  which  latter  is  then  carried  up  to  the  cervix,  where,  in  the 
course  of  a  few  minutes,  the  heat  and  moisture  of  the  parts  soften  the  extract, 
which  is  then  readily  smeared  over  the  external  and  internal  surfaces  of  the 
neck. 

The  belladonna,  so  highly  lauded  by  some  accoucheurs,  is  by  others  thought 
to  be  useless.  It  seems  to  me  that  this  difference  in  opinion  has  arisen  from 
confounding  simple  rigidity  with  spasmodic  contraction.  Though  without  action 
in  the  former  case,  I  think  it  very  useful  in  the  latter. 

If  all  these  measures  prove  unsuccessful,  or  if  an  accident,  which  endangers 
the  life  of  the  mother  or  child,  should  demand  a  prompt  termination  of  the  labor, 
the  accoucheur  will  have  to  choose  between  a  forcible  introduction  of  the  hand 
and  multiple  incisions  upon  the  neck.     (See  Difficulties  of  Pelvic  Version.) 

But  it  is  not  the  external  orifice  alone  which  may  retard  the  delivery  of  the 
foetus  by  retracting  on  its  neck,  for  very  often  the  internal  one,  or  rather  that 
portion  of  the  uterine  walls  which  corresponded  to  it  in  the  non-gravid  state, 
retracts  forcibly  on  the  neck  of  the  child,  even  before  the  head  has  cleared  the 
external  orifice ;  so  that  the  latter,  being  retained  in  the  portion  of  the  organ  that 
appertains  to  the  neck  after  delivery,  can  advance  no  further.  This  internal 
contraction  only  takes  place  where  the  waters  have  escaped  for  some  time,  and  it 
evidently  results,  as  Dewees  has  remarked,  from  the  double  tendency  of  the  womb 
to  regain  its  primitive  form,  and  to  accommodate  itself  to  the  shape  of  the  parts 
contained  within  its  cavity. 

There  is  every  reason  to  suspect  that  the  delay  in  the  progress  of  the  head  is 
dependent  on  this  cause,  when,  notwithstanding  the  energy  of  the  pains  and  the 
absence  of  all  other  sources  of  dystocia,  it  is  found  to  make  no  advance  at  all,  or, 
even  if  it  approaches  the  vulvar  orifice  during  the  contraction,  it  returns  to  its 
primitive  position  immediately  afterwards.  Besides  which,  if  the  finger  is 
slipped  above  the  head,  the  latter  will  be  found  free  in  the  excavation ;  but  one 


624  DYSTOCIA. 

of  the  orifices  (the  internal  one,  most  usually)  will  be  strongly  retracted  around 
the  neck. 

Bleeding,  general  bathing,  and  laudanum  injections,  may  be  employed  use- 
fully under  these  circumstances  also,  though  it  sometimes  happens  that  the  con- 
traction of  the  internal  orifice  persists  notwithstanding.  Under  these  circum- 
stances, should  version  be  judged  necessary,  the  most  serious  difficulty  may  be 
anticipated  in  passing  the  hand  through  the  retracted  part ;  and  if  the  application 
of  the  forceps  be  deemed  requisite,  as  it  would  be  if  the  head  were  already 
engaged,  but  delayed  by  the  retraction  of  the  internal  orifice,  this  latter  circum- 
stance, by  arresting  the  shoulders,  would  render  the  delivery  impossible.  It  is 
then  we  must  have  recourse  to  the  measures  so  much  vaunted,  and  so  often  em- 
ployed by  Dewees  with  success,  namely,  to  bleeding  in  the  arm,  pushed  ad  deli- 
quium  animi.  But,  in  order  to  avoid  drawing  too  great  a  quantity  of  blood,  the 
patient  should  be  directed  to  stand  up,  if  possible,  and,  as  soon  as  fainting  occurs, 
she  is  to  be  replaced  on  the  bed ;  when,  according  to  the  American  accoucheur, 
the  relaxation  in  the  retracted  orifice,  produced  by  the  syncope,  will  be  such  that 
the  pelvic  version,  or  the  extraction  of  the  head  by  the  forceps,  can  always  be 
performed.  Finally,  in  those  cases  where  the  woman's  general  condition  does 
not  permit  a  resort  to  bloodletting,  we  may  employ  the  opiates  in  a  full  dose, 
either  by  the  mouth  or  by  injection,  with  great  advantage. 

The  reader  will  also  understand  that,  in  a  natural  labor  by  the  pelvis,  the 
retraction  of  one  of  these  orifices  may  likewise  arrest  the  head.  Under  such 
circumstances,  if  the  source  of  difficulty  is  confined  to  the  external  one,  nume- 
rous incisions  might  be  made  in  the  ring  of  the  os  uteri ;  but,  if  it  is  at  the 
internal  orifice,  Dewees's  plan  should  certainly  be  followed.  It  is  likewise  impor- 
tant to  ascertain,  at  once,  whether  the  child  is  still  living ;  for  though  it  be  diffi- 
cult to  admit  that  a  strangulation  of  the  foetus  can  occur  from  direct  pressure, 
yet  it  is  not  the  less  true  that  the  umbilical  cord,  from  being  nearly  always  com- 
pressed in  these  unfortunate  cases,  exposes  the  child  to  a  speedy  death ;  and,  if 
the  infant  is  already  lost,  we  may  employ,  beneficially,  either  belladonna,  or  the 
opiates  internally,  according  to  the  orifice  retracted. 

In  cases  of  this  kind,  the  use  of  anesthetics  might  prove  serviceable,  by  pro- 
ducing relaxation  of  the  partial  spasm  of  the  uterine  fibres. 

§  3.  Obliquity  of  the  Orifice. 

In  consequence  of  the  usual  direction  of  the  uterus,  the  neck  is  slightly  turned 
downward  and  backward.  This  posterior  obliquity  may,  in  some  cases,  be  much 
greater,  whilst  in  others,  the  orifice  may  be  directed  strongly  forward,  or  toward 
one  of  the  sides  of  the  pelvis.  When  treating  hereafter  of  malpositions  of  the 
body  of  the  womb,  we  shall  have  occasion  to  speak  of  the  effect  of  retroversions 
and  lateral  obliquities  upon  the  direction  of  the  neck.  We  would  treat  at  pre- 
sent of  the  posterior  obliquity  of  the  orifice,  which  is  by  far  the  most  frequent. 

The  posterior  obliquity  of  the  neck  may  be  due  to  an  extreme  anteversion  of 
the  body  of  the  organ,  though  it  may  also  be  very  well  marked,  even  when  the 
fundus  of  the  womb  projects  no  farther  forward  than  usual.     This  deviation  of 


OBSTACLES     PRESENTED     BY    THE    UTERUS.  625 

the  orifice  may  also  take  place  during  labor ;  but  it  may  also  exist  in  the  latter 
stages  of  pregnancy. 

In  the  former  case,  the  obliquity  is  due  to  the  fact  that  the  dilatation  of  the 
orifice  is  effected  more  at  the  expense  of  the  posterior  than  of  the  anterior  lip, 
and,  consequently,  the  plane  of  this  opening-  would  naturally  be  found,  in  most 
cases,  behind  the  long  axis  of  the  organ.  Wherefore,  this  irregular  dilatation 
may,  independently  of  any  deviation  in  the  fundus,  produce  such  an  obliquity  of 
the  neck,  that  the  plane  of  its  orifice,  instead  of  being  horizontal,  has  very  nearly 
a  vertical  direction ;  that  is,  the  opening  looks  directly  towards  the  anterior  face 
of  the  sacrum,  its  anterior  margin  has  become  inferior,  and  its  posterior  one  is 
now  the  superior.  When  existing  before  the  commencement  cf  labor,  its  mode 
of  production  is  altogether  difierent.  We  know  that  in  vertex  presentations  the 
head  of  the  foetus  engages  in  the  excavation  in  the  latter  months,  pressing  the 
lower  part  of  the  uterus  before  it.  Now,  in  the  normal  direction  of  this  organ, 
it  is  evident  that  the  head  must  press  more  especially  upon  the  portion  anterior 
to  the  orifice,  which  anterior  portion  it  must  carry  before  it.  Hence,  it  is  plain 
the  external  orifice  of  the  neck  must  necessarily  be  situated  altogether  posterior 
to  the  projection  formed  by  the  head  in  the  lesser  pelvis. 

But,  whatever  may  be  the  manner  and  time  of  its  production,  its  effect  upon 
the  progress  of  the  labor  is  always  the  same.  Consequently,  when  the  child's 
head  is  urged  on  by  the  uterine  contractions,  it  presses  the  anterior  inferior  wall 
of  the  uterus  before  it,  and  thereby  evidently  retards  the  delivery.  In  fact,  the 
dilatation  of  the  neck  must  necessarily  be  very  slow  and  imperfect;  besides,  the 
expulsive  efforts  are  spent  against  the  anterior  part  of  the  cervix,  which  part, 
corresponding  to  the  void  in  the  pelvis,  and  being  distended  by  the  head,  is 
sometimes  forced  down  nearly  to  the  vulva,  and  threatened  with  a  rupture. 
Most  generally,  there  is  time  for  rectifying  this  unfavorable  situation  of  the  cer- 
vix ;  nevertheless,  the  patient  must  remain  in  bed  as  much  as  possible ;  for  it  is 
very  apparent  that,  in  the  erect  position,  the  body  of  the  womb  constantly  aug- 
ments this  posterior  obliquity  in  the  neck  by  being  carried  forwards.  The  ter- 
mination of  the  labor  may  also  be  facilitated  by  placing  the  orifice  in  its  natural 
position  with  the  finger ;  this  is  done,  during  the  interval,  by  hooking  the  ante- 
rior lip,  and  carefully  bringing  it  to  the  centre  of  the  vagina,  and  then  sustaining 
it  in  this  position  until  a  new  contraction  comes  on ;  when  the  head  is  forcibly 
pressed  down  and  engages  in  the  opening,  and  no  longer  permits  the  lip  to  regain 
its  abnormal  position.  The  labor  is  sometimes  speedily  terminated  after  this 
little  manoeuvre. 

It  occasionally  happens  that  the  cervix  uteri  is  well  dilated,  though  not  as  yet 
sufficiently  so  to  permit  the  parietal  protuberances  to  traverse  it ;  and  this  con- 
dition of  things  lasts  for  a  considerable  period,  notwithstanding  the  long  and 
acute  sufferings  of  the  patient.  In  such  cases,  the  engagement  of  the  head  may 
be  singularly  facilitated  by  making  a  slight  pressure  on  all  the  periphery  of  the 
orifice  with  the  extremity  of  the  index  finger. 

Again,  the  dilatation  may  often  be  completed  and  the  head  be  down  in  the 
excavation,  but,  notwithstanding  the  expulsory  efforts  of  the  womb,  it  is  retained 

40 


626  DYSTOCIA. 

there  by  the  anterior  lip  of  the  neck,  which  is  pressed  before  it ;  the  head  can- 
not overcome  the  resistance  thus  made  by  the  band  formed  by  the  anterior  lip, 
and  several  hours  may  elapse  without  any  advance  in  the  progress  of  the  labor. 
When  this  happens,  the  following  course  should  be  adopted  in  order  to  promote 
a  prompt  engagement  at  the  inferior  strait :  taking  advantage  of  an  interval,  the 
accoucheur  hooks  the  anterior  lip  with  his  finger  and  draws  it  towards  the  sym- 
physis pubis,  where  it  is  retained  until  the  pain  comes  on ;  then  the  extremity  of 
the  finger,  placed  under  this  portion  of  the  neck,  pushes  it  above  the  descending 
part  of  the  head,  until  it  gets  beyond  the  occipital  boss ;  when  the  occiput  is 
found  to  engage  almost  immediately  in  the  pubic  arch,  and  the  labor  terminates 
two  or  three  hours  sooner  than  it  would  have  done  without  this  little  manipula- 
tion. It  is  occasionally  necessary  to  repeat  these  attempts  several  times ;  but  as 
they  are  attended  with  no  inconvenience,  when  properly  performed,  they  may  be 
renewed  without  fear.  We  will  add,  that  the  most  favorable  period  for  this  pur- 
pose, is  that  when  the  head,  after  having  reached  the  pelvic  floor,  is  on  the  point 
of  clearing  the  inferior  strait ;  provided  the  pains  are  energetic,  and  the  cervix 
uteri  is  sufficiently  dilated  to  permit  the  passage,  if  the  axis  of  its  orifice  were 
parallel  to  the  axis  of  the  head. 

§  4.  Agglutination  of  the  External  Uterine  Orifice. 

This  is  a  very  rare  complication,  and  but  few  examples  of  it  are  reported  in 
the  books ;  though,  perhaps,  as  M.  Naegele  remarks,  from  whom  I  extract  the 
following  details,  this  rarity  is  owing  to  the  fact,  that  the  various  degrees  of 
agglutination  have  escaped  the  notice  of  the  physician;  the  powers  of  nature 
alone  triumphing  over  the  accident  in  most  cases. 

Its  existence  may  be  suspected  when  the  inferior  uterine  segment  descends 
low  down  in  the  excavation  at  the  commencement  of  the  labor,  and  presents  no 
trace  of  an  orifice ;  or  when  the  latter  presents  as  a  fold  or  a  hollow,  which  is 
slightly  depressed  at  its  centre,  and  very  often  not  corresponding  to  the  pelvic 
axis.  The  middle  of  this  little  depression  is  usually  occupied  by  a  filamentous 
web,  some  fleshy  tissue,  and  a  cellular  network,  in  the  centre  of  which  a  small 
narrow  opening  is  found ;  sometimes  the  lips  are  held  together  by  a  consistent 
mucus.  As  the  contractions  become  more  energetic,  the  lower  segment  of  the 
womb  is  forced  into  the  excavation,  and  becomes  so  thin  that,  at  the  first  explo- 
ration, the  finger  appears  to  be  separated  from  the  head  by  the  membranes 
alone ;  but,  notwithstanding  the  strength  of  the  pains,  the  uterine  orifice  is  not 
only  tightly  closed,  but  even  seems  to  ascend  somewhat,  and  to  be  carried  towards 
one  side.  The  orifice  may  open  spontaneously  under  the  pressure  of  the  ener- 
getic contractions ;  but  if  it  resists,  and  the  accoucheur  does  not  early  recognize 
the  source  of  the  difficulty,  a  rupture  of  the  womb,  or  a  paralysis  of  it,  which  is 
not  less  dangerous,  might  result  in  consequence. 

The  question  arises,  what  is  the  nature  of  this  agglutination  ?  It  has  probably 
followed  an  inflammation  of  the  cervix  uteri,  and  the  upper  part  of  the  vagina; 
since  the  pseudo-membranous  or  fibrous  tissue  that  composes  it,  is  similar,  says 
Nceg^le,  to  that  substance  which  serves  as  the  bond  of  union  between  the  pla- 


OBSTACLES     PRESENTED    BY    THE    UTERUS.  627 

centa  and  womb,  or  that  uniting  the  pleura  puhnonalis  to  the  pleura  costalis,  or 
the  intestines  with  each  other  and  with  the  abdominal  wall,  when  an  inflamma- 
tion of  these  parts  terminates  by  adhesion.  In  a  case  where  a  woman  died  during 
labor,  the  adhesion  of  the  neck  was  found,  at  the  jMst-mortem  examination,  to  be 
so  resistant  that  it  could  neither  be  lacerated  nor  broken  by  any  moderate  force, 
and  the  membrane  that  blocked  it  up  was  of  an  aponeurotic  character. 

The  precise  period  at  which  its  formation  commences  cannot  be  determined. 
In  a  woman  who  presented  this  peculiarity  during  labor,  the  orifice  was  patulous 
six  weeks  before  her  delivery. 

The  agglutination  of  the  orifice  has  been  remedied  in  most  cases  without  much 
difficulty,  the  membrane  having  been  easily  ruptured  either  by  the  finger  or  some 
blunt  instrument,  and  the  operation  has  generally  been  followed  by  the  loss  of 
only  a  few  drops  of  blood.  The  index  finger  should  be  preferred  to  everything 
else,  for  if  this  is  not  sufficient  to  break  down  the  obstacle,  we  can  expect  but 
little  aid  from  an  instrument.  It  is  really  difficult  to  understand  how  this  agglu- 
tination, which  almost  always  yields  to  the  pressure  of  the  finger,  can  resist  the 
impetus  of  the  strong  contractions  of  the  womb. 

§  5.  Swelling  and  Elongation  of  the  Anterior  Lip. 

It  is  not  at  all  unusual  to  find  the  head  descending  in  the  excavation  long 
before  the  complete  dilatation  of  the  os  uteri,  whereby  the  anterior  lip  is  neces- 
sarily compressed  between  the  former  and  the  symphysis  pubis.  As  a  general 
rule,  this  compression,  and  the  consequent  pain,  disappear  on  the  prompt  termi- 
nation of  the  labor;  but  if  the  latter  be  prolonged,  and  especially  if  the  pelvis 
scarcely  reaches  its  normal  dimensions,  the  compression  is  very  severe,  a  consi- 
derable tumefaction  will  result  in  that  part  of  the  anterior  lip  found  below  the 
constricted  point.  Duclos,  of  Toulouse,  has  met  with  three  instances  of  this 
kind,  two  of  which  were  in  the  same  woman;  M.  Naeg^le  has  published  another, 
Dr.  Lever  two  more,  and  M.  Danyau  one,  making  seven  in  all.  M.  Blot  men- 
tions a  case  in  which  the  tumor  formed  by  the  anterior  lip  was  an  inch  and  a 
quarter  thick,  and  forced  down  to  the  vulva.  The  labor  had  to  be  terminated 
by  the  forceps. 

The  following  case  is  one  of  those  reported  by  Duclos  :  A  woman,  thirty-four 
years  of  age,  who  was  in  labor  with  her  fifth  child,  was  suddenly  attacked  after 
twenty-four  hours  of  moderate  pains,  by  acute  sufferings,  which  called  forth  loud 
cries ;  an  elongated  body  appeared  between  the  lips  of  the  vulva,  and  its  appari-  • 
tion  was  accompanied  by  a  slight  hemorrhage,  pallor,  and  feebleness.  On  his 
arrival,  he  found  a  cylindrical  tumor  projecting  four  fingers'  breadth  beyond  the 
parts ;  it  was  two  inches  broad  near  the  vulva,  and  was  irregular,  resistant,  and 
of  a  wine-like  color.  After  a  careful  examination,  he  ascertained  that  it  was 
formed  by  the  elongated  and  tumefied  anterior  lip  of  the  cervix.  He  first  thought 
of  applying  the  forceps  on  the  child's  head,  but  afterwards  concluded  to  aid  its 
delivery  by  drawing  on  the  occiput,  and  operating  on  the  forehead  by  means  of 
the  index  finger  previously  introduced  into  the  rectum.  In  the  cases  observed 
by  Nsegele  and  Danyau,  as  also  in  one  of  the  women  reported  by  Lever,  the  labor 


6l8  DYSTOCIA. 

terminated  spontaneously.  There  is,  therefore,  nothing  to  be  done  in  most  in- 
stances ;  though  if  the  tumor  be  of  a  large  size,  very  tense  and  black,  and  appa- 
rently threatened  with  gangrene,  the  example  of  the  English  surgeon,  just 
named,  might  be  followed ;  that  is,  to  make  a  number  of  punctures,  for  the  pur- 
pose of  evacuating  the  infiltrated  liquids  and  diminishing  its  volume. 

On  .the  whole,  then,  I  may  remark,  with  M.  Danyau,  that  this  species  of  tume- 
faction can  scarcely  be  considered  as  a  mechanical  obstacle  to  the  delivery;  and 
that  the  unusual  length  of  the  labor  must  rather  be  attributed  to  the  extreme 
pain  it  occasions,  and  to  the  disorder  and  irregularity  of  the  uterine  contraction 
caused  thereby. 

The  cases  recently  mentioned  by  M.  Montgomery  under  the  name  of  thrombus 
of  the  lips  of  the  cervix,  and  which  we  have  already  noticed  (see  page  606),  are 
evidently  instances  of  this  affection.  The  observations  of  the  Irish  accoucheur 
appear  to  us  similar  to  those  just  mentioned.  As  regards  the  prognosis,  how- 
ever, it  is  important  to  distinguish  simple  infiltration  from  a  true  effusion. 

M.  Montgomery  thinks  that  this  condition  of  things  might  be  mistaken  for  a 
case  of  insertion  of  the  placenta  upon  the  neck,  the  tissue  of  the  infiltrated  lip 
bearing  considerable  resemblance  to  the  placental  tissue.  Still,  as  he  observes, 
it  may  always  be  readily  ascertained  that  the  tumor  is  not  only  applied  to  the 
internal  surface  of  the  womb,  but  that  it  is  also  situated  in  the  substance  of  the 
latter.  The  finger  can  never  be  made  to  penetrate  between  the  tumor  and  the 
internal  surface  of  the  uterus. 

§  6.  Abscesses  in  the  Lips  or  the  Cervix  Uteri. 

Genuine  abscesses  are  occasionally  developed  in  the  substance  of  the  lips  of 
the  OS  tincfe,  which,  independently  of  the  unfixvorable  influence  they  may  have 
over  the  gestation,  must  necessarily  disturb  the  regular  progress  of  the  labor ; 
because,  where  they  invade  a  considerable  portion  of  the  neck,  its  dilatation  is 
thereby  rendered  very  slow,  and  very  painful ;  besides  which,  their  size  may  be 
so  great  as  to  retard  the  passage  of  the  head.  The  reader  will  find  in  Bonet 
(Sejmlchretum,  vol.  ii,  lib.  iii,  sect.  38,  Obs.  2)  the  history  of  a  woman,  who 
died  without  having  been  delivered,  after  five  or  six  days  of  suffering,  in  whom 
a  large  abscess,  filled  with  putrid  pus,  and  occupying  the  neck  of  the  womb,  was 
found  at  the  pust-mortem  examination. 

If  the  presence  of  fluctuation  should  establish  the  diagnosis,  the  proper  course 
would  evidently  be  to  incise  the  tumor. 

§  7.  Induration,  with  Hypertrophy  or  the  Cervix  Uteri. 

This  aflection  is  more  frequently  observed  in  the  anterior  than  the  posterior 
lip,  though  it  may  affect  both ;  but,  in  no  case  has  the  volume  of  the  indurated 
part  been  great  enough  to  impede,  mechanically,  the  expulsion  of  the  child;  but 
the  alteration  very  often  retards  the  dilatation,  and  sometimes  even  renders  it 
impossible.  Venesection  and  tepid  bathing  may  be  resorted  to  with  advantage. 
Certain  English  practitioners  highly  extol  the  use  of  tartar  emetic,  given  in  nau- 
seating doses,  but  I  have  not  had  an  opportunity  of  testing  its  efficacy.  If  these 
means  prove  ineffectual,  or  if  some  more  grave  complication  requires  the  prompt 


OBSTACLES     PRESENTED     BY     THE     UTERUS.  629 

tevmination  of  the  labor,  wc  might  have  recourse  to  repeated  incisions  made  on 
the  neck  of  the  womb. 

§  8.  Of  the  Cancerous  Neck. 

Like  all  the  organs  of  the  economy,  the  cervix  uteri  may  be  affected  with 
seirrhus,  or  may  form  an  encephaloid  tumor;  and  where  this  does  take  place  the 
prognosis  is  very  unfavorable,  both  for  the  mother  and  child.  For  example,  of 
twenty-seven  females  reported  by  Puchelt,  five  died  during  the  labor,  nine  shortly 
after  the  delivery,  and  but  ten  recovered;  the  fate  of  the  other  three  is  not 
stated.  However,  if  the  disease  is  still  in  its  first  stage ;  if  the  patient's  general 
condition  is  not  seriously  altered ;  and  especially  if  the  malady  has  made  but 
little  progress,  or  the  tumor  is  small,  the  danger  is  not  so  imminent,  and  the 
expulsion  of  the  child  may  then  take  place  regularly.  But,  even  where  the 
delivery  is  effected  spontaneously,  its  influence  over  the  subsequent  progress  of 
the  tumor  is  not  the  less  disastrous ;  for  the  pressure  to  which  the  diseased  part 
is  exposed  seems,  in  most  cases,  to  hasten  its  development ;  and,  whether  the 
labor  be  terminated  naturally  or  by  the  resources  of  art,  its  progress  afterwards 
is  much  more  rapid.  The  child,  likewise,  is  very  often  lost  in  the  cases  under 
consideration ;  thus,  of  the  twenty-seven  women  above  cited,  fifteen  were  delivered 
of  a  stillborn  child,  and  ten  only  of  a  living  inflint;  nothing  is  said  of  the  fate  of 
the  other  two. 

The  indications  for  treatment,  when  the  cervix  uteri  is  affected  with  cancer, 
will  necessarily  vary,  according  to  the  seat  and  size  of  the  tumor;  for,  if  it  is  not 
very  voluminous,  or  if  it  is  located  on  the  posterior  lip,  or  the  pelvis  be  of  large 
dimensions,  there  is  every  reason  for  hoping  that  the  efforts  of  nature  will  prove 
adequate  to  the  dilatation,  and  the  expulsion  of  the  foetus. 

I  have  seen  the  former  process  effected  at  the  expense  of  the  sound  anterior 
lip,  where  the  other  was  invaded  by  a  cancer  throughout,  which  also  extended 
to  the  posterior  vaginal  wall.*     Wherefore,  there  is  no  occasion  for  immediate 

1  This  case  appears  to  me  too  remarkable  not  to  be  reported,  at  least  in  a  condensed  form. 

A  female,  aged  forty-five  years,  who  had  previously  had  several  children,  came  to  La 
Clinique  about  the  commencement  of  the  last  month  of  her  gestation:  when,  by  resorting 
to  the  touch,  it  vv-as  ascertained  that  the  posterior  vaginal  wall  was  occupied  throughout  by 
an  elongated  tumor,  which  was  curved  in  a  serpentine  form,  and  extended  from  the  poste- 
rior lip  of  the  cervix,  to  within  a  finger's  breadth  of  the  vulva.  The  lip  was  nearly  an  inch 
thick  in  all  its  transverse  extent  (which  latter  was  more  considerable  than  usual),  and  it  had 
contracted  adhesions  with  the  vagina  by  its  posterior  face.  The  tumor  presented  nearly  the 
same  thickness  in  all  parts;  its  anterior  surface  was  irregular  and  nodulated,  as  was  also 
the  posterior  lip  of  tlie  cervix  uteri ;  but  its  hinder  surface  adhered  to,  or  rather  was  con- 
founded with,  the  recto-vaginal  septum.  When  this  woman  arrived  at  full  term,  the  labor 
began,  and  the  dilatation  was  effected  very  slowly,  though  completely,  at  the  expense  of  the 
anterior  lip.  The  tumor,  whose  volume  seemed  to  ofler  an  insurmountable  obstacle  to  the 
delivery,  only  rendered  the  second  stage  of  the  travail  a  little  more  tedious  than  usual ;  for, 
being  pressed  back  by  the  child's  head,  it  became  nearly  transverse  in  the  excavation,  and 
formed  on  the  perineum  a  pad,  or  a  kind  of  crescent,  the  convexity  of  which  looked  down- 
ward, but  its  concavity  was  directed  upwards,  and  arrested  the  head;  finally,  under  the 
influence  of  the  powerful  contractions,  the  head  pushed  the  tumor  still  more  backwards,  by 


630  DYSTOCIA. 

action ;  althougli  it  must  not  be  forgotten  that,  if  the  degeneration  of  these  parts 
is  more  extensive,  the  powers  of  nature  alone  are  nearly  always  inadequate  to  the 
accomplishment  of  the  delivery. 

Some  authors  have  recommended  copious  bleedings ;  but  sanguineous  emis- 
sions, though  advantageous  in  cases  of  rigidity,  or  of  simple  induration  of  the 
neck,  would  here  only  enfeeble  the  patient  without  producing  any  change  in  the 
condition  of  the  orifice ;  and  the  only  available  resoui'ce  of  our  art  is  still  in  the 
repeated  incisions  on  the  periphery  of  the  cancerous  mass ;  because  turning,  and 
the  application  of  the  forceps,  which  have  been  advised  by  certain  accoucheurs, 
are  evidently  only  practicable  where  the  bistoury  may  have  previously  facilitated 
the  entrance  into  the  womb.  Without  this  precaution,  one  or  more  fissures 
dividing  the  lobes  of  the  scirrhus  would  necessarily  result  from  the  introduction 
of  the  hand  or  instrument,  which,  at  the  moment  of  the  head's  passage,  would 
extend  still  further,  and  encroach  perhaps  on  the  body  of  the  womb.  Or,  if  the 
fissures  should  not  form,  the  neck,  by  not  dilating,  would  create  an  obstacle  to 
the  delivery,  and  the  patient  would  be  exposed  to  a  rupture  of  the  organ,  to 
convulsions,  and  to  all  the  consequences  that  attend  labors  rendered  difficult  by 
mechanical  impediments;  unless,  indeed,  there  happened  to  be  a  rupture  of  the 
subvaginal  portion  of  the  womb  itself,  and  the  child's  passage  was  eff"ected 
through  this  accidental  orifice. 

Lastly,  in  those  cases  where  the  application  of  the  forceps  is  still  impossible, 
even  after  the  incisions  have  been,  made,  a  grave  question  is  offered  for  our  solu- 
tion. Supposing  the  child  is  still  living,  we  have  only  to  choose  between  its 
mutilation  and  the  Gajsarean  operation.  Though  this  la.st  operation  be  serious 
under  all  circumstances,  it  nevertheless  seems  preferable  here  to  the  first,  because 
it  affords  a  considerable  chance  of  saving  the  child ;  and  the  mother's  life  is 
already  so  greatly  compromised  by  the  disease  with  which  she  is  affected,  that 
we  should  not,  in  my  estimation,  hesitate  to  sacrifice  all  to  the  safety  of  her  infant. 

§  9.  Complete  Obliteration  of  the  Cervix  Uteri. 

At  the  present  day,  it  is  an  ascertained  fact  that  the  neck  of  the  womb  may 
be  entirely  obliterated  at  the  time  of  labor ;  and,  where  a  case  of  this  kind  does 
occur,  the  vaginal  Csesarean  operation  should  doubtless  be  performed.  But  it  is 
an  exceedingly  rare  occurrence,  and  the  accoucheur  must  not  permit  himself  to 
be  deceived  by  a  great  obliquity  of  the  cervix,  rendering  the  orifice  of  difficult 
access,  nor  by  an  agglutination  of  the  lips  of  the  os  tincae,  since  it  is  possible  for 
an  overlapping  of  the  two  latter  to  be  mistaken  for  an  absolute  obliteration  of 
the  orifice.  ''  Several  times,"  says  Dug(^s,  "  we  have  found  the  anterior  lip 
covered  and  embraced  by  the  posterior  one,  which  thus  masked  the  opening,  so 
that  the  finger  could  only  penetrate  it  in  a  very  oblique  direction ;  though,  when 
efiected,  this  introduction  furnished  a  means  of  rectifying  the  error  promptly, 
and  of  reducing  the  parts  to  a  more  favorable  state." 

A  complete  obliteration  of  the  cervix,  when  certainly  detected,  evidently  de- 
mands the  vaginal  Cesarean  operation. 

forcibly  depressing  the  perineum,  and  then  passed  in  front  of  it,  and  soon  cleared  the  ex- 
ternal parts. 


OBSTACLES     PRESENTED    BY    THE    UTERUS.  631 

ARTICLE   II. 
obstacles  dependent  on  the  body  of  the  womb. 

§  1.  Of  Uterine  Obliquity. 

When  studying  the  phenomena  of  gestation,  we  enumerated  the  various  causes 
that  forced  the  uterus  to  depart  more  or  less  from  the  direction  of  the  pelvic 
axis;  and  we  demonstrated  that,  under  the  influence  of  those  causes,  the  womb 
very  often  inclines  forwards  and  to  the  right  during  the  latter  months  of  preg- 
nancy. It  is  not,  therefore,  of  this  right  antero-lateral  inclination  we  are  about 
to  speak,  in  treating  here  of  uterine  obliquity  as  a  cause  of  dystocia;  because, 
where  it  is  slight,  and  where  it  may  be  considered  as  a  normal  result  of  the  deve- 
lopment of  the  womb,  it  affords  no  obstacle  to  the  parturition;  but,  when  the 
obliquity  is  more  extensive,  it  may  impede  the  spontaneous  expulsion  of  the 
child,  and  will,  therefore,  claim  our  attention. 

Deventer,  and  most  of  the  writers  on  this  subject  since  his  day,  have  described 
four  varieties  of  it,  namely,  the  anterior,  the  posterior,  the  right  lateral,  and  the 
left  latei'al  obliquity.  But,  the  modern  accoucheurs,  such  as  Baudelocque,  Gar- 
dien,  Desormeaux,  and  P.  Dubois,  believe  that  a  posterior  obliquity  cannot  take 
place ;  for  the  prominence  of  the  sacrum  and  of  the  lumbar  vertebrae,  they  say, 
prevents  the  uterus  from  being  carried  backwards;  however,  from  the  facts 
reported  by  Deventer,  Levret,  Merriman,  Dugcs,  and  Velpeau,  we  feel  warranted 
in  still  retaining  these  four  varieties. 

1.  Of  the  Anterior  Obliquity. — As  a  natural  result  of  the  resistance  presented 
by  the  posterior  abdominal  plane,  the  womb  inclines  forward,  where  it  only 
encounters  the  abdominal  muscles,  which  form  a  soft  and  an  extensible  wall. 
When  this  obliquity  is  inconsiderable,  the  physician  has  only  to  remain  a  simple 
spectator  of  the  efforts  of  nature ;  but,  when  it  exists  in  a  higher  degree,  it 
becomes  a  source  of  annoyance  and  pain  during  the  latter  months  of  gestation 
that  demands  attention ;  and  it  also  gives  rise  to  difiiculties  in  the  course  of  the 
labor  that  should  either  be  prevented  or  corrected. 

An  unusual  inclination  of  the  plane  of  the  superior  strait,  or  a  well-marked 
laxity  of  the  abdominal  walls,  favors  the  obliquity;  and,  where  this  laxity  is 
carried  to  an  extreme,  the  ventral  muscles  gradually  relax  and  yield,  the  womb 
inclines  more  and  more  forwards  and  downwards,  its  fundus  gets  above  the  pubis, 
and  then  falls  anteriorly,  like  an  inverted  sack,  on  the  thighs.  This  displace- 
ment has  been  designated  as  the  ventre  en  besace,  and  by  the  Latin  authors  it  is 
described  under  the  name  of  the  venter  propendulus.  This  displacement  gives 
rise  to  acute  pains  in  the  groins,  in  the  fore  part  of  the  thighs  and  loins,  when 
the  abdomen  is  not  supported  by  a  proper  bandage  during  pregnancy;  and,  at 
the  time  of  labor,  the  cervix  uteri  is  carried  so  far  back  against  the  anterior  face 
of  the  sacrum,  that  it  dilates  with  the  greatest  difl&culty ;  and,  if  the  membranes 
be  prematurely  ruptured,  or  if  the  pelvis  is  unusually  large,  it  nearly  always  hap- 
pens that  the  child's  head  presses  the  anterior  inferior  part  of  the  uterine  wall 


632  DYSTOCIA. 

before  it;  which  part  appears  at  the  vulva  while  its  orifice  is  directed  consider- 
ably upwards  and  backwards.  But,  if  the  pelvis  be  small,  this  engagement  of 
the  head  does  not  take  place,  and  the  anterior  uterine  wall  is  then  forcibly  com- 
pressed between  it  and  some  portion  of  the  superior  strait.  The  enormous  dis- 
tension in  the  former  case,  and  the  pressure  on  the  lower  part  of  the  uterus  in 
the  latter,  expose  this  portion  of  the  organ  to  laceration  or  gangrene.  Under 
such  circumstances,  the  abdominal  exploration  and  the  vaginal  touch  can  alone 
explain  the  cause  of  the  difficulties  and  pains  which  the  patient  experiences. 
The  obliquity  in  the  body  is  readily  recognized  by  the  external  examination;  and, 
if  the  head  be  engaged  in  the  excavation,  the  finger  introduced  into  the  vagina 
will  find  a  voluminous,  smooth,  and  rounded  tumor,  filling  up  the  whole  cavity 
of  the  lesser  pelvis,  and  upon  which  no  opening  similar  to  that  of  the  cervix  uteri 
can  be  detected ;  but,  when  carried  further  upward  and  backward  towards  the 
sacro -vertebral  angle,  it  will  reach  (though  at  times  with  great  difficulty)  the 
anterior  border  of  the  cervix ;  but,  most  generally,  it  will  be  impossible  to  recog- 
nize the  posterior  lip.  This  circumstance  has  several  times  been  mistaken  for  an 
imperforation  of  the  womb,  or  a  complete  obliteration  of  the  neck,  and,  as  a  con- 
sequence, the  vaginal  Caisarean  operation  has  occasionally  been  performed,  where 
nothing  more  than  an  obliquity  of  the  uterus  was  to  be  remedied.  If  the  head 
has  not  yet  engaged,  the  tumor  will  not  occupy  the  excavation,  but  the  same 
difficulty  will  still  be  experienced  in  finding  the  cervix.  Both  of  these  modes  of 
exploration  should  be  employed  j  for  we  have  already  learned  that  the  cervix  may 
be  oblique,  while  the  body  retains  its  natural  position ;  and  it  is  evident  that, 
under  such  circumstances,  a  resort  to  the  touch  alone  might  lead  us  to  suspect 
an  obliquity  that  did  not  really  exist;  and,  on  the  other  hand,  the  internal 
exploration  would  guard  against  the  errors  that  the  deformed  appearance  of  the 
woman's  abdomen  might  possibly  make  us  commit;  for  it  alone  can  enable  us  to 
distinguish  the  obliquity  from  that  deformity  already  alluded  to,  under  the  name 
of  anteflexion,  in  which  the  womb  is  shaped  like  a  retort.  In  the  former  case, 
the  cervix  will  be  detected  high  up  towards  the  posterior  plane  of  the  pelvis ;  in 
the  latter,  on  the  contrary,  it  will  correspond  to  the  centre  of  the  excavation,  not- 
withstanding the  great  forward  inclination  of  the  body  of  the  womb. 

2.  Of  the  Posterior  Ohliquity. — This  variety  of  obliquity  (which  is  denied,  as 
above  stated,  by  most  modern  authors),  must  be  attributed  to  an  excessive  resis- 
tance on  the  part  of  the  abdominal  walls,  which  prevents  the  uterus  from  follow- 
ing the  direction  of  the  axis  of  the  superior  strait,  when  it  rises  out  of  the 
pelvis ;  that  is,  from  inclining  forwards,  and  therefore  it  is  almost  exclusively 
met  with  in  women  bearing  their  first  child. 

The  direction  of  the  uterine  axis  is  not  to  be  judged  of  in  reference  to  the  axis 
of  the  body,  but  to  that  of  the  superior  strait.  Now,  it  is  undeniable  that  the 
womb,  in  some  cases,  instead  of  being  directed  from  above  downward  and  from 
before  backward,  has  its  long  axis  directed  from  behind  forward,  and  sometimes 
even  in  a  direction  parallel  to  the  plane  of  the  superior  strait,  so  that  whilst  its 
fundus  reposes  on  the  posterior  inferior  plane  of  the  abdomen,  its  neck  is  situated 
above  the  pubis. 


OBSTACLES    PRESENTED    BY    THE     UTERUS.  633 

I  cannot  bettei-  describe  the  signs  appertaining  to  this  particular  obliquity  than 
by  relating  a  few  examples  of  it;  and  these  citations  will  have  the  further  advan- 
tage of  verifying  the  fiict,  and  of  establishing  its  possibility. 

I  have  twice  had,  says  Merriman,  from  whom  I  extract  the  following  case,  an 
opportunity  of  observing  this  singular  and  unusual  position  of  the  uterus,  in 
which  the  os  uteri  is  carried  so  far  above  the  symphysis  pubis  that  it  is  inacces- 
sible to  the  finger,  and  the  posterior  part  of  the  pelvis  so  completely  filled  by  the 
body  of  the  womb  that  it  is  impossible  to  touch  the  sacrum.  A  case  of  the  kind 
has  peen  published  by  Dr.  S.  II.  Jackson ;  but  it  occurred  in  a  woman  who  had 
not  reached  full  term.  In  the  first  of  my  cases,  the  woman  was  at  term,  and  the 
labor  continued  for  several  days;  but  the  uterus  regained  its  ordinary  position 
after  severe  eff'orts,  and  the  labor  terminated  spontaneously :  the  child  was  still- 
born, but  the  mother  recovered.  The  other  was  published  a  long  time  ago,  in  a 
dissertation  on  retroversion  of  the  womb,  which  has  been  sharply  criticised  by 
Dr.  Dewees.  The  following  is  an  extract :  ^'  Mrs.  F was  taken  with  symp- 
toms of  labor,  on  Monday,  June  16,  1806,  at  which  time  a  discharge  of  the 
liquor  aranii  was  perceived,  and  severe  and  apparently  strong  pains  recurred  at 
distant  intervals.  In  the  course  of  the  day,  the  patient  was  examined  per  vagi- 
nam,  when  there  appeared  to  be  a  singular  condition  of  the  parts.  The  whole  of 
the  back  part  of  the  pelvis  was  filled  up  by  a  globular  tumor,  which  prevented 
the  finger  from  passing  in  the  direction  of  the  coccyx  and  sacrum,  but  it  was 
obliged,  in  tracing  the  tumor,  to  take  a  direction  towards  the  ossa  pubis,  above 
the  crest  of  which  it  could  be  passed ;  but  neither  here  nor  anywhere  else  could 
the  OS  uteri  be  felt. 

"By  introducing  the  finger  into  the  rectum,  it  appeared  that  the  tumor  was 
uterine,  and  that  some  bulky  part  of  the  foetus  was  contained  within  it ;  but 
whether  the  nates  or  the  head  could  not  be  clearly  distinguished. 

"On  Tuesday,  the  17th,  the  discharge  of  liquor  amnii  continued;  the  pains 
were  frequent  and  excruciating,  and  the  tumor  was  pressed  down  closer  upon  the 
perineum.  A  rigor,  terminating  in  convulsions,  and  followed  by  fever  and  deli- 
rium, took  place  this  day;  but  a  prompt  bleeding  and  evacuating  the  bowels, 
relieved  these  symptoms. 

"Wednesday  18th,  and  Thursday  19th,  no  material  alteration  was  observed. 
The  pains  continued  regular  and  distinctly  marked  through  these  days,  but  were 
much  less  severe  and  distressing  than  at  first. 

"  Friday  20th,  another  very  careful  examination  of  the  parts  was  made.  The 
uterine  tumor  presented  the  same  shape  and  bulk,  quite  obstructing  the  passage 
towards  the  sacrum,  for  even  the  coccyx  could  not  be  felt,  except  the  finger  was 
introduced  into  the  rectum  :  when  the  finger  in  the  vagina  was  carried  forward, 
in  the  only  direction  in  which  it  could  pass,  namely,  anteriorly,  it  reached  above 
the  pubes,  but  still  the  os  uteri  could  not  be  felt;  yet,  on  withdrawing  the  finger 
from  above  the  symphysis  pubis,  there  was  now,  for  the  first  time,  perceived 
upon  it,  the  true  appearance  of  a  show,  which  furnished  a  convincing  proof  that 
the  OS  uteri  was  situated  in  that  direction,  and  encouraged  us  to  hope  that  an 
alteration  in  the  state  of  the  uterus  was  at  hand. 


634  DYSTOCIA. 

"  Our  hopes  were  not  vain ;  for,  on  the  nest  day,  Saturday,  21st,  a  consider- 
able alteration  was  discovered  in  the  pains,  and  in  the  situation  of  the  globular 
tumor,  which  occupied  the  pelvis.  The  pains  were  more  powerful  and  effective, 
and  the  tumor,  which  had  been  contiguous  to  and  pressing  upon  the  perineum, 
was  found  to  have  a  little  receded,  while  a  flattened  mass  (which  proved  to  be 
the  head  of  the  child  in  a  state  of  complete  putrefaction,  with  the  bones  sepa- 
rated, and  the  brain  almost  dissolved)  was  forced  down  from  above  the  pelvis, 
between  the  ossa  pubis  and  the  uterine  tumor. 

"  After  a  few  hours  of  active  pains,  the  tumor  ascended  above  the  brim  of  the 
pelvis,  and  was  no  longer  to  be  felt ;  but  now  the  os  uteri  was  easily  distinguish- 
able, though  still  very  high. 

"It  was  judged  right  to  make  an  opening  into  the  head,  and  about  a  pint  of 
grumous  blood  and  brains  was  evacuated ;  this  allowed  an  opportunity  of  grasp- 
ing the  scalp,  and,  by  means  of  this,  so  much  assistance  was  afforded,  in  extract- 
ing the  child,  that  the  labor  was  terminated  in  a  few  more  pains. 

"  The  patient  perfectly  recovered,  and  lived  many  years  afterwards  in  good 
health,  but  never  had  another  child."     (Sj/)W2)sts.) 

"  In  a  woman,"  says  M.  Velpeau,  "  who  came  to  be  confined  at  my  amphi- 
theatre, in  the  month  of  May,  1828,  the  fundus  of  the  uterus  was  rather  inclined 
backwards  than  forwards.  The  head  of  the  foetus  formed  above  the  strait  a  con- 
siderable projection,  which  descended  in  front  of  the  symphysis  pubis  nearly  to 
the  vulva.  Besides,  the  walls  of  the  abdomen  were  so  thin  that  the  head,  fonta- 
nelles,  and  sutures  could  readily  be  detected  through  them :  the  occiput  was  to 
the  right,  and  the  face  to  the  left.  The  right  parietal  bone  rested  against  the 
anterior  face  of  the  symphysis  pubis,  and  the  left  remained  in  front.  The  os 
uteri,  which  was  on  a  level  with  the  superior  strait,  seemed  to  be  scooped  out  of 
the  substance  of  the  posterior  wall  of  the  womb,  which  made  it  much  longer 
behind  than  before.  In  order  to  reach  the  orifice,  and  penetrate  towards  the 
head  of  the  child,  I  was  obliged  to  bend  my  finger,  so  as  to  make  it  pass  almost 
horizontally  above  the  pubis.  After  seven  days  of  pain  and  pretty  strong  con- 
tractions, the  OS  uteri,  although  very  soft  and  very  dilatable,  was  scarcely  opened 
at  all.  M.  Desormeaux  agreed  with  me,  that  by  means  of  position,  and  the 
assistance  of  the  hand  properly  combined,  I  ought  to  try  to  carry  the  head  to  the 
centre  of  the  superior  strait,  by  making  it  slide  from  below  upwards,  and  from 
before  backwards  over  the  pubis.  I  began  to  execute  this  manoeuvre  at  half-past 
eight  o'clock,  and  continued  it,  alternating  with  several  of  the  students,  until 
nine  o'clock.  From  this  time  there  was  no  longer  a  tumor  in  front  of  the  sym- 
physis, and  the  labor  progressed  so  rapidly  that  in  less  than  an  hour  the  child 
was  born,  and  the  placenta  itself  expelled."     (^Meijs'  Translation,  p.  404.) 

Dr.  Billi,  Professor  at  Milan,  reports  a  case  (^Ajih.  de  Chir.,  1845,  p.  113)  in 
which  the  retroversion  was  so  complete,  that  the  orifice  was  situated  five  fingers' 
breadth  above  the  pubis,  whilst  the  posterior  part  of  the  excavation  was  occupied 
by  the  head  of  the  foetus.  The  fundus  of  the  uterus,  in  the  shape  of  a  hard 
and  rounded  tumor,  was  situated  between  the  vagina  and  the  rectum,  which  it 
compressed  violently. 


OBSTACLES    PRESENTED    BY    THE    UTERUS.  635 

I  might  also  add  similar  examples  from  Duges ;  but  these  two  are  probably 
quite  sufficient  to  render  what  is  meant  by  the  posterior  obliquity  of  the  womb 
fully  understood. 

By  summing  up  the  symptoms  so  well  described  by  Merriman,  we  shall  have  : 
1,  a  very  considerable  elevation  of  the  os  uteri,  which  is  carried  high  upward  and 
forward  above  the  symphysis  pubis ;  2,  a  tardy  dilatation  of  the  cervix ;  3,  the 
tumor,  constituted  by  some  part  of  the  foetus  (the  shoulder,  probably),  pressing 
before  it  the  posterior  inferior  portion  of  the  womb  that  envelopes  it,  is  strongly 
engaged  in  the  excavation,  and  occupies  all  the  cavity  of  the  lesser  pelvis  ;^  and, 
4,  the  head  situated  above  the  symphysis  pubis.  By  collecting  in  the  same  way 
the  principal  characters  of  M.  Velpeau's  case,  we  shall  find  a  remarkable  eleva- 
tion of  the  presenting  part;  a  very  unusual  elevation  of  the  cervix  uteri,  the 
orifice  of  which,  being  turned  directly  forward,  is  placed'  above  the  symphysis, 
and  is  scarcely  accessible  to  the  finger ;  and,  lastly,  a  considerable  tumor  formed 
by  the  child's  head,  just  in  front  of  the  anterior  face  of  the  symphysis.  And  we 
may  add,  that  such  a  tumor  had  previously  been  described  by  Duges,  in  several 
of  his  observations.* 

The  posterior  obliquity  of  the  womb  is  rarely  so  disastrous  in  its  consequences 
as  Merriman's  case  proved  to  be ;  for,  most  generally,  the  strong  contractions  of 
the  organ,  the  energetic  eflForts  of  the  patient  herself,  and  a  sufficient  amplitude 
of  the  pelvis,  succeed  in  overcoming  its  unfavorable  influence,  without  extraneous 
aid;  and,  besides,  it  often  happens  that,  at  the  time  the  membranes  are  ruptured, 
the  head  descends  into  the  excavation  along  with  the  discharged  waters.  But 
on  the  other  hand,  as  in  the  instance  of  the  author  just  quoted,  the  deviation  of 
the  foetus,  and  of  its  presenting  part,  goes  on  increasing,  and  then  it  may  require 
version. 

3.  Lateral  Obliquities. — For  the  reasons  formerly  given  (page  624),  the  right 
lateral  obliquity  is  far  more  frequent  than  the  left ;  indeed,  but  very  few  examples 
of  the  latter  are  ever  met  with.  These  variations  in  the  direction  of  the  uterus 
are  rarely  of  such  a  nature  as  to  constitute  a  serious  obstacle  to  parturition ;  they 
act  more  particularly  in  modifying,  and  sometimes  even  in  altogether  changing, 
the  presenting  part  of  the  foetus.  Let  us  suppose,  for  instance,  says  Duges,  that 
the  womb  be  oblique  enough  to  carry  the  child's  head  towards  the  border  of  one 

'  It  is  highly  probable  that  the  engagement  of  the  shoulder  in  the  excavation  is  owing  to 
the  putrefaction  of  the  foetus.  Merriman  has  not  noted  the  prominence  formed  above  the 
symphysis  pubis  by  the  head ;  the  absence  of  this  projection,  which  was  so  remarkable  in 
M.  Velpeau's  case,  was  certainly  due  to  an  engagement  of  the  shoulder,  and  the  head  was 
probably  thrown  back  on  the  opposite  one,  so  that  a  spontaneous  cephalic  version  took  place. 

^  It  has  been  remarked,  in  many  cases,  that  the  child's  head  presented,  after  birth,  a  red 
longitudinal  mark  between  one  of  the  parietal  protuberances  and  the  sagittal  suture.  This 
long  narrow  track  seems  to  be  owing  to  the  contusion  made  on  the  scalp  by  the  upper  border 
of  the  pubis.  In  a  case  of  this  kind,  reported  by  Paisley,  the  midwife  could  not  detect  the 
child's  head  until  after  the  discharge  of  the  waters.  The  head  would  not  descend,  and  the 
woman  died  of  exhaustion ;  and,  at  the  autopsy,  the  frontal  and  parietal  bones  of  the  right 
side  were  found  applied  against  the  pubis,  which  had  made  a  depression  there  of  one  or  two 
inches  in  extent. 


636  DYSTOCIA. 

of  the  iliac  fossoe,  as  I  have  seen  in  two  cases;  but  it  can  hanlly  remain  at  this 
point,  for  it  will  either  be  pressed  back  into  the  excavation,  or  else  it  will  slip 
further  forward  and  outward,  and  the  child,  by  thus  becoming  more  and  more 
oblique,  will  ultimately  present  one  or  the  other  shoulder  at  the  superior  strait. 

Treatment  of  Uterine  Obliquity. — In  a  large  majority  of  cases,  the  obliquity 
of  the  womb,  whatever  may  be  its  variety,  presents  no  special  indication  for 
treatment;  it  constitutes  a  source  of  delay  in  the  progress  of  the  parturition,  but 
it  scarcely  ever  becomes  a  serious  cause  of  dystocia.  Consequently  in  these,  as 
in  all  other  slow  labors,  the  first  duty  of  the  practitioner  is  to  icait.  In  some 
very  rare  instances,  where  it  happens  that  an  excessive  degree  of  obliquity  is  not 
rectified  under  the  influence  of  the  powers  of  nature,  the  intervention  of  art 
becomes  necessary;  and  the  indications  then  presented  are, — to  restore  the  womb 
to  its  normal  position,  to  sustain  it  there,  and  to  remedy  any  accidents  that  may 
happen. 

The  measures  whereby  the  first  two  indications  may  be  fulfilled,  are  perfect 
rest  on  the  back,  when  the  obliquity  is  anterior,  or  on  the  side  opposite  to  the 
one  occupied  by  the  fundus  uteri,  when  it  is  lateral,  and  the  employment  of  the 
hands  to  support  and  maintain  the  deviated  organ,  or  of  a  large  bandage  properly 
applied,  to  produce  the  same  effect.  The  patient  should  be  advised  not  to  bear 
down  until  after  the  displacement  is  remedied.  If  these  means  are  not  sufficient, 
it  will  be  necessary,  while  thus  operating  externally  on  the  body,  to  act  at  the 
same  time  on  the  neck;  for  that  purpose  introducing  two  fingers  into  the  uterine 
orifice,  and  taking  advantage  of  an  interval  between  the  pains,  to  draw  it  gently 
towards  the  centre  of  the  pelvis,  whilst  the  other  hand  is  employed  in  pressing 
the  fundus  of  the  organ  in  the  opposite  direction. 

These  measures  generally  succeed,  and  their  use  should  be  continued  as  long 
as  the  double  interest  of  the  mother  and  child  will  permit ;  but  if  they  prove 
unsuccessful,  and  the  reduction  of  the  obliquity  and  the  delivery  become  impos- 
sible, our  only  resource  is  to  open  an  artificial  passage,  by  making  an  incision 
into  that  portion  of  the  uterine  wall  which  projects  into  the  vagina  (the  vaginal 
Csesarean  operation).  Still  this  ought  to  be  considered  an  ultimate  resource,  and 
one  not  to  be  resorted  to  until  after  the  impossibility  of  introducing  the  hand 
into  the  uterus  to  eff"ect  the  pelvic  version  has  been  fully  ascertained. 

In  the  posterior  obliquity,  the  woman  ought  to  remain  seated  or  standing,  or, 
if  possible,  even  inclining  a  little  forward.  If  the  head  forms  a  projection  above 
and  in  front  of  the  pubis,  as  in  the  case  of  Velpeau,  and  those  reported  by 
Duges,  the  hand  should  support  the  hypogastrium,  and,  by  perseverance,  it  will 
succeed  in  pressing  back  the  head  to  the  centre  of  the  excavation.  This  ma- 
noeuvre will  be  rendered  more  easy  by  the  vertical  position,  by  walking,  or,  if 
neces-sary,  by  the  woman's  resting  on  her  hands  and  knees,  so  that  the  fundus  of 
the  womb  will  hang  forward,  as  it  were.  A  kind  of  see-saw  movement  then 
takes  place,  which,  by  depressing  the  part  of  the  child  that  occupies  the  fundus, 
elevates  that  near  the  neck.  Finally,  should  all  these  plans  fail,  the  pelvic  ver- 
sion must  be  resorted  to. 


OBSTACLES     PRESENTED    BY    THE    UTERUS.  637 

§  2.  Op  Hernia  op  the  Womb. 

Most  of  the  cases  of  hernia  of  the  womb  may  be  referred  to  what  we  have 
described  under  the  name  of  anterior  obliquities  of  this  organ.  These  are  true 
eventrations  -f^  and  it  is  exceedingly  rare  for  the  uterus,  by  escaping  through  one 
of  the  natural  openings  of  the  abdomen,  such  as  the  inguinal  or  the  crural  rings, 
to  constitute  a  hernia,  properly  so  called.  Some  well-established  examples  of  it, 
however,  are  found  in  the  books;  for  instance,  Simon,  in  his  Memoir  on  the 
Csesarean  operation,  and  Sabatier,  in  his  work  on  the  displacements  of  the  womb 
and  vagina,  both  of  which  are  found  in  the  valuable  collection  of  the  Academic 
de  Chirurgie,  have  related  several  very  curious  instances  of  the  kind. 

In  most  cases,  the  displacement  of  the  womb  had  existed  prior  to  the  fecunda- 
tion, and  the  organ  thus  situated  without  the  abdominal  enclosure,  continued  to 
be  developed  until  full  term.  In  some  others,  which  are  more  difficult  to  admit, 
this  organ  having  attained  a  certain  degree  of  development,  gradually  dilated 
one  of  the  crural  or  inguinal  rings,  and  constituted  an  external  hernia.  These 
latter  have  been  admitted  by  Desormeaux,  but  they  are  rejected  by  M.  Moreau, 
who  considers  them  as  genuine  eventrations,  and  we  are  disposed  to  adopt  the 
latter  view,  at  least  so  far  as  regards  the  case  reported  by  Piuysch.  Sometimes, 
however,  the  existence  of  an  old  hernia  has  occasionally  seemed  to  favor  the  de- 
velopment of  a  hernia  of  the  uterus.^ 

The  characters  of  this  latter,  during  the  gestation  and  labor,  are  too  well 
marked  to  require  a  detailed  account  of  the  signs  of  recognition.  But,  at  the 
time  of  the  parturition,  the  inefficiency  of  the  efforts  of  nature  should  be  fully 
tested  by  a  prolonged  delay,  before  resorting  to  the  Caesarean  operation,  which  is 
the  only  resource  recommended  by  very  many  accoucheurs ;  for,  in  some  cases, 
the  labor  has  been  known  to  terminate  spontaneously.  In  a  case  related  by 
Ruyseh,  a  midwife,  by  raising  the  tumor,  succeeded  in  returning  the  foetus  into 
the  abdomen,  and  the  delivery  was  effected  as  usual. 

'  A  term  applied  to  the  hernias  following  any  accidental  opening  in  the  abdominal  walls ; 
as  also  to  the  falling  of  the  belly,  resulting  from  an  extreme  relaxation  of  the  anterior  ven- 
tral walls. — Translator. 

*  One  Ramus,  aged  twenty-four  years,  and  having  borne  six  children,  had  a  right  inguinal 
enterocele,  which  appeared  some  time  before  her  marriage.  At  the  third  month  of  a  seventh 
pregnancy  she  was  attacked  by  an  annoying,  dragging  sensation  on  the  left  side  of  the  hypo- 
gastrium.  The  tumor  hitherto  observed  in  the  latter  region  disappeared,  and  she  discharged 
blood  by  the  vagina.  By  placing  her  hand  over  the  inguinal  hernia,  she  discovered  there  a 
hard  and  strange  body,  that  was  painful  on  pressure,  and  which  she  several  times  attempted 
to  push  back  again,  without  success.  Seven  weeks  afterwards  she  felt  some  movements  at 
that  point,  and  sent  for  a  physician,  who  detected  at  the  lower  and  right  portion  of  the  ab- 
domen a  tumor,  that  descended  on  the  thigh  of  this  side,  covering  the  pubis,  and  even  ex- 
tending across  as  far  as  the  left  thigh  ;  this  tumor  was  twenty-six  inches  in  circumference  at 
the  middle,  and  twenty-four  inches  at  its  junction  with  the  abdomen.  Several  attempts  at 
reduction  were  made  without  effect.  The  pains  came  on  at  the  eighth  month,  and  hystero- 
tomy was  then  performed,  but  the  reduction  was  still  impossible  after  the  delivery,  and  the 
uterus  was  left  on  the  exterior.  Both  the  mother  and  child  were  saved.  (^Ledisma  dc  Sala- 
manca: Gaz.  de  Med.,  715,  1840.) 


638  DYSTOCIA. 

§  3.  Of  Prolapsus  Uteri. 

It  is  possible  for  a  prolapsus  of  the  womb  to  exist  in  a  non-pregnant  woman, 
and  yet  the  latter  may  conceive,  as  is  fully  proved  by  the  following  observation 
of  Marrigues,  reported  by  Chopart.  "  A  female  who  was  affected  with  a  pro- 
lapsus, had  been  impregnated  by  the  direct  and  immediate  introduction  of  the 
fecundating  principle  into  the  uterus,  through  its  gradually  dilated  orifice. ''  The 
conception  having  once  taken  place,  the  uterus  may  go  on  developing  until  term, 
and  at  the  time  of  labor  may  present  an  enormous  tumor  hanging  between  the 
thighs ;  or  this  falling  may  only  occur  during  the  gestation ;  and  again  it  may 
suddenly  come  on  in  the  course  of  the  parturition,  where  the  patient  is  aban- 
doned to  herself,  or  is  attended  by  inexperienced  persons,  who  allow  her  to  re- 
main standing  or  walking  for  a  long  time,  or  who  permit  her  to  make  strong 
bearing-down  efforts,  with  a  view  of  hastening  her  delivery,  before  the  os  uteri 
is  sufficiently  dilated.' 

The  prolapsus  may  prove  a  source  of  serious  difficulty  in  the  progress  of  the 
parturition,  for  experience  has  shown  that  this  accident  may  not  only  be  produc- 
tive of  long  delays,  but  likewise  of  real  danger;  perhaps,  it  may  even  render  the 
spontaneous  expulsion  of  the  foetus  altogether  impossible,  either  (as  has  long 
since  been  remarked)  because  the  womb,  which  has  descended  to  the  lowest  part 
of  the  abdomen,  and  possibly  even  beyond  the  abdominal  enclosure,  is  removed 
as  it  were  from  the  influence  of  the  contractions  of  the  abdominal  muscles; 
or  because,  being  wedged  in  between  the  surface  of  the  child's  body  and  the 
walls  of  the  pelvis,  it  has  lost  a  great  part  of  its  energy  in  consequence  of  the 
long-continued  pressure. 

The  difficulties  to  be  overcome  will  also  vary  according  to  whether  the  pro- 
lapsus be  recent  or  of  long  standing;  for,  in  the  latter  case,  the  prolonged  con- 
tact of  the  organ  with  the  internal  face  of  the  thighs,  and  with  the  dress,  may 
have  produced  a  state  of  induration  of  the  cervix  which  opposes  its  ready  dilata- 
tion ;  indeed,  this  has  often  been  impossible,  and  the  physician  has  been  obliged 
to  incise  it  to  overcome  the  resistance  offered  by  the  indurated  parts.  On  the 
contrary,  where  the  accident  has  recently  occurred,  or,  still  better,  if  it  is  only 
manifested  during  the  labor,  the  dilatation  of  the  os  uteri  is  sometimes  effected 
spontaneously ;  and  the  duty  of  the  accoucheur  is  then  limited  to  facilitating  it 
by  the  use  of  the  appropriate  means. 

'  According  to  M,  Moreau,  the  patients  are  particularly  exposed  to  this  kind  of  displace- 
ment in  the  five  or  six  weeks  following  the  delivery.  The  uterus,  which  has  been  distended 
by  the  product  of  conception,  still  infiltrated  by  fluids,  hypertrophied  in  a  measure,  has  a 
much  larger  size  and  a  far  more  considerable  weight  than  usual ;  the  ligaments  that  were 
stretched  have  regained  as  yet  neither  their  consistence  nor  habitual  strength.  Now  if,  on 
the  one  hand,  there  is  more  weight  in  the  organ  to  be  sustained,  and,  on  the  other,  greater 
weakness  of  the  ligaments  which  should  sustain  it,  it  is  very  apparent  that  a  cause  which, 
in  the  ordinary  conditions  of  life,  would  be  insufficient  to  bring  about  a  displacement,  will 
produce  it  under  the  circumstances  just  indicated.  For  these  reasons,  therefore,  we  cannot 
too  strongly  urge  the  patients  to  keep  in  the  horizontal  position  during  the  early  part  of  their 
lying-in,  and  to  avoid  all  kinds  of  violent  exertions  for  the  first  six  weeks  following  their 
delivery. 


OBSTACLES    DUE    TO    THE    FCETUS.  639 

The  special  indications  presented  by  a  falling  of  the  womb,  when  it  occurs 
during  pregnancy,  have  already  been  treated  of.  (Page  321.) 

All  attempts  at  reduction  would  be  dangerous  during  the  labor ;  and,  conse- 
quently, the  accoucheur  must  then  be  satisfied  with  hastening  the  dilatation  of 
the  OS  uteri  as  much  as  possible,  and  with  preventing  the  lacerations  it  would 
sufi'er  by  suitable  incisions,  in  cases  of  induration. 

The  delivery  of  the  placenta  likewise  demands  much  circumspection,  since  it 
is  evident  that  we  cannot  trust  its  expulsion  to  nature,  and  still  less  can  we  draw 
on  the  cord  in  the  usual  manner;  hence,  the  after-birth  must  be  artificially  sepa- 
rated. Immediately  after  its  delivery  the  uterus  retracts,  and  then  the  reduction 
of  this  organ  is  often  quite  easy. 


CHAPTEE   V. 

OF  THE   OBSTACLES   DEPENDENT   ON  THE   FCETUS   OR   ITS   APPENDAGES. 

For  the  delivery  to  be  effected  spontaneously  and  without  danger,  it  is  not 
only  necessary  that  the  mother  be  well-formed,  and  the  labor  .not  complicated  by 
any  of  the  accidents  that  we  shall  hereafter  have  occasion  to  study,  but  also  that 
the  conformation  of  the  fcetus,  and  the  size  of  its  different  parts,  do  not  destroy 
the  just  relations  that  should  exist  between  it  and  the  canal  it  has  to  traverse. 
It  is  further  requisite  that  the  child  present  by  one  extremity  of  its  long  axis  ; 
for,  with  the  exception  of  a  few  rare  cases,  a  natural  delivery  is  only  possible 
where  it  presents  by  its  cephalic  or  its  pelvic  extremity.  But,  unfortunately, 
these  favorable  conditions  are  not  always  met  with ;  for  the  foetus  may  be  affected 
with  various  diseases  at  the  time  of  its  birth,  or  may  possess  some  deformity, 
which  sensibly  augments  its  dimensions ;  and  it  may  likewise  be  badly  situated, 
relatively  to  the  canal  it  has  to  pass  through.  Therefore,  we  must  successively 
consider  the  indications  presented  by  these  diseases,  deformities,  and  unfavorable 
positions. 

AETICLE   I. 

DISEASES   OP   THE   FffiTUS. 

The  diseases  of  the  child,  to  be  mentioned  in  this  connection,  are  those  which, 
by  sensibly  augmenting  the  size  of  one  of  its  parts,  create  an  obstacle  to  its  pas- 
sage through  the  pelvic  canal.  We  have,  therefore,  to  treat  of  hydrocephalus, 
hydrothorax,  ascites,  and  the  accidental  tumors  that  may  have  been  developed 
on  the  various  portions  of  its  body,  during  the  intra-uterine  life. 

§  1.  Hydrocephalus. 

Under  this  term  are  included  all  the  dropsies  of  the  head,  and  all  the  effusions 
or  infiltrations  of  serum  within  or  exterior  to  the  cranium. 


640  DYSTOCIA. 

Hydrocephalus  lias  been  described  by  authors  as  external  or  internal,  accord- 
ing to  the  seat  of  the  eifusion;  placing  under  the  former  variety  all  the  serous 
or  scro-sanguinolent  infiltrations  that  are  found  beneath  the  scalp  or  pericranium. 
This  latter  affection  has  never  hitherto  been  considerable  enough  to  constitute  an 
insurmountable  obstacle  to  parturition.  In  fact,  it  is  usually  associated  with  a 
state  of  general  oedema  that  destroys  the  foetus  at  an  earlier  period  of  gestation; 
and,  consequently,  its  expulsion  is  effected  without  difficulty,  whatever  may  be 
the  thickness  of  the  scalp.  I  saw  a  seven-months'  child,  at  La  Clinique,  in  1838, 
in  whom  this  part  was  a  finger's  breadth  in  thickness,  and  the  mother,  also,  was 
quite  cedematous ;  the  labor  terminated  without  difficulty.  Desormeaux  speaks 
of  two  very  similar  cases. 

Hydrocephalus  internus,  the  only  variety  requiring  a  particular  description,  is 
such  a  rare  disease,  that  Madame  Lachapelle  observed  but  fifteen  cases  of  it  in 
forty-three  thousand  five  hundred  and  fifty-five  labors. 

In  the  estimation  of  pathologists,  this  is  always  a  grave  affection,  on  account 
of  the  danger  to  which  it  exposes  the  child  after  birth ;  but  more  particularly  so, 
in  the  eyes  of  the  accoucheur,  from  the  difficulties  thereby  entailed  on  the  labor 
itself  Moreover,  these  difficulties  and  dangers  vary  with  the  quantity  of  liquid 
effused  into  the  cranium ;  because,  where  this  is  inconsiderable,  the  delivery  is 
still  possible,  owing  to  the  flexibility  and  the  softness  of  the  head,  the  walls  of 
which  are  nearly  all  membranous ;  so  that,  by  gradually  moulding  itself  to  the 
passage,  the  head  becomes  lengthened  out,  and  the  labor  is  either  terminated  by 
the  powers  of  nature  alone,  or  else  is  effected  without  much  difficulty  by  the 
application  of  the  forceps,  or  by  the  pelvic  version  ;  but  where  the  water  exists  in 
great  abundance,  the  dimensions  of  the  head  exceed  those  of  the  diameters  of  the 
pelvis*  so  much  that  the  delivery  is  absolutely  impossible,  unless  the  fluids  be 
evacuated  by  an  artificial  puncture,  or  by  a  spontaneous  rupture  of  the  sutures,  or 
fontanelles. 

The  following,  according  to  Duges,  are  the  signs  whereby  a  dropsy  of  the  head 
may  be  recognized  during  the  parturition  :  the  finger  falls  upon  a  large  and 
slightly  convex  surface,  which  covers  every  part  of  the  superior  strait  without 
engaging,  and  has  a  variable  consistence  at  different  points ;  for,  although  hard 
and  resistant  while  the  pain  lasts,  it  is,  on  the  contraiy,  soft  and  fluctuating  in 
some  places  during  the  interval  between  the  contractions.  Then,  by  passing  the 
index  regularly  over  it,  the  accoucheur  can  recognize  pieces  of  bone  separated  by 
membranous  interspaces,  or  soft  commissures,  as  broad  as  the  finger;  and,  at 
times,  the  fontanelles,  equal  in  extent  to  the  hollow  of  the  hand.  If  the  child 
has  presented  by  some  other  part  than  the  vertex,  and  the  head  is  only  accessible 
to  the  touch  by  its  base,  the  separation  of  the  bones  detected  by  the  finger  will  be 
much  less,  though  it  is  often  easily  appreciable.    Finally,  if  the  dropsy  be  incon- 

'  In  a  case  reported  by  Wrisberg,  the  cliild's  head  was  ten  and  a  half  inches  long,  and 
thirty-two  inches  in  circumference.  Meckel  has  the  skull  of  a  hydrocephalic  infant,  whose 
transverse  diameter  is  sixteen  and  a  half  inches,  and  its  height,  taken  from  the  occipital 
foramen  to  the  vertex,  measures  sixteen  inches;  and  Burns  gives  a  case  of  hydrocephalus, 
where  the  circumference  of  the  head  amounted  to  twenty-three  inches. 


OBSTACLES    PRESENTED    BY    THE    FCETUS.  641 

siderable,  the  same  characters  will  be  observed,  though  they  are  less  evident ; 
and,  besides,  the  head  being  then  more  convex,  and  not  so  soft,  will  engage 
better  in  the  pelvic  excavation. 

The  diagnosis  is  sometimes  rendered  difl&cult  by  the  elevation  of  the  head ;  but 
•when  the  latter  is  ascertained  to  be  presenting,  and  the  pelvis  found  to  be  well 
formed,  the  presence  of  the  pulsations  of  the  foetal  heart  on  a  level  with,  or  even 
above  the  umbilicus,  may  excite  a  suspicion  of  hydrocephalus. 

The  indications  for  treatment  presented  by  this  affection  vary  with  its  extent, 
and  according  to  whether  the  child  is  living  or  dead.  Besides  which,  as  Duges 
justly  remarks,  the  physician  must  not  only  base  his  determination  on  the  size 
of  the  head,  but  also  on  its  flexibility  and  its  inclination  to  engage  in  the  exca- 
vation. 

When  the  cranium  is  of  moderate  size,  is  soft,  reducible,  and,  from  the  influ- 
ence of  the  strong,  energetic  contractions  of  the  womb,  gradually  approaches  the 
inferior  strait,  we  should  temporize,  and  be  satisfied  with  favoring  a  spontaneous 
termination  of  the  labor  by  the  employment  of  the  proper  means.  But  if  the 
delivery  is  delayed,  and  the  pains  are  weakened  or  uselessly  spent  against  insur- 
mountable obstacles,  the  forceps  should  be  at  once  applied.  Nevertheless,  the 
pressure  and  tractions  on  the  head  ought  to  be  slow  and  gradual,  with  the  view 
of  preventing  a  rupture,  which  can  always  be  avoided  by  proceeding  with  gentle- 
ness, and  under  a  fear  of  the  instrument's  slipping. 

The  pelvic  version  would  doubtless  be  resorted  to  in  presentations  of  the  trunk ; 
but  if  the  operator  has  been  fortunate  enough  to  detect  the  large  size  of  the  head 
before  searching  after  the  feet,  he  should,  in  my  opinion,  endeavor  to  bring  the 
cephalic  extremity  to  the  superior  strait. 

When  the  size  of  the  head  is  such  that  a  spontaneous  delivery  is  wholly  im- 
possible, and  the  application  of  the  forceps  or  the  pelvic  version  is  not  practi- 
cable, there  is  no  other  resource  for  saving  the  mother  than  to  puncture  the 
cranial  vault,  which  alone  can  afibrd  an  outlet  to  the  serum  accumulated  in  its 
cavity.  This  operation  may  be  performed  with  the  trocar,  the  bistoury,  or  with 
any  pointed  knife  whatever,  after  having  taken  the  precaution  to  envelope  its 
blade  with  tape,  so  as  to  leave  only  the  point  uncovered.  This  simple  puncture 
of  the  membranous  intervals  is  always  preferable  to  the  mutilation  of  the  child. 
For,  although  the  sudden  collapse  of  the  brain,  which  usually  follows  the  eva- 
cuation of  the  liquid,  nearly  always  occasions  the  death  of  the  foetus,  still  the 
latter  may  possibly  survive  such  an  operation ;  since  a  puncture  of  this  kind 
made  after  birth  has  occasionally  been  followed  by  a  complete  cure.  Smellie's 
and  Stein's  scissors  should,  therefore,  be  proscribed  in  these  cases,  and  we  ought 
to  decide  on  plunging  them  into  an  intact  brain  only,  when  the  opening  made 
with  a  smaller  instrument  has  not  been  free  enough  to  permit  the  escape  of  the 
liquid.  In  no  case  is  a  bloody  operation  on  the  female  permissible,  because  the 
life  of  the  infant  is  then  too  seriously  compromised,  by  the  mere  foct  of  hydroce- 
phalus, to  think  of  sparing  it  at  the  expense  of  that  of  the  mother. 

Where  the  child  is  dead,  cei^halotomy  would  appear  to  us  preferable,  unless 
some  serious  difficulties  in  its  performance  were  likely  to  be  met  with. 

41 


642  DYSTOCIA. 

If  ccplialotoiuy  be  decided  upon  in  cases  of  pelvic  presentation,  some  difficulty 
may  be  experienced  in  perforating  the  cranium.  Though  it  is  often  possible  to 
p.iss  the  instrument  through  the  arch  of  the  palate,  I  would  prefer  repeating 
what  I  have  already  done  in  a  case  to  whicli  I  had  been  called  in  consultation  by 
M.  Ducros,  namely,  to  introduce  the  blunt  hook  into  the  orbit,  and  enter  the 
cranium  through  the  optic  foramen.  This  process  had  been  before  recommended 
by  M.  Dujardin  in  a  note  addressed  to  the  Academy  of  Medicine  in  1851. 

§  2.  Hydrothorax  and  Ascites. 

Ascites  is  even  more  rare  than  hydrocephalus,  though  it  is  met  with  somewhat 
oftener  than  hydrothorax.  The  signs  indicative  of  dropsy  of  the  chest  are  a 
considerable  enlargement  of  the  thorax,  a  widening  of  the  intercostal  spaces,  and 
an  evident  fluctuation  in  these  enlarged  intervals.  On  the  contrary,  the  extra- 
ordinary size  of  the  belly,  the  distension  of  its  walls,  and  the  fluctuation  detected 
there,  characterize  ascites.  The  foetus,  being  retained  by  the  amplitude  of  one 
or  the  other  of  these  cavities,  is  arrested  in  its  progress  through  the  pelvis,  and 
the  accoucheur  finds  the  excavation  filled  up  by  a  large,  soft,  and  fluctuating 
tumor.  In  some  cases  of  extreme  distension  of  the  abdomen,  the  walls  of  this 
cavity  have  been  found  to  yield,  so  that  a  great  part  of  the  tumor  remained  above 
the  superior  strait,  whilst  the  rest  of  the  trunk  gradually  descended  into  the 
excavation ;  and  when  one  portion  of  the  abdomen  had  reached  the  exterior,  the 
liquid  gravitated  towards  this  point,  where  the  resistance  was  less,  the  portion 
remaining  internally  progressively  diminished  in  volume,  and  the  labor  termi- 
nated naturally.  Frank  speaks  of  a  dropsical  child  that  presented  by  the  breech, 
in  whom  a  quantity  of  the  serum  had  escaped  from  the  abdomen  into  the  scro- 
tum ;  and  an  evacuation  of  all  the  liquid  was  secured  by  makuig  an  incision  into 
this  part,  which  course  should  be  repeated,  if  a  similar  case  were  to  occur. 
But  when  the  aqueous  tumor  of  the  chest  or  abdomen  is  large  enough  to  be 
arrested  by  one  of  the  straits,  we  should  have  recourse  to  puncture  with  the 
trocar. 

A  peculiarity  which  might  readily  be  mistaken  for  ascites,  consists  in  the 
accumulation  of  a  large  amount  of  urine  in  the  bladder  of  the  foetus. 

When  treating  of  the  secretions  of  the  foetus,  it  was  stated  that  a  certain 
amount  of  urine  was  doubtless  excreted  during  its  iutra-uterine  existence,  and 
we  mentioned  in  support  of  the  opinion,  some  instances  in  which  obliteration 
of  the  urethra  had  given  rise  to  enormous  distension,  and  even  rupture  of  the 
bladder.  In  a  case  comumnicated  to  the  Academy  of  Medicine  by  M.  Depaul, 
the  bladder  was  so  distended  as  to  prove  an  insurmountable  obstacle  to  the 
extraction  of  the  foetus. 

Whether  aware  of  the  true  cause  of  the  difficulty  or  hesitating  between  as- 
cites or  extreme  distension  of  the  bladder,  it  is  evident  that  if  properly  directed 
tractions  are  inefi'ectual,  an  evacuation  of  the  fluid  is  the  only  Vesource  in  either 
cise.  We  would  merely  add,  in  accordance  with  jM.  Depaul,  that  since  the  per- 
meability of  the  urethra  may  sometimes  be  re-established  after  birth,  it  is  strictly 
indicated  to  perform  the  puncture  as  carefully  as  it  would  be  done  in  the  adult. 


OBSTACLES     PRESENTED     BY    THE     FCETUS.  613 

The  insertion  of  the  cord  would  be  a  sure  guide  in  choosing  the  most  favorable 
point. 

In  a  case  observed  by  M.  Moreau,  ascites  and  considerable  distension  of  the 
bladder  existed  simultaneously.  The  first  puncture,  though  it  discharged  a  large 
amount  of  peritoneal  fluid,  did  not  enable  the  extraction  to  be  made,  and  a 
second  one  vras  necessary  to  evacuate  the  urine  contained  in  the  bladder.  The 
delivery  of  the  child  was  effected  without  difficulty  immediately  afterward. 

§  3.  Emphysematous  Condition  of  the  Fcetus. 

Merriman  has  remarked  that,  when  the  foetus  has  been  dead  for  some  time,  a 
large  quantity  of  gas  may  be  created  in  consequence  of  the  putrefaction  it  has 
undergone ;  thereby  greatly  augmenting  the  volume  and  the  distension  of  the 
belly,  and  consequently  retarding  the  expulsion.  "I  have  known,"  says  he, 
"  two  instances  of  rupture  of  the  vagina,  arising  from  the  rashness  of  midwives, 
who  forcibly  dragged  the  children,  enormously  swelled  with  putrid  air,  into  the 
world.  In  one  case,  the  vagina  was  torn  completely  through.  Both  the  women 
died  in  a  few  hours.  Had  the  bellies  of  the  children  been  punctured,  to  give 
vent  to  the  air,  these  fatal  occurrences  would  have  been  avoided.     (^Sj/nopsis.^ 

M.  Depaul  has  recently  published  a  case,  in  which  not  only  was  a  large  quan- 
tity of  gas  developed  in  the  abdominal  and  thoracic  cavities,  but  the  limbs  of  the 
child  were  so  greatly  infiltrated  as  to  present  nearly  double  their  natural  size. 
After  extracting  the  head  by  the  forceps,  it  was  deemed  necessary  to  apply  the 
cephalotribe  forceps,  and  close  them  with  such  force  as  to  reduce  the  size  of  the 
trunk  considerably,  and  at  the  same  time  obtain  a  firm  hold  for  traction.  Whilst 
proceeding  thus,  a  large  amount  of  exceedingly  fetid  gas  escaped  with  a  report, 
and  very  strong  tractions  were  required  to  disengage  the  chest  and  deliver  the 
child.     The  uterus  in  contracting  expelled  a  similar  kind  of  gas. 

Supposing  the  diagnosis  to  be  well  established,  we  agree  with  Merriman  in  the 
opinion  that  a  previous  puncture  of  the  abdomen  and  chest,  would  certainly  have 
facilitated  the  use  of  the  cephalotribe,  or  perhaps  have  even  rendered  its  em- 
ployment unnecessary. 

§  4.  Tumors  of  the  Fostus. 

The  tumors,  of  divers  sorts,  with  which  the  foetus  may  be  affected  at  the  time 
of  birth,  and  the  size  of  which  is  occasionally  so  great  as  to  impede  its  sponta- 
neous expulsion,  are  not  susceptible  of  being  included  under  any  general  head, 
and  the  measures  to  be  employed  vary  for  each.  Where  they  are  pediculated,  it 
not  unfrequently  happens  that  the  pedicle  is  broken,  either  by  the  influence  of 
the  expulsory  efforts  of  the  womb,  or  the  tractions  made  by  the  accoucheur. 
When  their  induration  is  not  very  great,  they  temporarily  disappear,  at  times, 
from  being  compressed  between  the  foetal  surface  and  the  uterine  parietes,  or  the 
osseous  walls  of  the  pelvis.  The  proper  course  is  to  remove  them,  when  acces- 
sible, or  to  discharge  their  contents  by  means  of  a  puncture  where  they  contain 
a  liquid.  But,  unfortunately,  we  can  seldom  even  suspect  their  existence  until 
the  labor  is  already  so  far  advanced  that  it  is  hardly  possible  to  act.     If  their 


644  DYSTOCIA. 

volume  be  excessive,  the  child's  death  will  nearly  always  result  from  the  delay 
and  difficulty  in  the  parturition,  and  then  the  conduct  to  be  followed  is  clearly 
evident. 

§  5.  Anchylosis  op  the  Fcetal  Articulations. 

Dr.  Busch  has  recently  had  an  opportunity  of  observing  a  very  singular  case 
of  dystocia,  dependent  on  an  anchylosis  of  the  articulations  of  the  child's  limbs, 
in  which  the  forceps  was  applied,  but,  after  the  extraction  of  the  head,  the  trunk 
could  not  be  delivered.  Being  unable  to  discover  the  cause  of  the  difficulty, 
repeated  tractions  were  made,  at  first  moderate,  but  afterwards  more  powerful, 
when  a  cracking  noise  was  heard,  and  the  upper  part  of  the  trunk  cleared  the 
external  orifice ;  but  the  lower  portion  of  it  likewise  became  arrested,  and,  as 
the  child  was  dead,  it  was  dragged  out  without  hesitation,  and  the  same  cracking 
sound  was  again  heard.  At  the  autopsical  examination,  it  appeared  that  the 
articulations  of  the  limbs  had  been  anchylosed  in  the  ordinary  flexed  position, 
exhibited  by  the  foetus  in  the  womb,  and  that  the  bones  of  the  arms  and  thighs 
were  fractured.    (British  and  Foreign  Med.  Review,  p.  579,  April,  1838.) 


ARTICLE    II. 

DEFORMITIES   OF   THE   FCETUS. 

Under  this  title  we  shall  include  foetuses  of  an  extraordinary  size,  those  pre- 
senting certain  defects  of  formation,  and  known  as  acephalous  or  anencephalous 
foetuses,  &c.,  and  twins  connected  together  by  one  or  more  points  of  the  surface 
of  their  bodies.  We  shall  conclude  the  article  with  the  special  indications  pre- 
sented by  twin  labors. 

§  1.  Of  Excess  of  Volume. 

However  voluminous  we  may  suppose  a  child  to  be  at  the  time  of  birth,  it  is 
impossible  to  believe  that  its  volume  alone  can  constitute  an  insurmountable  ob- 
stacle to  a  spontaneous  delivery,  without  supposing  a  simultaneous  contraction  of 
the  pelvis ;  since  the  largest  children  are  never  more  than  twenty-three  inches 
from  the  vertex  to  the  heel ;  and,  as  Duges  remarks,  if  the  head  presents  in  its 
state  of  habitual  flexion,  the  sub-occipito-bregmatic  diameter,  which  corresponds 
to  the  oblique  one  of  the  superior  strait,  is  but  four  and  a  quarter  inches  at  the 
most,  that  is,  half  an  inch  less  than  the  oblique  diameter. 

Nevertheless,  for  this  to  occur,  it  is  necessary  that  the  flexion  of  the  head  be 
carried  to  the  extreme ;  for,  otherwise,  the  occipito-frontal  diameter,  which  has 
occasionally  amounted  to  five  and  a  quarter  inches,  in  very  large  children,  would 
come  into  relation  with  the  oblique  diameter  of  the  pelvis,  which  is  less.  But, 
fortunately,  this  demi-flexion  will  always  be  completed  in  the  vertex  presenta- 
tions by  the  force  of  the  uterine  contractions;  and  the  same  will  be  true  in  the 
spontaneous  expulsion  by  the  breech,  unless  ill-directed  tractions  interfere  un- 
favorably with  the  eiforts  of  the  womb.     Therefore,  it  will  only  be  in  cases  where 


OBSTACLES     PRESENTED     BY     THE     FCETUS.  645 

a  presentation  of  the  trunk  will  have  rendered  the  pelvic  version  imperative,  that 
an  unusual  development  of  the  foetus  can  render  its  extraction  difficult.  Conse- 
quently, in  all  these  cases,  the  precautions  to  draw  only  while  the  pain  lasts,  to 
turn  the  child's  anterior  surface  towards  the  sacrum,  and  to  avoid  the  crossing  of 
its  arms  behind  the  neck,  should  be  redoubled.  (See  Version.)  Finally,  if  the 
spontaneous  expulsion  of  the  head  be  difficult,  we  should  resort  to  an  application 
of  the  forceps,  the  same  as  if  it  were  an  original  presentation  either  of  the 
cephalic  or  of  the  pelvic  extremity. 

§  2.  Op  Monstrosities. 

As  the  Cyclopes,  the  anopses,  the  acephalous  and  anencephalous  foetuses,  are 
delivered  as  easily  as  those  having  a  normal  conformation,  we  need  not  dilate 
upon  them  here. 

§  3.  Of  Multiple  and  Adherent  Fcetuses. 

"We  pointed  out  the  signs,  in  the  article  on  gestation,  by  which  the  presence 
of  two  or  more  children  in  the  uterine  cavity  might  be  recognized,  during  preg- 
nancy; but  these  characters  equally  belong  to  separate  and  distinct  twins,  and 
can  in  nowise  aid  in  ascertaining  the  adherence,  or  the  more  or  less  intimate 
fusion,  of  two  living  beings  into  each  other.  The  diagnosis  is  likewise  very 
difficult  at  the  period  of  labor,  for,  even  after  the  twin  pregnancy  has  been 
recognized,  it  is  only  by  negative  evidence  that  we  can  suspect  the  adhesion  of 
the  two  children. 

If  two  bags  of  waters  are  detected  by  the  finger,  if  it  is  necessary  to  rupture 
the  membranes  twice,  if  the  waters  are  discharged  at  two  separate  and  distinct 
periods,  the  presence  of  independent  twins  in  the  womb  may  be  regarded  as  cer- 
tain ;  for  there  are  never  two  envelopes  for  a  double  monster,  and  two  perfect 
twins  are  very  seldom  enclosed  in  the  same  amniotic  pouch.  Again,  if  two  feet 
or  even  a  single  one  descend  with  the  head,  more  particularly  if  the  feet  yield  to 
the  tractions  made  on  them,  and  appear  at  the  vulva  without  the  head  having  a 
tendency  to  reascend,  we  may  affirm  there  are  two  infants,  because  a  monster  is 
never  composed  of  two  individuals  so  united  that  the  head  of  the  one  is  along- 
side of  the  feet  of  the  other ;  but  if  several  limbs  present  simultaneously,  we  can 
only  ascertain  whether  the  children  to  which  they  respectively  belong  are  joined 
together  or  are  independent,  by  carrying  the  hand  up  into  the  womb.  (Duges, 
Mim.  de  V Academic.') 

Is  it  proper  to  interfere  in  all  cases,  whether  the  monstrosity  be  recognized  or 
not,  or  should  the  delivery  be  abandoned  to  nature  for  a  certain  length  of  time  ? 
The  recorded  instances,  which  prove  that  a  spontaneous  delivery  may  take  place, 
are  too  numerous  at  the  present  day  to  warrant  an  active  intervention  until  after 
a  sufficient  length  of  time  has  been  accorded  to  the  uterine  contractions  to  effect 
the  expulsion.  The  mechanism  by  which  the  delivery  is  finally  accomplished 
will  also  vary  according  to  the  particular  kind  of  monstrosity. 

When  the  two  foetuses  are  united  by  the  breech  or  head,  their  expulsion  takes 
place  without  any  marked  difficulty,  and  they  generally  escape  one  after  the 


646  DYSTOCIA. 

other,  more  particularly  when  they  happen  to  be  joined  at  the  breech.  But  if 
connected  at  the  occiput,  the  point  of  union  is  seldom  flexible  enough  to  permit 
the  two  heads  to  descend  simultaneously,  and  if  the  patient  is  at  her  full  term 
the  intervention  of  art  will  become  necessary. 

Where  there  are  two  heads  for  a  single  trunk,  the  mechanism  varies  according 
to  whether  the  monstrosity  presents  by  the  vertex  or  by  the  breech  j  but  the 
delivery  is  still  possible,  if  the  twins  are  slightly  adherent  and  so  movable  as  not 
to  be  invariably  parallel,  for  then  the  two  heads  may  engage  successively  and  not 
simultaneously.  In  the  vertex  presentations,  the  anterior  head,  which  is  the 
most  inferior  on  account  of  the  obliquity  of  the  body  of  the  child  situated  in  the 
line  of  the  axis  of  the  superior  strait,  engages  first;  and  then  the  other,  which 
had  been  primitively  arrested  by  the  sacro-vertebral  angle,  follows  it.  On  the 
contrary,  where  the  infant  is  delivered  by  the  breech,  the  posterior  head  will 
engage  the  first,  in  consequence  of  the  inclination  impressed  on  the  trunk  by  the 
axis  of  the  pelvic  canal ;  and  the  anterior  one,  which  was  hitherto  delayed  by 
the  symphysis  pubis,  will  engage  immediately  afterward. 

When  each  head  has  its  own  body,  but  the  two  trunks  are  united  by  their 
lateral,  anterior,  or  posterior  faces,  whether  throughout  their  whole  extent,  or 
only  in  a  partial  degree,  a  spontaneous  delivery  is  more  difficult  than  in  the 
former  cases;  but,  when  it  does  occur,  it  takes  place  just  in  the  same  way.  If 
there  is  only  one  head  for  two  bodies,  the  latter  are  expelled  simultaneously,  and 
the  only  difficulties  which  can  then  present,  depend  on  the  unusual  size  of  the 
head,  which  is  sometimes  very  large. 

The  process  does  not  always  advance  as  favorably  as  we  have  just  stated,  since 
it  is  not  at  all  unusual  for  one  of  the  heads  (where  the  double  condition  involves 
the  whole  body,  or  is  limited  to  the  head)  to  be  arrested  above  either  the  sacro- 
vertebral  angle  or  the  symphysis  pubis,  and  thus  delay  the  subsequent  descent  of 
the  one  that  is  already  engaged,  or  on  the  point  of  engaging. 

What  has  just  been  stated  concerning  the  mechanism  by  which  the  expulsion 
of  the  bicephalous  foetuses  is  effected,  would  naturally  lead  us  to  suppose  that, 
whenever  one  of  the  heads  shall  have  been  arrested  above  the  superior  strait,  the 
pelvic  version  should  be  resorted  to,  if  the  monstrosity  presents  by  its  cephalic 
extremity  or  trunk;  and  if  the  breech  descends  fii-st,  to  draw  on  the  lower 
extremities.  But,  in  either  case,  when  the  greater  portion  of  the  body  is  de- 
livered, it  would  be  necessary  to  carry  it  up  in  front  of  the  symphysis  pubis,  so 
as  to  favor  the  engagement  of  the  posterior  head,  prior  to  the  anterior  one. 
Again,  if  the  head  that  presents  first  shall  have  been  engaged  too  long  in  the 
pelvic  excavation  to  admit  of  being  pressed  back,  and  of  the  feet  being  brought 
down,  it  would  be  proper  to  make  an  application  of  the  forceps,  if  the  foetus 
were  still  living;  but,  under  such  circumstances,  this  latter  measure  will  often 
prove  ineffectual,  for  the  tractions  made  by  the  instrument  will  not  overcome  the 
resistances  offered  by  the  second  head.  We  have,  therefore,  in  this  case  only  to 
choose  between  a  bloody  operation  on  the  mother,  and  a  division  of  the  child's 
neck,  which  would  permit  the  head  that  offered  first  to  be  removed,  and  thus 
render  the  pelvic  version  practicable.    And  here,  notwithstanding  the  high  autho- 


OBSTACLES     DUE    TO     THE    FCETUS. 


047 


rities  to  the  contrary,  I  do  not  hesitate  to  advocate  the  mutilation  of  the  foetus; 
for,  in  cases  of  this  nature,  I  would  have  no  scruple  in  sacrificing  the  infant's 
life  to  the  safety  of  the  mother. 

§  4.  Op  Multiple  and  Independent  F(etuses. 

Although  the  expulsion  of  the  child  often  takes  place  in  twin  pregnancies 
with  as  much  facility  or  sometimes  even  with  greater  rapidity  than  in  ordinary 
labors,  yet  it  must  not  be  supposed  that  the  whole  duration  of  the  labor  is  always 
shorter;  for  very  often,  on  the  contrary,  the  parturition  will  be  found  to  drag 
along,  and  become  tedious.  Indeed,  by  reflecting  on  the  circumstances  which 
then  complicate  the  process,  it  will  not  be  a  difficult  matter  to  explain  this  un- 
usual delay,  since  it  is  well  known  that  an  excessive  distension  of  the  womb 
greatly  diminishes  both  the  force  and  frequency  of  its  contractions ;  and,  as  the 
labor  often  comes  on  before  the  end  of  the  ninth  month,  the  cervix  uteri  has  not 
yet  undergone  those  modifications  which  usually  render  its  dilatation  at  term 
quite  easy ;  besides  which,  the  elevation  of  the  presenting  part,  whose  engage- 
ment is  impeded  by  the  presence  of  the  second  foetus,  also  assists  in  retarding 
this  dilatation.  The  stage  of  expulsion,  which  the  small  size  of  the  twins  would 
at  first  sight  seem  to  facilitate,  is  often  delayed  by  the  feebleness  of  the  con- 
tractions, and  also  by  the  decomposition  and  considerable  loss  of  force  occa- 
sioned by  the  presence  of  an  ovum,  still  remaining  intact  within  the  cavity  of 
the  womb ;  and  such  is  the  unfavorable  influence  of  this  latter  circumstance,  that 
it  is  only  through  the  thickness  of  the  second  ovum  that  the  contraction  of  the 
greater  part  of  the  uterine  fibres  can  possibly  reach  the  body  of  the  child  that 
first  presented  at  the  upper  strait.  But  when  the  first  child  presents  by  the 
pelvic  extremity,  the  escape  of  the  head  is  particularly  apt  to  be  attended  with 
difficulties;  for,  if  the  perineum  be  resistant,  even  in  a  slight  degree,  as  in  primi- 
parge,  for  example,  the  intervention  of  art  will  nearly  always  be  indispensable, 
because  the  uterus,  being  wholly  occupied  by  the  other  ovum,  can  have  no  farther 
influence  on  the  head  of  the  first. 

The  following  table,  which  gives  the  presentation  of  both  children  in  three 
hundred  and  twenty-nine  cases  of  twin  pregnancy,  will  serve,  as  a  matter  of  curi- 
osity, to  show  the  relative  frequency  of  the  positions. 


IN    329    TWIN    PREGNANCIES,    THE    TWO    CHILDEEN    PRESENTED    AS    FOLLOWS  : 

Both  by  the  head. 
134  times. 

The  1st  by  the  head  ; 

the  2d  by  the  breech. 

5.')  times. 

Both  by  the  breech. 
12  times. 

The  1st  by  the  breech; 
the  2d  by  the  head. 
31  times. 

The  1st  by  the  breech; 
the  2d  by  one  foot. 
11  times. 

Both  by  the  feet. 
8  times. 

The  1st  by  the  feet; 

the  2d  by  the  head. 

29  times. 

The  1st  by  the  breech  ; 

the  2d  by  die  elbow. 

1  time. 

The  1st  by  the  head  ; 

the  2d  by  the  shoulder. 

7  times. 

The  1st  by  the  face-; 
the  2d  by  the  head. 
1  time. 

The  1st  by  the  feet; 

the  2d  by  one  hand. 

1  time. 

The    1st  by  the  feet; 

the  2d  by  the  breech. 

1  time. 

Nearly  always  the  twins  present  one  after  the  other  at  the  superior  strait,  and 


648  DYSTOCIA. 

the  expulsion  of  the  first  is  promptly  followed  by  the  birth  of  the  second;  and 
the  same  is  true  of  the  others  when  there  are  more  than  two.  But  it  occasionally 
happens  that  the  labor  does  not  progress  so  regularly,  and  that  the  children  may 
be  born  at  a  considerable  interval  from  each  other,  and  their  expulsion  be  ren- 
dered difficult  by  the  attendant  delays  and  dangers.  It  most  generally  happens 
that  the  womb,  being  fatigued  by  the  efforts  necessary  for  the  expulsion  of  the^ 
first  born,  retracts  a  little  after  this  partial  depletion,  and  remains  in  a  state  of 
rest  for  some  minutes,  in  consequence  of  having  lost  a  part  of  its  contractile  pro- 
perties ;  still  retaining,  however,  a  greater  volume  than  usual.  By  placing  the 
hand  on  the  anterior  abdominal  region,  the  accoucheur  will  be  able  to  verify  the 
abnormal  size  of  the  organ,  and  to  detect,  through  this  wall,  the  inequalities 
appertaining  to  the  foetus;  besides,  another  amniotic  pouch,  or  the  presenting 
part  of  a  second  child,  can  readily  be  detected  at  the  upper  part  of  the  uterine 
neck  by  the  vaginal  touch.  In  general,  the  repose  of  the  womb  is  but  momen- 
tary, and  in  about  a  quarter  of  an  hour,  sometimes  at  the  end  of  five  or  ten 
minutes,  though  rarely  later  than  twenty  or  thirty  minutes,  the  patient  feels  the 
pains  coming  on  again,  at  first  feeble  and  slow,  but  soon  becoming  stronger  and 
more  energetic.  Care  should  be  taken  to  rupture  the  membranes,  if  this  had 
not  already  occurred,  and  then  to  abandon  the  rest  of  the  labor  to  the  powers  of 
nature.  This  second  delivery  is  soon  over,  as  a  general  rule,  when  the  foetus  pre- 
sents in  a  natural  position,  for  the  parts  have  been  so  enlarged  by  the  passage  of 
the  first  child,  that  they  ofier  but  little  resistance  to  the  escape  of  the  second. 
But,  in  some  cases,  the  pains  which  have  been  suspended  after  the  birth  of  one 
of  the  twins,  do  not  reappear  for  some  hours,  and  sometimes  even  not  for  several 
days.^ 

Now,  what  is  to  be  done  in  cases  of  this  kind  ?  Is  the  labor  to  be  abandoned 
wholly  to  nature,  or  should  we  attempt  to  deliver  at  once  ?  In  some  instances, 
there  can  be  no  hesitation  as  to  the  proper  course ;  thus,  when  the  birth  of  the 
first  child  has  been  tedious  and  difficult,  and  has  required  the  intervention  of  art, 
and  the  forces  of  the  patient  seem  to  be  exhausted  by  the  former  eifort ;  when 
any  accident  whatever,  that  threatens  the  life  of  the  mother,  or  of  the  second 
twin,  has  occurred  during  or  after  the  delivery  of  the  first;  and,  whenever  the 
second  one  presents  in  such  an  unfavorable  position^  at  the  superior  strait  as  to 
demand  the  pelvic  version,  this  ought  to  be  performed  immediately.  But,  in  all 
these  cases,  the  expulsion  should  by  no  means  be  rapid,  and  the  accoucheur  will 

'  Four  women,  registered  in  the  Dublin  Hospital,  were  delayed  ten  hours  in  the  delivery 
of  their  second  child.  The  reader  will  also  find,  in  the  Medical  and  Physical  Journal 
(April,  1811),  the  details  of  a  case  in  which  the  second  child  was  not  born  until  fourteen 
days  after  the  first;  and  the  author  of  that  communication  states,  that  another  case  had  come 
to  his  knowledge,  in  which  six  weeks  had  elapsed  between  the  birth  of  the  twins.  A  woman 
was  delivered  on  the  4th  of  March,  1814,  of  two  children ;  she  found  herself  so  well  on  the 
second  day  that  she  rose  to  attend  to  her  affairs,  but,  on  the  sixth,  she  was  again  delivered 
of  two  more.     (Gentleman's  Magazine,  1814.) 

2  It  is  not  very  unusual  to  find  the  second  child  presenting  by  the  shoulder;  which  is  pro- 
bably owing  to  the  vacuum  in  the  womb  after  the  expulsion  of  the  first  one,  a  void  that  sin- 
gularly facilitates  the  displacement  of  the  second. 


OBSTACLES    DUE    TO    THE    FCETUS.  649 

draw  very  slowly  on  the  pelvic  extremity,  so  as  not  to  empty  the  uterus  too  soon, 
and  thus  avoid  the  inertia  and  attendant  hemorrhage  which  might  result  in 
consequence  of  a  rapid  depiction.  It  would  even  be  prudent,  when  the  defec- 
tive position  shall  have  been  converted,  by  the  evolution,  into  a  presentation  of 
the  pelvis,  to  trust  the  rest  of  the  delivery  to  the  expulsory  efforts  of  the  womb. 
The  application  of  the  forceps  will  rarely  be  necessary,  because,  if  the  head  is  so 
far  engaged  ^s  to  render  the  pelvic  version  impossible,  the  labor  will  probably 
terminate  without  assistance.  Nevertheless,  should  the  incapacity  of  the  uterus 
be  complicated  with  any  accident  serious  enough  to  compromise  the  life  of  the 
mother  or  child,  it  would  be  proper  to  have  recourse  to  this  instrument  if  the 
head  had  arrived  at  the  inferior  strait  j  but  in  all  other  cases  the  pelvic  version 
ought  to  be  preferred,  because  the  introduction  of  the  hand  and  the  evolution  of 
the  foetus  will  not  foil,  by  the  irritation  they  produce,  to  determine  the  retraction 
of  the  uterine  walls,  and  thus  prevent  subsequent  inertia. 

"When  the  two  children  present  well,  and  the  expulsion  of  the  first  is  effected 
naturally  and  without  great  fatigue  to  the  woman,  I  wait,"  says  Merriman,  "until 
the  pains  of  the  second  childbirth  come  on ;  ordinarily,  this  happens  shortly  after 
the  escape  of  the  first  born.  If  efficacious  pains  do  not  occur  in  the  course  of  a 
quarter  or  half  an  hour,  I  provoke  the  contraction  by  rubbing  the  abdominal 
tumor  gently  with  the  hand,  and  by  titillating  the  os  uteri  with  the  finger ;  if 
these  irritations,  made  simultaneously  on  the  body  and  neck,  are  ineffectual, 
and  several  hours  elapse  without  the  womb  contracting,  I  deem  it  advisable  to 
excite  the  contractions  by  rupturing  the  membranes,  after  having  previously  ad- 
ministered the  ergot.  This  course  is  based  on  the  two  following  reasons :  where 
we  have  delayed  too  long  a  time,  the  pains  have  always  appeared  to  me  more 
severe  than  they  would  have  been  if  the  action  of  the  uterus  had  been  solicited 
sooner;  and  the  expulsion  of  the  second  child  has  commonly  seemed  to  me  more 
easy  through  the  parts  recently  dilated  by  the  first  delivery." 

In  all  such  cases,  our  rules  of  conduct  should  be  based  on  the  condition  of  the 
womb  itself,  rather  than  on  the  length  of  time  that  may  have  elapsed  since  the 
birth  of  the  first  child ;  because  it  must  be  evident  that  relaxation  and  in- 
ertia of  this  organ  would  forbid  all  attempts  at  extraction,  and  that  we  should 
never  endeavor  to  deliver  the  second  child  before  having  excited  the  organic 
contractility  of  the  uterus,  by  all  the  available  means.  If,  by  chance,  these 
measures  prove  inadequate,  it  will  be  better  to  wait  several  hours,  or,  if  neces- 
sary, even  for  several  days,  rather  than  expose  her  to  the  terrible  consequences 
resulting  from  inertia. 

When  one  of  the  twins,  though  dead,  has  remained  in  the  uterus  for  several 
months,  whilst  the  development  of  the  other  was  constantly  progressing,  the  little 
abortion  is  ordinarily  expelled  simultaneously  with,  or  shortly  after,  the  first 
child ;  but,  unless  the  accoucheur  is  very  careful,  and  the  size  of  the  womb  after 
the  delivery  should  not  excite  his  attention,  its  sojourn  there  may  be  considerably 
prolonged.  No  doubt,  in  these  cases,  the  hand  ought  to  be  carried  up  into  the 
womb,  for  the  purpose  of  delivering  the  aborted  foetus,  but  this  will  not  always 


650  DYSTOCIA. 

prove  an  easy  matter.  In  a  case  of  the  kind,  communicated  to  me  by  Dr.  Casau- 
bon,  the  internal  uterine  orifice  became  strongly  contracted  immediately  after  the 
extraction  of  the  placenta,  and  it  was  not  without  great  difficulty  that  he  even- 
tually succeeded  in  overcoming  its  resistance,  and  reaching  the  uterine  cavity. 
The  little  product  was  then  removed,  and  proved  to  be  an  abortion  of  four 
months.     The  other  infant  had  arrived  at  the  end  of  the  eighth  month. 

In  certain  cases,  the  presence  of  two  children  may  render  the  delivery  difficult, 
and  require  some  special  precautions;  thus,  it  may  happen:  1.  That  both 
present  simultaneously  at  the  strait,  and  retard  each  other's  expulsion;  here  the 
most  movable  head  should  be  carefully  pushed  up,  so  as  to  permit  the  other  to 
engage  first.  The  difficulty  will  be  greatly  enhanced,  if  the  two  heads  be  en- 
gaged in  the  excavation  at  the  same  time,  and  neither  of  them  can  be  pressed 
back;  under  such  circumstances,  the  application  of  the  forceps  upon  the  one 
that  appears  the  most  engaged,  and,  if  this  does  not  succeed,  the  perforation  of 
one  of  them,  seem  to  me  the  only  practicable  operations.  However,  even  here, 
very  prompt  action  is  unnecessary,  for  it  might  happen,  if  both  heads  were  small, 
that  a  natural  expulsion  could  be  effected ;  an  example  of  which  is  reported  by 
Allen,  in  vol.  xii  of  the  dIedico-Chirurgical  Transactions.  The  same  plan  is  to 
be  pursued  when,  instead  of  the  heads,  the  breech  or  the  feet  of  the  two  infants 
present  together. 

2.  The  first  child  may  present  by  the  shoulder;  here,  the  pelvic  version  is 
evidently  indicated,  but,  in  performing  it,  the  operator  must  be  very  careful  to 
seize  the  feet  of  the  right  child,  before  commencing  the  evolution,  for  if  both  the 
bags  of  waters  were  ruptured,  nothing  would  be  more  easy  than  to  get  hold  of 
two  feet  belonging  to  different  children. 

3.  Where  the  first  presents  by  the  feet,  whether  spontaneously,  or  as  a  conse- 
quence of  the  pelvic  version,  the  greater  part  of  the  trunk  is  extracted  without 
difficulty,  but  the  head  may  be  arrested  in  the  excavation,  or  above  the  superior 
strait.  Thus,  in  the  twentieth  observation  of  the  fourth  Memoir  of  Madame 
Lachapelle,  the  head  of  the  first  born  had  drawn  under  it  that  of  its  brother, 
which  had  a  tendency  to  present  by  the  vertex,  so  that  the  latter  one  blocked  up 
the  passage  of  the  former,  while  the  first  prevented  the  second  from  getting  above 
the  superior  strait ;  but,  fortunately,  the  children  were  small,  and  the  head  of  the 
second  twin  escaped  spontaneously,  alongside  of  the  neck  of  the  first,  and  then 
the  head  of  the  first  followed  the  neck  of  the  second.  A  very  similar  case,  given 
by  Dr.  Erwin,  is  related  by  Dr.  Dewees.  Had  these  two  foetuses  been  of  the 
ordinary  size,  it  is  clearly  evident  that  their  expulsion  could  not  have  been 
effected  until  one,  or,  possibly,  both  heads,  had  been  reduced  by  craniotomy.  The 
mutilation  of  one  child  seems  to  me  the  only  resource  we  have  in  these  difficult  cases ; 
thus,  it  has  properly  been  recommended  to  amputate  the  neck  of  the  first  twin, 
which  would  render  the  spontaneous  expulsion  of  the  second  one  possible,  or  at  least 
would  permit  its  extraction  by  the  forceps;  after  which,  the  head  of  the  mutilated 
infant  should  be  sought  after  and  brought  down.  However,  before  resorting 
to  this  cruel  operation,  an  application  of  the  forceps  ought  to  be  attempted  on  the 


OBSTACLES    DUE    TO    THE    FCETUS.  651 

head  that  descended  first,  as  appears  to  have  been  done  successfully  by  a  surgeon 
of  Dijon.  In  fact,  from  the  smallness  of  the  children,  it  is  possible  that,  in 
many  cases,  the  second  head  will  aiford  but  a  feeble  obstacle  to  the  passage  of 
the  trunk  of  the  child  we  are  endeavoring  to  extract  by  the  instrument. 

4.  M.  Jacquemier  relates  a  curious  case  witnessed  by  him  at  the  Maternity 
Hospital.  A  woman,  who  had  been  in  labor  nine  days,  was  brought  to  the  hos- 
pital in  a  dying  condition;  the  waters  were  discharged  three  days  before,  and  the 
forceps  had  been  applied  without  success.  At  the  autopsy,  two  children  were 
found  in  the  womb.  One  head  had  descended  into  the  excavation  in  the  left 
occipito-cotyloid  position,  and  had  passed  the  uterine  orifice.  The  other  child 
was  in  the  second  position  of  the  left  shoulder;  its  head  rested  in  the  right  iliac 
fossa,  and  the  front  of  its  neck,  which  was  situated  below  the  anterior  shoulder 
of  the  first  foetus,  embraced  the  neck  of  the  latter  in  a  semicircle,  so  as  to  prevent 
a  further  descent  of  the  trunk  ;  thus  explaining  the  fruitlessness  of  the  tractions 
made  by  the  forceps.     Both  children  were  large. 

5.  Again,  two  feet  occasionally  present  at  the  orifice ;  when,  if  the  accoucheur 
deem  it  advisable  to  aid  the  expulsory  eiforts  of  the  womb  by  tractions,  he  might, 
by  supposing  they  belonged  to  one  child,  draw  on  both,  and  thus  engage  parts  of 
both  twins  at  the  same  time,  which  could  not  pass  out  together;  therefore,  if  there 
is  the  least  doubt  of  the  character  of  the  pregnancy,  he  should  ascertain,  before 
making  any  tractive  efforts  whatever,  that  the  two  limbs  really  belong  to  the  same 
individual,  which  is  done  by  passing  the  hand  up  into  the  womb  as  far  as  the 
hips ;  though  it  must  be  confessed  that  this  diagnosis  is  frequently  attended  with 
great  difficulty. 

Pleissman  states  that,  on  one  occasion,  he  found  the  orifice  plugged  up  by  the 
parts  that  had  become  engaged,  and  which  at  first  sight  appeared  to  him  to  be 
a  quantity  of  hands  and  feet.  A  more  careful  examination  enabled  him  to  dis- 
tinguish four  inferior  extremities,  which  were  delivered  as  far  as  the  ham,  and 
one  arm.  "At  first,"  he  says,  "I  was  in  great  perplexity,  because  I  could  find 
no  way  of  introducing  my  hand  into  the  womb,  for  the  purpose  of  distinguishing 
and  seizing  the  two  feet  belonging  to  each  child,  and  because  all  my  efforts  to 
make  even  one  of  these  extremities  go  back  again  proved  abortive ;  besides  which, 
in  drawing  on  any  two  of  them,  I  might  confound  and  bring  down  the  feet  of 
two  different  foetuses  at  the  same  time  ;  and,  lastly,  even  if  I  succeeded  in  seizing 
the  two  feet  belonging  to  the  same  child,  I  might,  by  drawing  on  them,  engage 
the  other  parts,  and  thus  augment  the  difficulties.  Being  greatly  embarrassed 
as  to  the  proper  course,  and  yet  obliged  to  act,  the  employment  of  a  measure 
recommended  by  Hippocrates,  under  different  circumstances,  happily  suggested 
itself;  it  was,  to  suspend  the  patient  by  her  feet,  hoping  that  the  heads  and  the 
bodies  of  the  children  would,  by  their  weight,  draw  one  or  more  of  the  extremi- 
ties towards  the  fundus  of  the  womb,  which  was  still  distended  by  the  waters. 
The  husband  and  brother-in-law  of  the  woman  passed  their  arms  under  her  hams, 
and  thus  held  her  suspended,  so  that  only  the  head  and  shoulders  rested  on  the 
bolster.  I  intended,  as  soon  as  I  mounted  on  the  bed,  to  press  back  one  or  more 
of  the  free  extremities  into  the  womb,  but  two  had  already  returned  from  the 


652  DYSTOCIA. 

mere  position  of  the  mother,  and  the  other  three  soon  followed  by  the  aid  of  my 
fingers.  Immediately  afterwards,  I  was  enabled  to  introduce  my  hand  into  the 
uterus,  and  to  withdraw  successively  therefrom  three  children  by  the  feet." 

In  bringing  forward  this  case,  I  only  desire  to  illustrate  what  has  been  said 
concerning  the  difficulty  of  diagnosis.  I  ought  also  to  call  attention  to  the  im- 
possibility of  the  reduction,  and  the  singular  procedure  resorted  to,  with  a  success 
that  seems  to  warrant  its  employment  again  under  similar  circumstances. 

ARTICLE   III. 

PROLAPSUS,  OR  FALLING   OF  THE   CORD. 

The  descent  of  the  cord  is  quite  a  rare  accident,  since  Madame  Lachapelle 
states  that  she  met  with  it  but  forty-one  times  in  fifteen  thousand  six  hundred 
and  fifty-two  labors ;  but  it  is  probable,  as  she  appears  to  think  herself,  that  there 
has  been  an  error  in  the  registers,  for  the  statements  given  by  other  observers 
show  a  much  larger  proportion.  I  shall  only  bring  forward  the  account  of 
Michaelis,  who  says  that  he  had  detected  fifty-four  cases  of  falling  of  the  cord  in 
two  thousand  and  four  hundred  labors ;  and  a  summary,  by  Dr.  Churchill,  of 
ninety  thousand  nine  hundred  and  eighty-three  labors,  in  which  there  were  three 
hundred  and  twenty-two  cases  of  prolapsus,  or  one  in  two  hundred  and  eighty- 
two,  nearly.  (Rigby.) 

The  falling  of  the  cord  is  most  frequently  observed  in  the  vertex  presentations, 
which  circumstance  is  readily  explained  by  the  comparative  rarity  of  the  others. 
But,  in  proportion  to  the  relative  numbers,  it  is  more  frequent  in  breech  presen- 
tations, and  far  more  so  in  those  of  the  trunk.  In  thirty-three  cases  of  labor  at 
term  accompanied  by  this  accident,  Mauriceau  observed  seventeen  presentations 
of  the  vertex,  one  of  the  face,  one  of  the  feet,  nine  of  the  hand  or  arm,  three  of 
one  hand  and  one  foot,  one  of  the  breech  and  one  hand,  and  one  of  the  head  and 
one  hand.  In  sixteen  thousand  six  hundred  and  fifty-two  deliveries.  Dr.  Collins 
has  met  with  ninety-seven  cases  of  prolapsus,  namely,  twelve  times  in  twin  preg- 
nancies (and  in  seven  of  these  twelve  the  prolapsed  cord  belonged  to  the  second 
child)  ;  nine  times  in  footling  presentations ;  twice  in  those  of  the  breech ;  four 
times  with  the  shoulder ;  seven  times  when  an  escape  of  the  hand  complicated  a 
head  presentation;  seven  with  a  dead  and  putrefied  foetus;  and  lastly,  in  three 
cases  the  delivery  took  place  before  term ;  that  is,  twice  at  seven  and  once  at 
eight  months ;  and  the  others  were  simple  vertex  presentations. 

Certain  authors  have  endeavored  to  draw  a  line  of  distinction  between  the 
prolapsus  or  presentation  and  the  falling,  properly  so  called;  designating,  under 
the  former  title,  those  cases  in  which  the  cord,  though  found  in  the  uterine 
orifice,  is  still  retained  in  the  amniotic  sac,  on  whose  lower  part  it  lies ;  and, 
under  the  latter,  those  cases  only  in  which  it  hangs  down  in  the  vagina,  or  even 
protrudes  beyond  the  vulva,  after  the  rupture  of  the  membranes ;  but  such  a 
distinction  is  puerile,  as  it  can  only  serve  to  designate  two  degrees  of  the  same 
accident. 


OBSTACLES    DUE    TO    THE    FCETUS.  653 

A.  The  causes  that  may  be  considered  as  predisposing  to  a  prolapsus  are  :  the 
unusual  length  of  the  cord  itself,  a  large  amount  of  water,  deformities  of  the 
pelvis,  an  obliquity  of  the  womb,  and  those 
malpositions  of  the  child  which  prevent  the  Fig.  95. 
presenting  part  from  engaging  readily  in  the 
superior  strait  and  excavation.  The  attach- 
ment of  the  placenta  near  the  os  uteri  also  pre- 
disposes to  a  prolapsus,  by  keeping  the  cord 
just  at  the  uterine  oriBce.  With  regard  to  the 
determining  causes,  we  must  place  in  the  first 
rank  a  sudden  rupture  of  the  membranes,  and 
the  rapid  escape  of  a  large  quantity  of  water, 
which  generally  sweeps  along  with  it  a  fold  of 
the  cord.  Consequently,  when  the  neck  of  the 
womb  is  almost  effaced,  the  bag  of  waters  very 
prominent,  and  the  head  not  engaged  in  the  

^  '  ....  The  right  posterior  occipilo-iliac  posi- 

excavation,  we  must  carefully  avoid  rupturing  tion,  complicated  by  a  failing  of  the  cord. 
the  membranes  during  a  pain,  for  the  gush  of 

liquid,  which  then  escapes  with  considerable  force,  nearly  always  carries  along  a 
loop  of  the  cord,  which  thus  precedes  the  presenting  part.  (Martin,  of  Lyons, 
Comptes  Rendus,  page  13.)  To  these  causes,  let  us  further  add  the  descent  of 
a  hand  or  a  foot,  which  seems  to  act  as  a  guide,  as  it  were,  for  the  cord,  and  to 
open  the  way  for  it. 

B.  The  signs  whereby  this  accident  can  be  recognized,  vary  according  to 
whether  the  membranes  are  ruptured  or  are  still  intact.  In  the  latter  case,  the 
diagnosis  is  quite  difficult;  nevertheless,  we  can  often  detect  something  like  a 
soft,  small  cord,  through  the  portion  of  the  membranes  covering  the  os  uteri,  and 
slipping  away  before  the  least  pressure,  but  the  true  nature  of  which  can  only  be 
determined  by  the  rapid  pulsations  in  it.  The  rapidity  of  these,  which  Madame 
Lachapelle  aptly  compares  to  the  ticking  of  a  watch,  can  alone  enable  us  to  dis- 
tinguish them  from  some  other  pulsations  produced  by  certain  arteries  that  occa- 
sionally ramify  in  the  substance  of  the  neck,  and  which  are  synchronous  with  the 
mother's  pulse.  This  error  would  be  more  difficult  to  avoid,  should  the  finger, 
when  applied  on  the  membranes,  encounter  one  of  the  arterial  ramifications  of 
the  cord,  which,  as  in  the  cases  described  by  Benckiser  (see  Umbilical  Cord), 
may  spread  out  on  the  membranes  before  entering  into  the  proper  tissue  of  the 
placenta.  The  size  and  the  mobility  of  the  prolapsed  cord  would  also  aid  in 
making  out  the  diagnosis.  On  the  other  hand,  the  thickness  and  the  spongy 
condition  of  the  membranes,  the  inequalities  they  occasionally  present,  and  the 
folds  of  the  child's  scalp,  might  perhaps  lead  us  to  suspect  a  falling  of  the  cord, 
if  the  clearly  ascertained  absence  of  pulsation  did  not  promptly  rectify  the  mis- 
take. But  after  the  rupture  of  the  membranes  all  the  difficulty  disappears,  for 
then  the  cord  hangs  down  in  the  vagina,  and  often  escapes  beyond  the  vulva,  and 
therefore  may  always  be  readily  explored. 

The  two  portions  of  the  prolapsed  fold  are  not  uniform  in  their  relations  with 


G54  DYSTOCIA. 

each  other;  most  generally,  they  touch  or  are  simply  approximated  together; 
and  sometimes  they  are  separated  by  the  whole  thickness  of  the  presenting  part. 
Nor  is  the  fold  more  regular  in  its  length ;  at  times  it  only  embraces  the  head, 
holding  it  like  a  sling,  while  at  others  it  appears  externally  between  the  woman's 
thighs,  though  most  usually  it  is  lodged  in  the  vagina,  or  at  least  only  reaches 
the  exterior  in  the  latter  stages  of  the  labor.  It  has,  in  some  very  rare  instances, 
been  known  to  go  up  again,  and  thus  become  reduced  spontaneously.  (Guille- 
mot.) As  a  general  rule,  it  is  situated  just  in  front  of  one  of  the  sacro-iliac 
symphyses,  or  behind  the  ilio-pectineal  eminence. 

A  prolapsus,  therefore,  can  always  be  detected ;  but  it  is  much  more  difficult 
though  at  the  same  time  it  is  highly  important  to  determine,  after  the  explora- 
tion, whether  the  child  is  living  or  not.  A  momentary  disappearance  of  the  pul- 
sations is  not  a  sufficient  sign ;  for  it  not  unfrequently  happens  that  the  throbbing 
ceases  in  it  during  the  pain,  because  the  cord  is  then  strongly  compressed,  but  it 
reappears  again  as  soon  as  the  pain  is  over.  This  want  of  circulation  in  the  ves- 
sels of  the  cord  may  continue  for  five  or  ten  minutes,  and  it  has  even  been  known 
to  last  for  a  quarter  of  an  hour,  without  necessarily  terminating  in  death.  It  is 
therefore  during  the  interval  alone  that  any  researches  of  this  nature  should  be 
made,  and  the  child's  death  can  only  be  determined  with  certainty  when  this 
exploration,  repeated  several  times  under  like  conditions,  shall  have  always  fur- 
nished a  negative  result.  A  cold,  soft,  withered,  and  greenish  cord,  doubtless 
belongs,  in  most  cases,  to  a  dead  child,  but  this  is  not  always  true ;  and,  on  the 
other  hand,  as  death  may  result  very  promptly  from  a  compression  of  the  cord, 
the  latter  may  still  be  warm  and  fresh,  though  the  foetus  be  dead. 

C.  Prognosis. — The  falling  of  the  cord  is  only  serious  as  regards  the  foetus; 
but  to  it  the  danger  is  imminent,  since  death  itself  may  result  in  consequence  in 
the  course  of  a  few  minutes.  Thus,  in  three  hundred  and  fifty-five  cases  col- 
lected by  Churchill,  two  hundred  and  twenty  children,  or  nearly  two-thirds, 
died ;  though  it  is  worthy  of  remark  that,  in  many  of  these  cases,  the  mothers 
were  not  transported  to  the  hospital  until  some  time  after  the  descent  of  the 
cord,  and  when  its  pulsations  had  entirely  ceased. 

The  compression  of  the  cord,  and  the  consequent  interruption  of  the  foeto- 
placental  circulation,  is  the  principal  if  not  the  only  cause  of  death ;  though  cer- 
tain authors,  among  whom  I  can  enumerate  Velpeau  and  Gruillcmot,  suppose 
that,  when  the  cord  protrudes  beyond  the  vulva,  the  blood  may  lose  its  fluidity 
in  consequence  of  being  chilled  by  the  external  temperature,  perhaps  may  even 
coagulate,  and  that  the  delay  in  the  circulation  thereby  produced,  combining  its 
influence  with  that  of  a  slight  pressure,  completely  interrupts  the  current. which, 
up  to  that  moment,  had  only  been  retarded ;  Delamotte,  Baudelocque,  and  Ma- 
dame Lachapelle,  do  not  admit  this  effect  of  the  cold.  "  For  I  have  seen,"  says 
this  illustrious  midwife,  "the  cord  hang  out  of  the  vulva  for  several  hours 
together  without  the  foetus  suff"ering  therefrom  in  anywise,  because  there  was  no 
compression ;  and  this,  in  some  of  the  cases,  notwithstanding  the  patients  had 
come  a  greater  or  less  distance,  either  on  foot  or  in  some  vehicle,  from  their  resi- 
dences to  our  hospital." 


OBSTACLES     DUE    TO     THE     FCETUS.  655 

But  wliatever  view  may  be  adopted,  it  is  still  to  a  compression  of  the  cord  that 
we  must  attribute  the  greatest  share  in  the  production  of  the  child's  death ;  and 
under  this  aspect,  its  position,  when  prolapsed,  will  greatly  modify  the  prognosis. 
The  points  where  it  is  least  exposed  to  compression  are  just  in  front  of  the  sacro- 
iliac symphyses ;  and,  as  M.  Naigele  has  justly  remarked,  the  frequency  of  the 
vertex  positions  in  which  the  occipito-frontal  diameter  corresponds  to  the  left 
oblique  one  of  the  pelvis,  renders  the  danger  in  general  much  less  if  the  fold  of 
the  cord  happens  to  be  placed  behind  and  to  the  left. 

The  influence  of  this  compression  has  been  variously  interpreted.  According 
to  some,  the  child  will  die  from  apoplexy  in  consequence  of  an  excess  of  blood, 
which  continues  to  arrive  by  the  vein,  but  can  no  longer  return  to  the  placenta 
through  the  umbilical  arteries;  agreeably  to  others,  the  circulation  will  be  free 
in  the  arteries,  the  vein  alone  being  obliterated,  and  then  the  foetus  will  die  from 
anemia  or  syncope.  But  it  is  only  necessary  to  examine  the  intertwining  exhi- 
bited by  the  vessels  of  the  cord,  to  become  convinced  that  this  partial  compres- 
sion cannot  exist  except  as  an  accidental  circumstance,  and  that,  as  a  general 
rule,  the  current  must  be  interrupted  in  all  three  vessels  at  the  same  time.  The 
most  plausible  opinion,  and  we  believe  the  only  one  admissible,  is  that  asphyxia 
is  the  sole  cause  of  death  j  for,  as  we  have  elsewhere  stated,  the  placenta  is  the 
only  organ  of  hematosis  for  the  child  up  to  the  moment  when  the  pulmonary 
respiration  is  established ;  and,  therefore,  if  the  circulation  in  the  cord  is  inter- 
rupted by  any  compression  before  birth,  the  blood  of  the  foetus  can  no  longer 
derive  the  elements  necessary  for  its  renovation  by  its  mediate  contact  with  that 
of  the  mother  in  the  placenta ;  and  from  that  moment  the  child  finds  itself  placed 
in  the  same  conditions  as  an  adult  deprived  of  respirable  air,  and,  like  him,  dies 
asphyxiated. 

In  most  cases,  it  is  not  until  after  the  membranes  are  ruptured  that  the  descent 
of  the  cord  exposes  it  to  a  sufficient  degree  of  compression  to  compromise  the 
infant's  life.  Indeed,  if  we  might  judge  from  some  observations  of  Madame 
Lachapelle,  the  pressure  which  it  undergoes  is  never  great  enough  to  obliterate 
.  the  umbilical  vessels,  so  long  as  the  head  is  not  engaged  in  the  superior  strait. 
For  our  own  part,  we  are  inclined  to  believe  that  the  simple  pressure  of  the  head 
on  the  cord  may  be  so  considerable  as  to  interrupt  the  foeto-placental  circulation, 
even  before  the  discharge  of  the  amniotic  waters.  D'Outrepont  relates  two  cases 
which  confirm  this  view;  and  the  numerous  instances  in  which  we  find  the  me- 
conium mixed  in  large  quantities  with  the  lic^uor  amnii  at  the  time  of  the  rupture 
of  the  membranes,  can  only  be  explained,  in  our  estimation,  by  a  momentary 
compression  of  the  umbilical  cord. 

D.  Treatment. — As  regards  the  treatment,  the  delivery  might  be  left  to  the 
powers  of  nature:  1,  whenever  there  is  a  certainty  that  the  child  is  dead;  2, 
when,  though  the  infant  be  living,  the  membranes  are  only  ruptured  as  the  head 
becomes  firmly  engaged  in  the  excavation,  and  when,  from  the  fact  of  the  con- 
tractions being  energetic,  there  is  every  reason  to  hope  that  they  alone  will  be 
sufficient  to  terminate  the  labor  promptly;  which,  in  fact,  usually  occurs  in 
women  who  have  a  non-resistant  perineum,  from  having  previously  borne  chil- 


656  DYSTOCIA. 

dren ;  and,  3,  where  the  head  is  small,  the  pelvis  large,  and  the  cord  situated  in 
front  of  one  of  the  sacro-iliac  symphyses ;  for  then  it  is  only  necessary  to  return 
the  cord  into  the  vagina  to  protect  it  from  the  contact  of  the  air.  But,  notwith- 
standing these  favorable  conditions,  it  will  still  be  necessary  to  watch  the  state 
of  the  cord  attentively,  and  to  apply  the  forceps  as  soon  as  the  pulsations  are 
found  to  grow  weaker  or  to  become  intermittent. 

Under  all  other  circumstances,  the  intervention  of  art  will  be  indispensable. 
Thus,  where  the  presentation  is  such  as  to  render  a  natural  delivery  impossible, 
or,  even  if  possible,  where  the  expulsion  of  the  foetus  would  require  a  long  and 
painful  labor,  the  forceps  should  be  applied  or  the  pelvic  version  be  resorted  to 
without  delay.  The  former  operation  will  be  the  only  one  practicable  in  a  ver- 
tex or  face  presentation,  supposing  both  to  be  firmly  engaged  in  the  excavation, 
and  that  the  previous  attempts  at  reduction  had  proved  ineffectual.  In  a  pre- 
sentation of  the  breech,  the  operator  ought  to  search  for  the  feet,  if  the  present- 
ing part  be  still  above  the  superior  strait,  or  bring  down  the  groins  with  the  blunt 
hook,  if  it  has  descended  into  the  excavation. 

In  a  presentation  of  the  vertex  or  face,  where  these  parts  have  not  as  yet  en- 
gaged in  the  excavation,  we  should  first  endeavor  to  reduce  the  cord.  Several 
plans  have  been  recommended  for  this  reduction ;  but  the  manual  method,  the 
oldest  of  all,  is  still  entitled  to  the  preference,  notwithstanding  the  great  number 
of  instruments  that  have  been  proposed  for  the  purpose.  The  operator  can  always 
proceed  with  greater  facility  behind,  and  on  the  sides  of  the  pelvis,  close  to  the 
sacro-iliac  symphysis ;  the  right  hand  will  be  used  when  the  cord  is  to  the  left, 
and  the  left  one  if  it  is  at  the  mother's  right.  Where  the  loop  is  small,  it  will 
only  be  necessary  to  push  it  up  by  the  middle ;  but,  in  the  contrary  case,  it  is  to 
be  gathered  up  and  pressed  back  little  by  little,  just  as  the  taxis  is  usually  per- 
formed in  the  reduction  of  hernia.  But  merely  pushing  the  cord  back  into  the 
uterus  will  not  be  sufficient  to  protect  it,  and  it  must  be  carried  up  above  the 
superior  strait,  and  the  hand  retained  in  the  vagina  during  several  contractions 
to  prevent  it  from  falling  down.  Some  accoucheurs,  fearing  that  it  could  not  be 
kept  in  position,  notwithstanding  this  plan,  have  directed  the  introduction  of  the 
whole  hand  into  the  womb,  with  a  view  of  placing  the  cord  on  one  of  the  child's 
limbs  ;  though  this  precaution  is  useless  in  most  cases,  it  would  certainly  be  pre- 
ferable to  the  pelvic  version,  says  M.  Guillemot,  where  there  is  a  slight  contrac- 
tion of  the  pelvis.  But  the  instrumental  method  must  be  attempted,  where  the 
smallness  of  the  external  parts,  or  an  undilated  os  uteri,  &c.,  render  the  intro- 
duction of  the  hand  very  difficult  or  impracticable.  Some  of  the  various  instru- 
ments proposed  for  this  purpose  might  then  be  used ;  perhaps  M.  Dudan's, 
recommended  by  31.  Guillemot,  is  one  of  the  simplest  and  best :  He  takes  a  gum 
elastic  (male)  catheter  of  the  size  No.  9,  armed  with  its  stilet,  and  having  a 
piece  of  narrow  ribbon  introduced  into  the  last  eye  of  the  catheter,  which  is 
retained  there  by  the  extremity  of  the  stilet;  the  ribbon  is  next  attached  to  the 
umbilical  cord,  without  drawing  it  too  tight.  If  the  loop  of  the  latter  is  short, 
it  is  applied  near  the  middle,  but  if  long,  the  cord  is  to  be  first  doubled  up ; 
being  thus  secured,  the  extremity  of  the  instrument  carrying  the  cord  is  then 


OBSTACLES    DUE    TO    THE    F(ETUS.  657 

directed  along  the  hand  that  had  previously  been  introduced  into  the  vagina, 
and  placed  within  the  uterine  cavity.  The  hand  in  the  vagina  assists  the  return 
of  the  cord  by  preventing  it  from  slipping  in  the  noose  of  the  ribbon. 

When  the  reduction  is  completed,  we  must  wait  until  the  head  becomes  en- 
gaged, before  withdrawing  the  instrument;  then  the  stilet  is  first  removed  and 
afterwards  the  catheter.  Where  the  reduction  proves  to  be  impossible,  the  pelvic 
version,  if  the  head  is  high  up,  and  the  forceps,  if  it  is  already  engaged,  are  the 
only  resources  left  us.  But  whenever  version  is  resorted  to,  it  is  necessary  to 
carry  up  the  cord  into  the  uterus,  whilst  searching  after  the  feet  (Boer),  lest  it 
be  compressed  either  by  the  arm  of  the  accoucheur,  or  somewhat  later  by  the 
hips  and  the  trunk  of  the  child. 

ARTICLE   IV. 

OF    SHORTNESS   OF   THE    CORD. 

The  cord  may  be  very  short  naturally ;  and,  as  elsewhere  stated,  it  has  been 
known  not  to  exceed  four  or  five  inches  in  length,  but  such  cases  are  very  rare; 
most  generally  its  brevity  is  accidental,  that  is,  it  results  from  the  numerous 
turns  made  around  the  body,  limbs,  or  neck  of  the  child.  The  formation  of 
these  circular  loops  is  favored  by  an  unusual  length  of  the  cord. 

The  latter,  in  a  case  reported  by  Baudelocque,  measured  fifty-nine  inches,  and 
made  seven  folds  around  the  infant's  neck ;  and  Schneider  saw  a  cord  that  mea- 
sured three  and  a  quarter  yards  (three  metres),  and  made  six  turns  on  the  neck. 
Nothing  is  more  common  than  to  find  children  whose  bodies  and  necks  are  en- 
circled by  two  or  three  of  these  folds. 

An  accidental  shortening  of  the  cord  may  render  the  labor  difficult,  either  by 
retarding  its  progress,  or  by  making  it  absolutely  impossible,  or  by  causing  the 
death  of  the  foetus.  This  latter  circumstance  may  result  from  the  constriction 
undergone  by  the  vessels  of  the  neck,  when  the  cord  is  tightly  wound  around 
this  part;  or  it  may  be  owing  to  an  interruption  of  the  circulation  in  the  umbi- 
lical vessels,  produced  solely  from  the  stricture  of  the  cord  itself,  where  it  closely 
encircles  a  limb ;'  again,  these  two  causes  may  act  simultaneously,  and  determine 
the  child's  death  much  more  speedily. 

'  This  constriction  is  sometimes  exceedingly  great,  and  authors  have  certainly  erred  in 
denying  that  it  could  ever  be  such  as  to  strangle  the  fetus.  Besides,  it  is  not  only  at  the 
time  of  labor,  and  as  a  consequence  of  the  tractions  produced  by  the  expulsory  efforts  of  the 
womb,  that  an  effect  of  this  kind  is  observed,  but  these  turns  may  also  form  during  the  preg- 
nancy, and  their  constriction  may  then  be  extensive  enough  to  occasion  death.  Thus,  M. 
Monod  met  with  a  foetus  upon  whose  limbs  they  had  left  very  deep  marks,  not  merely  in 
the  soft  parts,  but  even  on  the  bones  themselves.  The  infant's  neck  often  exhibits  undoubted 
traces  of  them,  and  in  one  case,  examined  by  M.  Taxil,  there  were  three  circular  folds  around 
the  neck,  which  was  so  diminished  in  size  that  its  diameter  did  not  exceed  two  or  three 
lines  (four  millimetres).  It  is  to  such  circular  turns  that  M.  Montgomery  refers  those  spon- 
taneous amputations,  which  M.  Richerand  and  some  others  have  supposed  were  dependent 
on  a  gangrene  of  the  part. 

42 


658  DYSTOCIA. 

The  delay  in  the  Labor,  caused  by  a  shortness  of  the  cord,  is  not  usually  mani- 
fested, until  the  stage  of  expulsion,  properly  so  called,  begins;  and  then,  as  M. 
Guillemot  justly  remarks,  the  attendant  phenomena  -will  vary  according  to  the 
point  of  attachment  of  the  placenta.  When  inserted  at  the  fundus,  it,  like  the 
wall  to  which  it  is  attached,  seems  to  descend  at  each  contraction,  and  approach 
the  OS  uteri,  but  after  the  pain,  it  retreats  with  the  fundus  to  its  original  eleva- 
tion. In  ordinary  cases,  the  hand  can  detect  this  fact  by  being  merely  placed 
over  the  uterine  tumor ;  but  when  a  very  short  cord  is  forcibly  stretched  between 
the  placenta  and  some  part  of  the  child's  body,  a  particular  phenomenon  can  be 
recognized  by  the  touch ;  that  is,  the  finger,  when  applied  on  the  head,  finds  it 
advancing  during  the  pain,  and  retreating  as  soon  as  it  is  over,  because  at  this 
moment  the  fundus  of  the  womb,  which  had  been  depressed  by  the  contraction, 
regains  its  primitive  position,  and  draws  after  it  the  placenta,  cord,  and  foetus. 
But  this  sign  will  evidently  be  wanting  where  the  after-birth  is  attached  to  the 
lateral  parts  of  the  uterus. 

We  have  met  with  a  case  in  which  the  unusual  shortness  of  the  cord,  which 
was  only  nine  inches  in  length,  certainly  detained  the  head  above  the  superior 
strait  for  fifteen  hours  after  the  rupture  of  the  ovum  and  the  entire  dilatation  of 
the  OS  uteri ;  and  we  can  affirm  that,  notwithstanding  the  closest  attention,  we 
were  unable  to  discover  any  of  the  signs  given  by  former  authors ;  though  it  is 
true  that  the  rapidity  in  the  delivery  of  the  after-birth,  after  the  child's  expul- 
sion, did  not  permit  us  to  ascertain  at  what  point  the  placenta  was  inserted. 

Before  the  membranes  are  ruptured,  this  phenomenon  might  be  confounded 
with  the  successive  elevation  and  descent  of  the  head,  that  takes  place  in  nearly 
every  case  of  labor.  But  to  avoid  such  an  error,  it  will  suffice  to  remark,  that 
the  ascent  of  the  head  then  takes  place  during  the  contraction,  and  it  only  falls 
back  after  the  pain  is  over;  being  just  the  contrary  of  what  occurs  when  the 
cord  is  dragged  upon.  Finally,  in  ordinary  cases,  when  the  head  engages  at  the 
perineal  strait,  it  is  found  to  project  during  the  contraction,  and  to  retreat  imme- 
diately after  it  from  the  reaction  of  the  perineum,  which,  after  having  been  for- 
cibly distended  during  the  pain,  retracts  strongly,  and  thereby  presses  it  back 
into  the  vagina.  But,  as  Delamotte  and  Gruillemot  have  remarked,  whenever 
these  movements  of  progression  and  repulsion  merely  depend  on  the  elasticity  of 
the  perineum,  "  they  are  only  present :  1.  When  the  head  engages  at  the  inferior 
strait,  and  then  they  are  the  less  evident  as  the  pains  are  more  rapid  and  more 
energetic ;  while,  on  the  contrary,  they  commence  much  sooner  when  dependent 
on  a  brevity  of  the  cord,  and  become  more  sensible  as  the  head  approaches  the 
vulva,  because  the  tension  on  the  cord  is  then  increased ;  besides  which,  they  are 
persistent,  whatever  may  be  the  strength  of  the  contractions,  and  are  the  more 
marked  as  the  latter  become  stronger. 

"  2.  On  the  other  hand,  when  the  placenta  is  attached  to  the  lateral  walls  of 
the  womb,  these  movements  are  very  obscure,  and  the  diagnosis  quite  difficult. 
In  both  cases,  the  shortness  of  the  cord  is  accompanied  by  pain,  which  is  felt  at 
the  point  of  attachment  of  the  placenta,  particularly  in  the  latter  moments  of 
the  parturition ;  this  pain  is  a  sensation  of  dragging,  or  tearing,  which  commonly 


OBSTACLES     D'JE    TO    THE    FCETUS.  659 

coincides  with  the  movements  of  progression  and  repulsion ;  and  which  might 
be  compared  to  those  felt  by  the  patient  when  an  attempt  is  made  to  remove  the 
after-birth,  before  its  complete  separation."   (Guillemot.) 

According  to  M.  Naegele,  Sen.,  these  circular  turns  may  be  discovered  by  auscul- 
tation during  pregnancy  or  labor,  by  the  existence  of  a  bellows  murmur  accom- 
panying the  foetal  pulsations.  I  agree  with  M.  Danyau  in  the  opinion,  that  further 
research  is  required  to  establish  the  absolute  value  of  this  new  means  of  diagnosis. 
(See  Bellows  Murmur.) 

The  reader  will  now  understand  that  a  shortening  of  the  cord  may  retard  the 
progress  of  the  head,  whether  it  be  still  at  the  superior  strait,  or  whether  it  has 
cleared  the  excavation  and  is  on  the  point  of  engaging  at  the  inferior  strait.  We 
ought  to  add  that  even  the  shoulders  may  be  arrested,  and  the  delivery  of  the 
trunk  be  prevented  after  the  complete  disengagement  of  the  head,  by  the  circular 
turns  which  are  occasionally  made  around  the  child's  neck  by  too  short  a  cord. 
We  were  witnesses  to  a  case  of  this  kind,  that  occurred  at  the  Clinique,  in  1838, 
where  a  division  of  the  cord,  which  was  not  made  until  two  hours  after  the  escape 
of  the  head,  could  alone  effect  a  termination  of  the  labor :  the  foetus  was  born 
dead.     Delamotte  (page  305)  furnishes  an  instance  precisely  similar  to" this. 

The  intervention  of  art  is  therefore  sometimes  necessary,  although  it  often  hap- 
pens that  the  trunk  is  delivered  spontaneously.  However,  the  mechanism  is  not 
the  same  in  cases  of  natural  and  of  accidental  shortening ;  for,  in  those  of  nor- 
mal brevity,  the  head  may  remain  applied  against  the  vulva  after  its  disengage- 
ment, without  much  inconvenience,  and  the  extra-uterine  respiration  may  be 
estoblished  and  kept  up.  In  a  short  time,  the  womb  gradually  contracts  on  the 
parts  of  the  child  that  it  still  contains,  and,  being  itself  forced  along  by  the 
bearing-down  efforts  of  the  patient,  it  sinks  into  the  vagina,  and,  by  thus  ap- 
proaching the  vulvar  orifice,  may  easily  force  the  trunk  to  the  exterior.  Occa- 
sionally, this  descent  of  the  womb  does  not  occur  at  all,  or  else  is  not  sufficient 
to  permit  the  escape  of  the  child ;  and  then  a  rupture  of  the  cord,  or  a  detach- 
ment of  the  placenta,  can  alone  enable  the  uterine  efforts  to  complete  the  deli- 
very. Thus,  in  a  case  of  the  kind  reported  by  Malgouyre,  the  discharge  of  the 
waters,  the  delivery  of  the  child,  and  the  expulsion  of  the  after-birth,  all  occurred 
simultaneously  :  and  the  following  instance  is  related  by  Dr.  Rigby.  After  two 
or  three  hours  of  severe  pains,  the  foetus  was  suddenly  expelled,  and  the  cord 
was  broken  at  about  two  inches  from  the  umbilicus,  so  that,  when  the  midwife 
attempted  to  deliver  the  after-birth,  she  could  not  find  the  other  end  of  the  cord; 
but,  having  introduced  her  hand  into  the  womb,  she  felt  and  extracted  the  pla- 
centa; and  it  was  then  discovered  that  the  cord  had  been  lacerated  at  its  point 
of  insertion. 

In  labors  complicated  by  an  accidental  shortening  of  the  cord,  the  child's  head 
passes  beyond  the  vagina,  and  retains  its  position  there  until  a  renewal  of  the 
pain;  and  when  the  latter  comes  on,  the  head  is  observed  to  pass  to  the  sides  of 
the  vulva,  whilst  the  shoulders,  back,  and  breech  successively  disengage.  This 
expulsion  is  sometimes  effected  so  rapidly  that  it  is  difficult  to  follow  it ;  but,  if 
it  be  delayed  in  the  least,  a  prompt  intervention  is  requisite,  for,  as  elsewhere 


660  DYSTOCIA. 

stated,  the  compression  made  by  the  folds  around  the  neck  may  speedily  prove 
fatal  to  the  child. 

In  breech  presentations,  the  labor  usually  terminates  in  the  following  manner, 
when  abandoned  to  itself;  the  nates,  after  having  been  forced  down  to  the  vulva 
by  the  uterine  contractions,  turn  up  toward  the  side  where  the  cord  is  situated, 
and  then  the  trunk  descends,  becoming  flexed  on  itself  in  the  passage ;  so  that, 
by  the  time  the  head  reaches  the  excavation,  the  body  of  the  child  forms  a  curve, 
■whose  concavity  corresponds  very  nearly  to  the  symphysis  pubis. 

Independently  of  the  delay  that  it  may  cause  in  the  progress  of  parturition, 
and  the  consequent  danger  to  the  foetus,  a  shortening  of  the  cord  may  produce 
other  and  serious  accidents  to  the  mother.  It  is  to  this  circumstance,  particu- 
larly, that  we  must,  in  most  cases,  attribute  the  rupture  of  the  cord,  and  the  pre- 
mature separation  of  the  placenta,  points  to  which  we  shall  return,  when  treating 
of  uterine  hemorrhage.  The  danger  of  these  accidents  will  vary  greatly  with  the 
period  of  their  occurrence ;  thus,  at  the  commencement  of  labor,  the  bleeding 
thereby  occasioned  might  seriously  compromise  the  lives  of  both  mother  and 
child,  if  the  resources  of  our  art  were  not  promptly  interposed.  But,  if  they 
do  not  occur  until  the  moment  when  the  head  is  ready  to  clear  the  vulvar  orifice, 
they  may  rather  be  considered  in  a  favorable  light,  for,  as  we  have  just  seen,  this 
is  one  of  the  means  that  nature  employs  for  terminating  the  delivery. 

Again,  if  the  cord  and  the  adhesions  of  the  placenta  should  obstinately  resist, 
it  is  possible  that  an  inversion,  or  at  least  a  depression  of  the  uterus,  might  be 
the  immediate  consequence  of  the  child's  expulsion.  The  inversion  occurs 
towards  the  end  of  the  labor,  when  the  female  is  urged  to  bear  down,  by  the 
distended  condition  of  the  parts;  and  as  she  still  continues  to  strain,  after  the 
cessation  of  all  uterine  contractions,  the  relaxed  womb  yields  the  more  readily  to 
the  action  of  the  diaphi'agm,  which  tends  to  depress  its  fundus,  because  the  short 
umbilical  cord  drags  the  uterine  wall,  where  the  placenta  is  attached,  in  the  same 
direction. 

Treatment. — The  disastrous  consequences  that  may  result  from  a  shortening 
of  the  cord  present  different  indications  for  treatment,  according  to  the  stage  of 
the  labor  at  which  its  existence  is  detected.  When  the  membranes  are  still  un- 
broken, if  the  OS  uteri  be  freely  dilated,  the  contractions  energetic,  and  there  is 
every  reason  to  suppose,  from  the  signs  before  given,  that  a  dragging  on  the  cord 
is  the  cause  of  the  delay,  they  should  be  ruptured  at  once ;  for,  after  the  waters 
have  escaped,  the  uterus  will  contract,  its  fundus  will  approach  the  cervix,  and 
the  cord,  being  no  longer  dragged  upon,  will  permit  the  head  to  descend  into  the 
excavation.  If  the  head  be  at  the  inferior  strait,  at  the  time  when  the  alternate 
movements  of  elevation  and  descent  begin  to  manifest  themselves  during  and 
after  the  contraction,  the  forceps  should  be  applied.  But  where  the  head  has 
only  the  resistance  of  the  soft  parts  to  overcome,  we  must  be  content  with  pre- 
venting it  from  remounting  in  the  excavation  after  each  pain,  as  much  as  pos- 
sible ;  for  that  purpose  we  must  apply  the  hand  strongly  on  the  perineum,  and 
while  supporting  it,  favor  the  escape  of  the  head  by  pressing  it  up  in  such  a  way 
as  to  aid  its  process  of  extension  or  disengagement.    It  would  also  be  advisable  to 


OBSTACLES     DUE     TO    THE     FCETUS.  661 

have  the  hypogastrium  compressed  at  the  same  time  by  an  assistant,  in  order  to 
prevent  the  uterus  from  ascending  during  the  interval  between  the  pains. 
Lastly,  after  the  head  is  delivered,  the  accoucheur  should  immediately  loosen  the 
turns  of  the  cord  around  the  neck,  and  slip  them  over  it ;  and  where  these  folds 
are  so  tight  as  to  resist  the  tractions  made  with  that  object,  they  should  be 
divided,  but  it  is  not  requisite  to  apply  the  ligature  to  the  umbilical  extremity  of 
the  cord  at  once.  In  most  cases,  indeed,  it  is  necessary  to  allow  this  to  bleed  a 
little  after  the  birth,  in  order  to  relieve  the  apoplectic  state  of  the  foetus ;  for,  by 
applying  the  ligature  too  soon,  we  would  be  deprived  of  this  resource.  Never- 
theless, where  the  expulsion  is  unusually  delayed,  the  foetal  end  of  the  cord  will 
have  to  be  slightly  pinched  between  the  two  fingers  to  prevent  hemorrhage. 

A  drassing;  of  the  cord  entwined  around  the  trunk  or  limbs  is  not  at  all  unfre- 
quent  in  the  natural  labors  by  the  breech,  and  when  pelvic  version  has  been 
effected.  It  is  to  be  remedied  by  making  moderate  tractions  on  its  placental 
extremity,  and  if  these  are  not  sufficient,  it  should  be  divided,  and  the  labor  ter- 
minated as  speedily  as  possible.  The  same  precepts  are  applicable  in  all  cases 
where  the  brevity  of  the  cord  is  natural ;  and  if  the  accoucheur  is  obliged  to 
carry  his  hand  up  into  the  womb  to  ascertain  the  nature  of  the  obstacle,  he 
should  take  advantage  of  the  occasion  to  effect  the  pelvic  version,  and  to  draw 
down  the  child  until  the  base  of  its  chest  appears  at  the  vulva ;  then  the  cord  is 
to  be  cut  and  tied,  or  else  compressed  with  the  fingers,  and'  the  extraction  of  the 
foetus  completed  at  once. 

It  is  advisable  to  introduce  the  hand  again  into  the  uterus,  after  the  placenta 
is  delivered,  to  ascertain  that  the  fundus  of  the  organ  is  neither  depressed  nor 
inverted. 

ARTICLE   V. 

MALPOSITIONS   OF   THE   FCETUS. 

The  ancients  applied  the  term  malposition  to  all  those  cases  in  which  the  top 
of  the  head  did  not  correspond  to  the  os  uteri.  But,  as  we  have  already  demon- 
strated, the  labor  nearly  always  terminates  favorably,  both  for  the  mother  and 
child,  in  the  presentations  of  the  face  and  breech,  though  it  is  a  little  more  diffi- 
cult than  usual ;  and  experience  has  even  proved  that  it  is  barely  possible  in 
those  of  the  trunk.  Nevertheless,  the  first  three  presentations  offer  certain  ano- 
malies and  irregularities,  that  may  at  times  render  the  labor  difficult,  and  require 
the  intervention  of  art ;  for,  although  the  presentations  of  the  vertex,  face,  and 
breech,  are  usually  free  and  regular,  yet  they  may  be  irregular  or  inclined.  (See 
page  412,  et  aeq.)  But  these  last  so  rarely  constitute  an  obstacle  to  the  sponta- 
neous termination  of  the  labor,  that  we  have  not  hesitated  to  include  them  in  the 
description,  heretofore  given,  of  the  mechanism  of  natural  labor.  In  fact,  the 
only  modification  they  determine  in  this  mechanism  is  that  the  head,  in  clear- 
ing the  superior  strait  or  traversing  the  excavation,  undergoes  a  movement  of 
correction,  whereby  the  occipito-frontal  or  the  sub-occipito-bregmatic  circumfer- 
ence becomes  parallel  to  the  plane  of  the  strait.    But  this  movement  is  necessary; 


^62 


DYSTOCIA. 


Fig.  96. 


for,  if  the  head  exhibits  its  normal  size,  the  delivery  is  only  possible  under  that 
condition,'  and,  when  it  does  not  take  place,  the  resources  of  art  are  indispen- 
sable. Certain  anomalies,  capable  of  interfering  with  the  expulsion,  may  also 
take  place  in  the  movements  of  the  head.  We  must  now  ascertain  what  are  the 
indications  for  treatment  presented  in  these  particular  cases. 

§  1.  Inclined  Positions  of  the  Vertex. 

Under  this  title  we  include  all  those  positions  that  have  been  described,  by 
Baudelocque,  as  the  positions  of  the  sides  of  the  head,  of  the  ears,  the  temples, 

and  the  occiput;  the  former  of  which  is  re- 
cognized by  the  presence  of  an  ear,  the  angle 
of  the  jaw,  or  by  the  parietal  protuberance; 
while  a  presentation  of  the  occiput  is  detected 
by  the  triangular  form  of  the  posterior  fonta- 
nelle,  by  the  lambdoid  sutures,  and  the  vici- 
nity of  the  neck. 

In  general,  when  an  inclination  of  this 
kind  is  detected  at  the  onset  of  labor,  or 
shortly  after  the  membranes  are  ruptured, 
there  is  nothing  to  be  done;  for  it  is  well 
known  that,  in  far  the  greater  number  of 
cases,  the  conversion  is  eiFected  spontane- 
ously; but,  if  the  head  still  retains  its  primi- 
tive position  for  five,  six,  seven,  or  eight 
hours  after  the  discharge  of  the  waters,  and 
its  descent  is  thereby  impeded,  we  must  attempt  an  artificial  correction.  It  is 
possible  to  accomplish  this  with  the  hand  alone,  which  is  always  to  be  tried 
before  resorting  to  an  introduction  of  the  lever  or  forceps;  and  it  is  unnecessary 
to  add  that  any  obliquity  of  the  uterus,  should  it  exist,  must  first  be  remedied. 
As  a  general  rule,  that  hand  should  be  used  whose  palmar  face  would  grasp  the 
vertex  the  most  readily;  and,  when  introduced  into  the  womb  (see  Version),  it 
grasps  the  occiput  so  as  to  draw  upon  it,  after  having  first  removed  it  from  the  iliac 
fossa ;  whilst  considerable  pressure  is  made  with  the  other  hand  over  the  hypo- 
gastric region,  in  order  to  force  the  head  to  descend.  When  the  correction  can- 
not be  effected  by  the  hand  alone,  most  accoucheurs  recommend  the  employment 
of  the  lever;  but  we  should  decidedly  prefer  having  recourse  to  the  forceps,  the 
blades  of  which  would  act  at  first  as  a  lever  in  rectifying  the  head,  and  then,  by 
their  traction,  the  labor  could  be  terminated  almost  immediately.    Because,  where 


The    left   occipito-iliiic    position.   stron<i;ly 
inclined  on  its  posterior  parietal  region. 


'  However,  we  have  known  this  conversion  of  an  inclined  vertex  position  into  a  free  one 
to  occur  at  the  inferior  strait  in  a  woman  with  her  first  chil<l ;  the  head  was  placed  in  the 
left  anterior  occipitoiliac  position,  and  was,  at  the  same  time,  inclined  on  the  right  parietal 
region.  In  descending  into  the  pelvis,  it  retained  this  position,  so  that,  when  it  had  reached 
the  floor  of  the  excavation,  we  detected  the  ear;  but  it  became  rectified,  after  several  strong 
pains,  and  cleared  the  inferior  strait  immediately  after  having  undergone  the  movement  of 
correction.     The  head  was  small,  although  the  fu;tus  was  at  full  term. 


OBSTACLES     DUE    TO     THE     FCETUS.  663 

seven  or  eight  hours  have  been  spent  (according  to  our  precept)  in  the  vain  hope 
that  the  powers  of  nature  would  be  adequate  to  rectify  the  inclination;  and, 
where  the  operator  has  unsuccessfully  attempted  to  produce  the  correction  by  his 
hand  alone,  it  must  be  evident  that  an  early  termination  of  the  labor  is  indicated 
in  the  double  interest  of  the  mother  and  child;  and  that,  consequently,  the 
forceps  should  be  preferred  in  such  cases  to  the  lever. 

The  attempt  to  seize  the  head  properly  with  the  forceps  and  bring  it  down 
into  the  excavation,  does  not  always  succeed,  in  which  case  the  difficulty  may  be 
overcome  by  turning;  at  least,  I  found  it  to  answer  in  two  cases  of  failure  by 
the  forceps.  I  think,  also,  that  I  should  be  disposed  to  have  recourse  to  it 
immediately,  when  the  uterus  was  but  slightly  contracted,  and  still  contained  a 
considerable  amount  of  water. 

§  2.  Anomalies  in  the  Mechanism  of  Labor. 

The  occipito-posterior  positions  which  are  not  converted  naturally  into  anterior 
or  pubic  ones,  may  also  allow  of  the  spontaneous  disengagement  of  the  head, 
though,  as  we  have  already  stated,  they  sometimes  present  insurmountable  ob- 
stacles to  the  termination  of  the  labor.  We  repeat  that  we  have  but  little  confi- 
dence in  efi"orts  made  with  the  fingers  to  produce  this  movement  of  rotation,  and 
that  the  application  of  the  forceps  seems  to  us  the  most  useful  means  that  can  be 
employed.  (See  Forceps.) 

It  is  important  to  observe  that  the  continuance  of  the  occiput  posteriorly,  some- 
times prevents  the  engagement  of  the  head,  which  remains,  long  after  the 
membranes  are  ruptured,  above  the  superior  strait,  and  that,  notwithstanding  the 
contractions  are  powerful.  In  such  cases,  the  posterior  fontanelle  is  hidden  by 
the  swelling  of  the  scalp,  and  in  order  to  diagnose  the  position,  it  is  necessary  to 
carry  the  finger  upward  and  in  front,  when  the  anterior  fontanelle  will  be  disco- 
vered. At  each  contraction,  the  vertex  strikes  the  horizontal  branch  of  the 
pubis,  and  the  presentation  then  tends  to  become  converted  into  one  of  the 
nucha,  so  called  by  the  old  accoucheurs.  I  have  noticed  this  anomaly  more 
especially  in  the  left  occipito-posterior  positions,  and  have  always  been  obliged  to 
use  the  forceps ;  quite  powerful  efforts  are  usually  required  to  extract  the  head. 

The  vertex  positions,  even  when  not  inclined,  sometimes  present  anomalies  in 
their  mechanism.  Thus  the  movement  of  rotation,  which,  in  the  transverse 
positions,  is  calculated  to  bring  the  occiput  under  the  pubic  arch,  is  occasionally 
delayed  for  a  long  time,  and  thereby  greatly  retards  the  labor.  When  this  delay- 
is  dependent  on  the  feebleness  of  the  uterine  contractions,  an  application  of  the 
forceps  is  the  best  remedy.  But,  according  to  many  authors,  it  may  also  be 
owing  to  what  Levret  called  the  wedging-in  of  the  shoulders ;  that  is,  the  latter 
then  present  their  long  bis-acromial  diameter  to  the  smallest  one  of  the  superior 
strait,  and  thus  become  firmly  engaged  or  wedged  there,  in  such  a  way  that  they 
cannot  descend  any  further,  and  therefore  arrest  the  progress  of  the  head.  This 
wedging  of  the  shoulders,  which  can  scarcely  occur  without  a  slight  contraction 
of  the  abdominal  strait,  has  been  detected  by  Levret,  by  Delamotte,  by  Euysch, 
et  ah.,  and  its  occasional  occurrence  is  admitted  by  Desormeaux  and  Dug^s ; 


Q64:  DYSTOCIA. 

consequently,  it  should  be  regarded  as  being  possible.  This  cause  of  dystocia 
would  scarcely  ever  be  suspected  during  the  labor,  unless  attention  were  drawn 
to  it  by  the  mobility  of  the  head  in  the  excavation  (Fried) ;  this  is  the  only  sign 
that  would  be  likely  to  arouse  attention,  where  a  normal  conformation  of  the 
inferior  strait  has  been  ascertained,  and  where  the  contractions  are  strong  and 
sustained.  Under  such  circumstances,  Levret  advises  (and  Desormeaux  seems 
to  approve  the  counsel)  the  patient  to  be  placed  on  her  elbows  and  knees,  with 
her  head  declining,  with  a  view  of  removing  the  weight  of  the  child's  shoulders 
from  the  mother's  parts ;  and  then  the  accoucheur  should  slip  his  hand  along 
between  the  head  and  the  pelvic  walls,  seize  the  shoulder  that  is  locked  at  the 
sacro-vertebral  angle,  draw  it  to  one  side  and  change  its  position.  Although  the 
performance  of  this  manoeuvre  is  attended  with  difficulty,  yet  it  is  the  only  one 
practicable  if  the  foetus  be  living ;  but  where  it  is  dead,  he  ought  to  diminish 
the  head  by  craniotomy,  so  as  to  open  a  more  ready  passage  up  to  the  shoulders. 
Supposing  this  diagnosis  to  be  well  made  out,  it  would  seem  proper  to  follow 
the  recommendation  of  Desormeaux,  but  the  fact  is,  it  is  so  very  difficult  that,  as 
M.  Jacquemier  judiciously  remarks,  the  use  of  the  forceps,  though  in  reality 
irrational,  is  perhaps  the  only  remaining  resource. 

After  the  head  is  delivered,  the  expulsion  of  the  body  may  be  impeded  by  the 
size  of  the  shoulders,  and  the  danger  to  which  the  child  is  exposed  in  conse- 
quence, may  demand  the  intervention  of  art.  The  forefingers  may  then  be 
hooked  into  the  axillae  and  strong  tractions  performed  with  them.  Unfortu- 
nately, however,  these  are  sometimes  fruitless,  and  then,  says  M.  Jacquemier, 
"  the  successive  disengagement  of  the  arms  might  be  attempted  with  advantage." 
The  rotation  of  the  head,  in  virtue  of  which  the  occiput  gets  under  the  sym- 
physis pubis,  may  likewise  be  rendered  difficult,  or  even  wholly  impossible,  by 
the  size  of  the  sero-sanguinolent  tumor  of  the  scalp,  that  is  always  formed  when 
the  head  remains  in  the  excavation  for  some  time ;  for,  by  engaging  itself  in  the 
void  of  the  pubic  arch,  this  tumor  may  render  the  movement  of  rotation  abso- 
lutely impossible.   (Harnier.)     Of  course,  the  forceps  must  then  be  applied. 

Direct  occipito-pubic  or  occipito-sacral  positions  are  very  rare,  though  certainly 
it  is  a  mistake  to  deny  their  existence.  We  have  already  stated  that  the  occi- 
put may  be  in  relation  with  any  point  of  the  superior  strait.  In  the  immense 
majority  of  cases  these  direct  positions  are  converted,  after  the  labor  begins,  into 
diagonal  ones ;  for  the  convexity  of  the  forehead  in  the  occipito-pubic  positions, 
and  that  of  the  occiput  in  the  occipito-sacral  ones,  having  to  glide  over  the 
sacro-vertebral  angle,  are  almost  always  turned  either  to  the  left  or  to  the  right. 
In  some  cases  however,  the  primitive  positions  continue,  and  the  labor  termi- 
nates in  nearly  the  usual  manner.  It  occasionally  happens  that  if  the  head  is 
large,  and  the  pelvis  but  moderately  developed,  though  well  formed,  the  former 
is  arrested  at  the  superior  strait,  and  impacted,  as  it  were,  by  the  two  extre- 
mities of  its  occipito-frontal  diameter.  In  such  cases,  the  application  of  the 
forceps  is  the  only  resource. 


obstacles   due   to   the   fcetus.  605 

§  3.  Inclined  Positions  op  the  Pelvis. 

Sometimes  one  hip,  at  others  the  lumbar  region,  or  the  lower  part  of  the  ab- 
domen, according  to  the  direction  of  the  inclination,  may  engage  first  at  the 
upper  strait ;  particularly  where  the  uterine  obliquity  is  well  marked.  We  must, 
therefore,  correct  this  obliquity,  which  is  the  original  cause  of  the  anomaly ;  then, 
if  that  is  not  sufficient  to  replace  the  breech  in  a  horizontal  position,  the  feet  are 
to  be  sought  after  and  brought  down,  or  else  one  of  the  groins  be  acted  on  by 
hooking  a  forefinger  into  it. 

§  4.  Positions  of  the  Face. 

The  face  positions  may  likewise  be  irregular ;  that  is,  it  may  happen  either 
that  only  one  cheek  engages,  in  consequence  of  a  lateral  inclination,  or  else  that 
the  head,  being  but  little  extended,  the  forehead  is  found  at  the  centre  of  the 
superior  strait ;  or,  on  the  other  hand,  this  extension  being  carried  to  an  ex- 
treme, that  the  chin  and  the  front  of  the  neck  are  alone  accessible  to  the  finger; 
but  in  all  these,  as  in  the  preceding  cases,  nature  herself  is  generally  able  to 
accomplish  the  delivery.  The  instances  in  which  the  forehead  is  first  placed  at 
the  centre  of  the  upper  strait  are  quite  frequent;  but  the  extension  being  com- 
pleted at  the  moment  when  it  engages  in  the  excavation,  the  face  then  becomes 
completely  horizontal.  (See  Mechanism  of  Labor  by  the  Face.)  The  same  is 
true  of  the  malar  positions,  the  correction  of  which,  like  that  of  the  j^arietal 
positions  of  the  vertex,  is  effected  during  the  period  of  descent.  In  those  rare 
cases  where  the  inclination  resists  the  power  of  the  uterine  contractions,  the  cor- 
rection with  the  hand  at  first,  then,  in  case  of  failure,  the  application  of  the 
forceps,  if  the  head  is  engaged  and  immovable,  or  the  pelvic  or  cephalic  version, 
if  it  be  high  up,  and  can  easily  be  displaced,  appear  to  us  the  proper  measures. 
The  spontaneous  reduction,  just  alluded  to,  as  the  most  ordinary  termination 
of  the  frontal  or  malar  positions,  is  much  more  difficult  in  the  cases  where  the 
chin,  in  consequence  of  the  excessive  extension  of  the  head,  has  a  tendency  to 
engage  first,  and  approach  the  centre  of  the  excavation.  For  then,  according  to 
the  observation  of  Madame  Lachapelle,  the  head  not  only  presents  unfavorable 
diameters,  but  the  body  likewise  shows  a  disposition  to  descend  along  with  the 
face ;  though  at  the  same  time  it  presses  the  latter  back  from  the  passage,  and 
thus  creates  an  obstacle  to  its  escape,  while  the  contraction  transmitted  by  the 
spine  rather  tends  to  augment  than  to  correct  the  inclination.  Under  such  cir- 
cumstances, we  can  trust  less  to  the  powers  of  nature,  and  therefore  must  endea- 
vor to  change  the  position  by  a  resort  to  pelvic  version. 

These  lateral  inclinations  are  usually  primitive,  and,  as  we  have  already  stated, 
are  reduced  spontaneously  into  correct  positions.  But  it  may  also  happen  that  a 
position  which  is  entirely  regular  at  the  beginning  of  labor,  may  become  con- 
verted into  an  inclined  one,  which  nothing  can  restore.  Thus,  Dr.  Birnhaum, 
of  Bonn,  mentions  a  case  of  right  transverse  mento-iliac  position,  of  the  most 
regular  kind,  which  became  converted  into  a  left  anterior  occipito-iliac  one, 
strongly  inclined  upon  the  right  parietal  bone.  The  labor  had  to  be  terminated 
by  the  forceps. 


QGQ  DYSTOCIA. 

It  is  well  known  that  a  spontaneous  delivery  in  face  positions  requires  that 
they  should  be  converted  into  mento-pubic  ones;  but  this  process  of  rotation, 
which  is  easily  effected  in  the  mento-anterior  varieties,  that  is  to  say,  in  the  cases 
where  the  chin  was  primitively  in  relation  with  some  part  of  the  anterior  half  of 
the  pelvis,  is  much  more  difficult  in  the  mento-posterior  positions,  and  sometimes 
even  it  does  not  take  place  at  all.  And  it  must  be  acknowledged  that  an  unre- 
duced engagement  of  the  foce,  and  its  want  of  tendency  to  reduction,  constitute 
one  of  the  most  serious  difficulties  met  with  in  the  obstetrical  art. 

Now,  with  a  view  of  more  clearly  specifying  the  various  indications  for  treat- 
ment that  may  present  under  such  circumstances,  we  will  suppose  four  different 
cases  of  face  positions,  namely  : 

1st.  A  woman  has  been  in  labor  for  a  considerable  time,  the  membranes  are 
ruptured,  and  five  or  six  hours,  or  even  more,  have  elapsed  since  the  waters 
escaped,  during  all  which  period  the  uterine  contractions  have  been  very  strong; 
a  good  confoi-mation  of  the  pelvis,  and  a  complete  dilatation  of,  and  no  resistance 
from,  the  os  uteri  are  recognized  by  the  touch,  and  yet  the  presenting  part  still 
remains  high  up  and  does  not  engage  in  tire  excavation ;  but,  in  searching  for 
the  causes  that  retain  this  part  at  the  superior  strait,  under  so  many  favorable 
circumstances,  it  is  found  that  the  face  presents  in  a  mento-posterior  position. 
Here  there  would  be  reason  to  conclude,  in  my  estimation,  that  the  delay  in  the 
labor  is  dependent  on  the  non-reduction  of  the  mento-posterior  position  into  an 
anterior  one ;  and,  therefore,  I  think  that  an  attempt  should  be  made  to  convert 
the  face  position  into  one  of  the  vertex.  This  could  be  done  by  introducing  that 
hand  whose  palmar  face  embraces  the  vertex  most  readily;  which  would  be  the 
right  one  when  the  chin  is  directed  backwards  and  to  the  right  side,  and  the  left 
in  the  opposite  case ;  then,  after  having  grasped  the  head  with  the  whole  hand, 
endeavor  to  push  it  up  above  the  superior  strait,  and,  if  successful,  surround  the 
vertex  with  the  palmar  fiice  of  the  four  fingers,  and  flex  the  head  on  the  chest, 
when,  the  position  of  the  face  being  converted  into  one  of  the  vertex,  the  uterine 
contractions  will  accomplish  the  rest. 

As  this  manoeuvre  will  rarely  prove  successful,  it  should  be  attempted  very 
carefully,  and  version  substituted  for  it  without  much  delay. 

2d.  If,  to  the  mentoposterior  position  just  described,  whether  the  face  be 
engaged  or  be  still  above  the  abdominal  strait,  any  accident  ichatever  be  joined 
that  demands  a  jn-omiH  termination  of  the  labor,  it  is  evident  that  the  pelvic 
version  is  the  only  operation  that  could  be  resorted  to  with  a  prospect  of  advan- 
tage. 

3d.  If  the  mento-posterior  position  is  coincident  with  a  moderate  contraction 
of  the  pelvis,  most  authors  advise  the  conversion  of  the  facial  position  into  one  of 
the  vertex,  and  then  the  application  of  the  forceps  upon  the  flexed  cephalic  ex- 
tremity. It  seems  to  us,  that  this  previous  cephalic  version  would  prove  very 
difficult,  if  attempted  long  after  the  membranes  are  ruptured,  and  we  should  give 
preference  to  turning  by  the  feet.  We  shall  have  occasion  hereafter  to  justify 
this  precept,  which  is  opposed  to  that  given  in  the  second  edition  of  this  work. 


OBSTACLES     DUE     TO     THE     FCETUS.  6G7 

We  will  then  explain  why  it  appears  to  us  that  extraction  by  the  feet  may  be 
attempted  in  cases  of  contracted  pelvis. 

The  application  of  the  forceps  on  the  fiice  in  the  mcnto-posterior  positions, 
seems  to  us  an  extreme  measure,  which  should  only  be  employed  when  nothing 
else  can  be  done,  as  in  the  nest  variety. 

4th.  Lastly,  there  are  some  unfortunate  cases  where  it  is  impossible  to  push 
up  the  presenting  part,  either  because  the  head  has  cleared  the  cervix  uteri,  or 
because  the  strong  contraction  of  the  womb  renders  ever  attempt  abortive;  and, 
therefore,  both  the  pelvic  and  the  cephalic  versions  are  altogether  out  of  the 
question.  The  accoucheur  must  then  necessarily  have  recourse  to  instruments. 
The  lever,  the  common  forceps,  the  crotchet,  and  the  embryotomy  forceps,  have 
all  been  proposed  in  turn ;  but,  before  resorting  to  the  latter,  the  first  should 
always  be  tried. 

In  certain  cases,  the  lever  has  proved  very  useful,  and,  where  applied  on  the 
vertex  or  occiput,  has  occasionally  depressed  this  part,  and  thus  converted  a  face 
presentation  into  one  of  the  vertex.  It  is  oftentimes  more  easily  managed  than 
the  forceps,  when  the  head  is  high  up,  owing  to  the  difficulty  of  getting  the 
second  blade  of  the  latter  to  the  proper  height  and  position ;  and  I  may  men- 
tion that  it  proved  very  serviceable  in  a  case  to  which  I  was  called  by  Dr.  Four- 
nier,  where  the  head  had  engaged  in  the  excavation,  in  the  right  mento-poste- 
tior  position,  and  could  neither  be  pushed  up  nor  advantageously  grasped  by  the 
forceps. 

I  believe  that,  in  common  with  many  practitioners,  I  have  erred  in  proscribing 
this  instrument  almost  altogether  from  practice;  for  the  lever,  in  my  opinion, 
may  render  very  important  aid  in  those  posterior  positions  that  approach  a  trans- 
verse character;  and  in  which,  from  being  still  high  up,  an  application  of  the 
forceps  is  exceedingly  difficult.     (See  Lever.) 

As  to  the  forceps,  though  proscribed  by  Madame  Lachapelle,  in  the  cases 
under  consideration,  it  may  be  tried  as  a  dernier  resort,  as  that  would  be  far 
better  than  embryotomy  when  the  child  is  living;  but,  to  be  successful,  it  is 
necessary  that  the  operator  should  be  well  versed  in  the  movements  that  are  to 
be  given  to  the  head  by  the  instrument.  Thus,  supposing  the  blades  are  pro- 
perly applied  on  the  sides  of  the  head  (and  the  difficulty  of  this  is  well  known), 
should  we  attempt  to  bring  the  chin  round  in  front  (Sraellie)  ?  or  would  it  be 
better,  leaving  the  chin  posteriorly,  to  endeavor  to  depress  the  forehead  and  occi- 
put, and  then  to  disengage  these  parts  first  under  the  pubis  ?  Relying  on  the 
cases  published  by  former  authors,  I  do  not  hesitate  to  decide  in  favor  of  the  last 
manoeuvre  ;  for  every  practitioner  must  acknowledge  that  the  rotation  of  the  chin 
forwards  exposes  the  child  to  very  great  dangers  from  the  extent  of  the  move- 
ment in  the  atloido-axoid  articulation,  and  the  two  favorable  cases  reported  by 
M.  P.  Dubois,  which  he  himself  considers  as  exceptions,  cannot  make  us  over- 
look all  those  in  which  this  excessive  rotation  has  cost  the  child's  life.' 

'  I  have  had  occasion  to  prove  very  evidently  the  danger  attendant  on  this  extreme  rotary 
movement. 

In  July,  1815,  I  had  charge  of  a  case  of  right  mento-sacro-ihac  position  in  a  primiparous 


668  DYSTOCIA. 

If  tlie  child  were  dead,  the  remembrance  of  Sraellie's  want  of  success,  and  my 
own,  would  still  induce  me  to  endeavor  to  depress  the  vertex ;  nor  would  I  brino- 
the  chin  in  front,  before  having  vainly  attempted  cephalic  version  with  the  assist- 
ance of  the  instrument.  We  shall  see  hereafter,  how  far  the  modifications  of  the 
process  to  be  employed,  recommended  by  MM.  Champion,  Baumers,  and  Dan- 
yau,  are  capable  of  facilitating  this  rotary  movement. 

Grounding  myself,  therefore,  on  the  observations  of  Sraellie  (t.  xi,  p.  579),  of 
Meza  (Acta  regice  Societatis  Med.  Hauniensis,  t.  xi,  p.  379),  and  of  Siebold 
(^Siehold's  Journal,  an.  1830,  p.  209),  I  should  not  hesitate,  after  having  ap- 
plied the  blades  as  accurately  as  possible  on  the  sides  of  the  head,  to  draw 
directly  downwards  and  backwards,  with  a  view  of  depressing  the  vertex. 

I  am  well  aware  of  the  objections  to  this  mode  of  procedure,  and  that  it 
may  be  said  that,  during  the  moveujent  of  flexion,  which  you  impress  on  the 
head,  the  long  occipito-mental  diameter  must  necessarily  pass  one  of  the  diame- 
ters of  the  excavation,  thereby  often  creating  an  insurmountable  obstacle  to  the 
delivery.  I  do  not  deny  the  force  of  this  objection,  and  am  willing  to  confess 
that  in  theory  it  is  not  altogether  satisfactory;  though  what  avails  the  inefficacy 
of  theoretical  opinions,  where  positive  facts  bearing  on  this  point  can  be  adduced, 
and  some  of  which  I  have  just  quoted?  But  the  somewhat  material  authority  of 
facts  is  not  the  only  one  I  might  invoke ;  for  does  not  our  reason  tell  us  that, 
when  any  of  those  cases  (fortunately  very  rare)  are  presented  in  practice,  which 
seem  beyond  the  pale  of  all  theoretical  notions,  and  in  which  the  practitioner  is 
constrained  to  do  what  he  can,  not  what  he  would,  the  wisest  course  is  to  follow 
as  closely  as  possible  the  route  traced  out  by  nature  ?  Now,  has  it  not  often 
happened  that  the  labor  terminated  alone,  in  the  mento-posterior  positions  of  the 
face,  and  yet  the  chin  has  remained  behind  throughout  ?  And  what  has  been 
the  mechanism  under  such  circumstances  ?  By  consulting  the  published  cases, 
we  shall  find  that  the  uterine  contraction  was  incapable  of  depressing  the  chin, 
and  has  seemed  to  transfer  its  action  to  the  occiput ;  and  then  the  forehead,  the 
vertex,  and  the  occipital  extremity,  by  slipping  behind  the  symphysis  pubis,  have 

female,  and  the  continuance  of  which  rendered  delivery  impossible,  and  required  the  inter- 
vention of  art.  After  fruitlessly  endeavoring  to  press  up  the  head,  we  were  obliged  to  use 
the  forceps,  the  child  being  still  alive.  Having  applied  the  blades  upon  the  sides  of  the 
head,  we  endeavored  to  bring  down  the  vertex,  but  it  was  impossible.  Neither  was  one  of 
the  branches  of  the  forceps  applied  as  a  lever  upon  the  vertex,  more  successful.  We 
thought  it  right  before  having  recourse  to  embryotomy,  to  endeavor  to  turn  the  chin  in  front ; 
therefore,  replacing  both  blades  of  the  forceps,  we  turned  the  head  so  as  to  make  the  chin 
correspond  with  the  right  extremity  of  the  transverse  diameter,  and  next,  after  a  slight  re- 
arrangement of  the  blades,  behind  the  right  acetabulum.  The  face  was  then  in  the  lower 
third  of  the  excavation,  and  the  vulva  being  partially  opened  by  the  instrument,  we  saw 
distinctly  motions  of  the  lips  and  tongue  of  the  foetus.  The  rotation  was  then  completed 
and  when  once  the  chin  came  in  front,  the  head  was  disengaged  by  the  usual  flexion. 
Though  the  heart  of  the  foetus  still  beat  feebly,  it  coidd  not  be  restored  to  life  by  long-con- 
tinued and  well-directed  efforts. 

I  am  convinced  that  the  death  of  the  foetus  was  in  this  case  simply  due  to  the  extreme 
twisting  of  the  neck. 


OBSTACLES    DUE    TO    THE    FCETUS.  669 

successively  appeared  at  tlie  centre  of  the  pubic  arch.  Is  it  not,  therefore,  logi- 
cal to  recommend  an  attempt  to  impress  the  same  movement  of  flexion  on  the 
head,  in  the  hope  that  the  tractions  by  the  instrument,  coming  to  the  aid  of  the 
espulsory  efforts  of  the  womb,  would  succeed  in  accomplishing  what  these  latter 
alone  could  never  effect  ? 

What  we  have  stated  respecting  the  impossibility  of  spontaneous  conversion  in 
direct  mento-sacral  positions,  and  of  its  natural  explanation  in  the  diagonal  mento- 
posterior positions,  finds  here  its  practical  application.  The  consequence  is,  that 
if  the  chin  were  turned  directly  toward  the  anterior  face  of  the  sacrum,  we 
should,  before  flexing  the  head  with  the  forceps,  impress  upon  it  a  slight  rotary 
movement,  which  would  bring  the  chin  to  one  of  the  sacro-iliac  symphyses,  pre- 
ferably toward  the  right,  in  order  to  avoid  compressing  the  rectum,  which  is  situ- 
ated to  the  left. 

Again,  there  are  some  unfortunate  cases  in  which,  after  having  vainly  at- 
tempted all  the  different  manoeuvres  just  referred  to,  craniotomy  becomes  our 
only  resource.* 

Do  not  the  supposititious  cases  just  given  (which  could  easily  be  sustained 
from  the  facts  reported  by  authors),  by  rendering  us  acquainted  with  the 
various  difficulties  that  may  be  encountered  in  these  cases,  lead  us  to  adopt,  for 
the  mento-posterior  positions,  the  rules  heretofore  laid  down  by  Baudelocque, 
Gardien,  and  others,  for  all  face  positions  ?  And  though,  in  the  present  state  of 
our  science,  the  mento-anterior  positions  should  be  abandoned  to  nature,  yet  does 
the  same  rule  hold  good  with  the  regard  to  the  mento-posterior  ones  ?  In  a  word, 
if  this  last  position  be  clearly  recognized  before  or  shortly  after  the  membranes 
are  ruptured,  should  we  not,  prior  to  the  engagement  of  the  face,  and  while  the 
head  is  still  movable,  endeavor  to  convert  it  into  a  vertex  position,  and  thus  pre- 
vent the  difficulties  that  might  subsequently  arise  ?  If  I  had  to  decide  under 
such  circumstances,  I  would  certainly  resolve  the  question  in  the  affirmative. 

§  5.  Positions  or  the  Trunk. 

A  natural  delivery  in  trunk  presentations  is  a  very  unusual  occurrence,  and 
one  upon  which  the  accoucheur  should  never  rely.     It  is  therefore  an  absolute 

'  I  have  quite  recently  witnessed  a  case  of  this  nature  with  Dr.  Letannelet,  who  requested 
my  attendance  on  a  young  lady  in  her  first  labor.  I  saw  her  at  eight  o'clock  in  the  evening, 
and  detected,  as  my  learned  associate  had  previously  done,  a  right  mento-posterior  position 
(the  frontal  variety)  :  the  head  had  been  firmly  engaged  since  three  o'clock  in  the  afternoon, 
and  from  that  hour  had  not  advanced  a  single  line.  At  eleven,  as  no  change  had  taken 
place  either  in  its  position  or  elevation,  we  attempted  unsuccessfully  to  push  it  up.  Both 
M.  Letannelet  and  myself  tried  the  lever  and  the  forceps  in  vain ;  but  before  resorting  to 
craniotomy,  which  was  then  deemed  indispensable,  we  requested  M.  Dubois  to  see  the 
patient.  He  arrived  at  one  o'clock  in  the  morning,  and  renewed  the  attempts  that  we  had 
before  made,  without  any  better  success,  and  craniotomy  was  then  decided  upon ;  but  as  the 
woman  had  great  need  of  rest,  and  the  necessary  instruments  were  not  at  hand,  the  opera- 
tion was  deferred  until  eight  o'clock,  a.m.  when  it  was  accomplished  with  much  difllculty; 
for,  notwithstanding  his  dexterity,  M.  Dubois  had  the  greatest  trouble  in  extracting  the  head 
with  the  embryotomy  forceps. 


670  DYSTOCIA. 

rule  in  practice  to  attempt  to  bring  one  extremity  of  the  foetus  to  the  superior 
strait  as  soon  as  possible,  by  resorting  either  to  the  pelvic  or  the  cephalic  ver- 
sion. (For  the  divisions,  causes,  and  diagnosis  of  this  mechanism,  see  Natural 
Labor,  pa^e  461,  et  seq.}  and  for  the  indications,  the  chapter  devoted  to  Ver- 
sion.) 

§  6.  Complicated  Positions. 

Under  the  title  of  "fallings"  (procidentice),  Madame  Lachapelle  has  described 
the  untimely  descent  of  any  part  whatever  of  the  child,  which  cannot  of  itself 
constitute  a  particular  position  on  account  of  its  tenuity  or  mobility,  but  which, 
however,  might  complicate  the  presentation  of  a  more  extended  region.  Thus, 
the  umbilical  cord,  the  feet,  or  the  hands,  may  individually  or  collectively  come 
down  at  the  same  time  as  the  head  or  breech.  This  complication  will  be  very 
readily  detected  by  the  touch,  and  therefore  it  is  unnecessary  to  enumerate  the 
peculiar  signs  that  distinguish  each  of  these  parts. 

We  have  already  spoken  of  a  falling  of  the  cord,  and  of  the  means  of  remedy- 
ing it.  Again,  in  those  cases  where  one  hand  has  slipped  under  the  head  or 
breech,  the  labor  may  terminate  alone  if  the  pelvis  is  well  formed  and  the  con- 
tractions are  strong  and  continued ;  and  hence  we  should  delay  all  operations. 
Even  the  presence  of  both  hands  on  the  lateral  parts  of  the  head  has  not  always 
proved  an  insurmountable  obstacle  to  the  spontaneous  termination  of  the  labor, 
for  all  these  parts  have  occasionally  been  expelled  together ;  but  if  the  passage 
be  somewhat  contracted  and  the  soft  parts  resistant,  it  would  be  advisable  to  ter- 
minate the  delivery  artificially  by  the  application  of  the  forceps  or  by  version, 
according  to  whether  the  head  has  or  has  not  cleared  the  superior  strait ;  and  to 
bring  down  the  feet  in  the  breech  presentations.  This  latter  plan  should  also  be 
followed  if  one  foot  instead  of  the  hand,  or  if  both  a  foot  and  a  hand  accompany 
the  head.  Nevertheless,  before  resorting  to  an  artificial  delivery,  the  accoucheur 
should  always  endeavor  to  push  back  the  hand  or  foot  into  the  uterus  and  get  it 
above  the  head.  Most  frequently,  it  will  only  be  necessary  to  sustain  it  there 
during  the  pain,  which  urges  on  the  head,  to  find  the  latter  descending  alone 
and  arriving  at  the  inferior  strait,  and  then  the  labor  may  be  abandoned  to  na- 
ture. We  must  remark,  however,  that  a  foot  is  far  more  difficult  to  return  than 
the  hand,  and  that  in  consequence  of  its  volume  it  often  constitutes  an  obstacle 
which  cannot  be  surmounted  by  the  ordinary  resources ;  wherefore,  craniotomy 
is  sometimes  indispensable,  as  several  recorded  observations  fully  prove. 

A  descent  of  the  foot  has  hitherto  only  been  observed,  I  believe,  in  the  pre- 
sentations of  the  Jiexed  cephalic  extremity;  but  I  have  had  an  opportunity  of 
meeting  with  it  in  a  face  presentation ;  and  the  rarity  of  the  circumstance,  to- 
gether with  the  difficulties  that  attended  the  delivery,  induces  me  to  narrate  it 
here  in  detail : 

I  was  suddenly  aroused  on  the  4th  of  November,  1842,  at  five  o'clock  in  the 
morning,  by  M.  X ,  a  pork  butcher  in  the  Hue  du  Cadran,  who  came  to  re- 
quest my  attendance  on  his  wife,  who  had  been  in  labor  for  two  days  previously, 
under  the  care  of  Dr.  Lome,  her  physician  and  accoucheur.  Having  arrived  at 
the  bedside  of  the  patient,  I  learned  the  state  of  the  case  from  my  worthy  asso- 


OBSTACLES    DUE     TO     THE     FCETUS.  GTl 

ciate,  after  which  I  proceeded  to  an  examination  per  vaginara.  But  before 
stating  its  result,  I  must  transcribe  here  a  short  account  of  the  case,  sejit  me  by 
M.  Lome  himself,  who  gives  the  detail,  much  better  than  I  could  (from  simple 
recollection),  of  what  he  learned  of  this  woman's  previous  history,  as  also  an 
account  of  what  occurred  during  the  labor.     He  says  : 

"I  was  summoned  to  the  Rue  du  Cadran,  No.  7,  on  the  2d  of  November,  1842, 

at  six  o'clock  in  the  evening,  to  attend  Madame  X in  her  confinement.     I 

ascertained  from  the  patient  that  she  had  had  seven  children,  and  from  her  ac- 
count the  former  labors  had  terminated  in  the  following  manner,  namely : 

"1.  First  child:  a  long  and  painful  labor  of  three  days'  duration;  presenta- 
tion of  the  cephalic  extremity;  the  labor  was  natural,  but  the  infant  died  a 
few  days  after  its  birth. 

"2.  Second  and  third  child:  presentation  of  the  pelvic  extremity;  delivery 
spontaneous,  or  by  the  aid  of  simple  tractions ;  both  children  dead. 

"3.  Fourth  child  :  the  uterine  contractions  disappeared  for  twenty-four  hours 
after  the  rupture  of  the  bag  of  waters ;  expulsion  of  the  child  during  the  accou- 
cheur's absence. 

"  4.  Fifth  and  sixth  child  :  presentation  of  the  cephalic  extremity ;  labor  long 
and  painful;  delivery  natural.     One  of  these  infants  lived  a  few  months. 

"5.  Seventh  child:  shoulder  presentation  and  a  descent  of  the  arm.  M.  P. 
Dubois,  having  been  called  in  consultation,  ascertained  the-  child's  death,  and 
performed  embryotomy.  After  the  parturition  there  was  an  inflammation  of  one 
or  moi'e  of  the  abdominal  organs. 

"  Madame  X is  thirty-two  years  of  age,  is  of  a  medium  height  and  san- 
guineous temperament,  and  exhibits  all  the  evidences  of  good  health.  Nothing 
in  her  external  organization  would  lead  us  to  suspect  the  existence  of  any  defor- 
mity of  the  pelvis,  and  the  normal  pregnancy  seemed  to  be  at  its  regular  term. 
The  preceding  night  she  experienced  some  pains,  which  passed  off  in  the  morn- 
ing, but  again  reappeared  at  six  o'clock  in  the  evening.  I  examined  her,  soon 
after  my  arrival,  and  found  the  os  uteri  dilated  to  the  size  of  a  five  franc  piece ; 
I  readily  distinguished  the  bag  of  waters,  which  was  relaxed  in  the  intervals, 
but  was  tense,  and  protruded  through  the  uterine  orifice  during  the  pain ;  but  I 
could  recognize  no  part  whatever  of  the  foetus.  At  midnight,  the  amniotic  sac 
projected  into  the  vagina  like  a  stuffed  pudding,  and  descended  nearly  to  the 
vulva,  when  it  soon  ruptured  spontaneously  and  permitted  the  escape  of  more 
than  two  pounds  of  the  waters.  But  still  I  could  touch  no  part  of  the  child, 
even  after  the  discharge  of  the  waters,  at  any  height  within  the  reach  of  my 
finger.  Now,  however,  the  scene  suddenly  changed;  for  the  pains,  that  were 
hitherto  strong,  died  away;  and,  as  the  patient  assured  me  that  the  uterine  con- 
tractions had  been  thus  suspended  for  twenty-four  hours  in  a  former  labor  (the 
fourth),  and  afterwards  regained  a  sufficient  degree  of  force  to  effect  the  delivery, 
I  had  her  replaced  in  bed. 

"  I  found  the  woman  in  the  same  condition  at  eight  o'clock  in  the  morning  of 
the  next  day,  the  3d  of  November ;  some  pains  were  perceptible  in  the  left  groin 

and  flank,  but  the  parts  of  the  foetus  were  still  inaccessible No  notable 

change  occurred  in  the  course  of  the  day.     Nine  P.M. — I  recognized  the  left  leg 


672  .  DYSTOCIA. 

and  foot  lying  across  the  os  uteri  at  the  superior  strait ;  the  pains  were  very 
strong,  though  they  had  not  the  characters  of  the  expulsive  ones. 

"Nov.  4th,  the  pains  were  stronger,  but  the  labor  did  not  advance.  As  the 
OS  uteri  was  sufficiently  dilated,  I  concluded  to  search  after  the  second  foot,  but 
it  proved  to  be  rigid,  and  would  scarcely  permit  the  hand  to  enter.  I  found  a 
hard  and  rounded  tumor  just  above  the  foot  first  detected,  which  I  suspected  to 
be  the  head.  But  after  making  some  vain  attempts  to  push  it  up,  and  to  find 
the  right  foot,  I  sent  for  M.  Cazeaux." 

Having  received  this  history  of  the  case,  I  proceeded  to  an  examination  of  the 
state  of  the  parts.  I  found  a  foot  at  the  upper  portion  of  the  vagina,  which 
proved  to  be  the  left  one,  with  its  heel  directed  backwards,  and  a  little  to  the 
right;  then,  by  passing  my  finger  behind  the  symphysis  pubis,  I  detected  a 
voluminous  tumor,  which  was  pressed  so  forcibly  against  the  anterior  arch  of  the 
pelvis,  that  I  could  not  insinuate  the  finger  between  it  and  the  pubic  symphysis ; 
at  first,  I  thought  it  was  formed  by  the  right  buttock,  and  I  diagnosticated  a 
right  posterior  position  of  the  breech,  with  the  left  limb  doubled  up  on  the  an- 
terior part  of  the  belly,  and  the  other,  on  the  contrary,  stretched  out  along  the 
abdominal  and  thoracic  plane  of  the  child.  The  contractions  again  became 
strong  and  energetic,  but,  notwithstanding  the  complete  dilatation  of  the  cervix, 
the  presenting  part  did  not  engage.  While  searching  for  the  cause  of  this  delay, 
I  carefully  examined  the  pelvis,  and  detected  a  considerable  prominence  of  the 
sacro-vertebral  angle,  whereby  the  antero-posterior  diameter  was  reduced  to  three 
inches  and  one-eighth  at  the  most.  I  then  resolved  to  draw  on  the  foot,  but,  to 
my  great  surprise,  these  tractive  efforts  proved  wholly  ineffectual.  By  again 
placing  my  hand  on  the  tumor,  that  I  had  originally  taken  for  the  anterior  but- 
tock, I  found  it  to  be  harder  and  much  more  voluminous  than  I  had  at  first  sup- 
posed, and  I  recognized  it  as  the  head,  surmounted  by  a  large  and  soft  tumor,  or 
caput  succedancum.  I  tried  in  vain  to  find  the  sutures  and  fontanelles ;  but,  by 
gently  slipping  the  fingers  between  this  tumor  and  the  leg  belonging  to  the  pre- 
senting foot,  I  felt  a  very  irregular  surface,  and  soon  after  recognized  distinctly 
the  eyes  and  eyelids,  and  then  the  other  signs  of  a  face  presentation.  It  was,  in 
fact,  an  irregular  presentation  of  the  face,  in  which  the  chin  was  directed  back- 
Fig-  97.  wards  and  to  the  left,  and  somewhat  engaged 
at  the  superior  strait  (a  left  mento-iliac  posi- 
tion, and  the  head  not  completely  extended  : 
or,  in  other  words,  Baudelocque's  fourth  posi- 
tion of  the  forehead).  To  sum  up,  I  was  in 
attendance  on  a  woman  whose  sacro-pubic  dia- 
meter was  but  three  inches  and  one-eighth  at 
the  outside,  and  whose  foetus  was  presenting 
in  an  irregular  or  frontal  variety  of  the  left 
posterior  mento-iliac  position,  and  this  compli- 
cated by  a  descent  of  the  left  foot;  besides 
which,  the  waters  had  been  entirely  evacuated 

The  left  posterior  mento-iliac  position  com- 

pUcated  by  a  descent  of  the  left  fool.         for  thirty-two  hours,  and  the  uterus  was  strongly 


OBSTACLES     DUE    TO    THE    FCETUS.  673 

retracted.  I  was  not  discouraged,  however,  by  all  these  difl&culties;  my  first 
thought  was  to  push  up  the  foot  that  had  become  engaged  under  the  head,  but 
all  such  efforts  proved  abortive  ;  I  then  applied  (though  not  without  some 
trouble)  a  fillet  on  the  foot,  and  endeavored  to  press  back  the  head,  while  draw- 
ing at  the  same  time  on  the  fillet ;  but  this  was  equally  unsuccessful,  for  the  head 
was  firmly  sustained  by  the  powerful  contractions  of  the  womb,  and  did  not  move. 
As  the  child  was  still  alive,  I  next  decided  on  an  application  of  the  forceps.  The 
introduction  of  the  blades  and  their  articulation  were  effected  both  without  diffi- 
culty and  without  much  suffering  to  the  patient,  and  they  were  placed  on  the 
sides  of  the  pelvis;  but,  notwithstanding  the  most  powerful  tractions,  which  were 
kept  up  for  half  an  hour,  I  could  not  make  the  head  advance  in  the  least  degree. 
After  resting  for  a  few  moments,  I  withdrew  the  instrument  in  order  to  re-apply 
it,  and  this  time  I  was  fortunate  enough  to  place  the  blades  directly  on  the  sides 
of  the  head;  I  then  communicated  to  the  handles  a  slight  rotary  movement,  so 
as  to  get  the  face  in  a  transverse  position.  But  all  proved  ineffectual,  for  I  drew 
with  all  my  force,  and  M.  Lome  succeeded  me ;  both  of  us  exhausted  our  strength 
to  no  purpose,  and  I  then  withdrew  the  forceps,  and  permitted  the  woman  to  rest 
for  an  hour.  Having  decided  on  a  resort  to  craniotomy,  if  a  third  application 
should  be  equally  unsuccessful,  I  requested  my  associate  to  go,  during  this  inter- 
val, after  Smellie's  scissors,  and  the  embryotomy  forceps.  An  hour  afterwards 
the  common  forceps  were  again  introduced  and  easily  applied,  and  tractions  on  the 
foetus  were  once  more  made  by  M.  Lome  and  myself  for  half  an  hour  without  any 
better  success. 

Being  then  fully  convinced  of  the  impossibility  of  a  natural  delivery,  and  of 
the  impotence  of  our  efforts ;  as  also  that,  notwithstanding  the  existence  of  the 
heart's  pulsations,  the  unusual  delay  in  the  labor  (thirty-two  hours  after  the  am- 
niotic sac  was  ruptured),  and  the  compressions  made  by  the  instrument,  must 
have  necessarily  compromised  or  even  destroyed  the  viability  of  the  foetus,  and 
having  only  to  choose  between  a  bloody  operation  on  the  mother  or  a  mutilation 
of  the  child,  I  resolved  on  the  performance  of  embryotomy.  Smellie's  scissors, 
covered  at  their  points  by  a  little  pellet  of  wax,  were  guided  along  the  palmar 
surface  of  my  left  hand,  and  directed  perpendicularly  on  the  head,  where  they 
had  to  penetrate  through  the  soft  parts  to  the  depth  of  nearly  an  inch  before 
meeting  with  any  resistance  from  the  bony  vault;  I  then  rotated  them,  and 
they  entered  into  the  substance  of  the  brain  without  difficulty ;  I  next  opened 
the  blades  in  two  different  directions,  so  as  to  make  a  crucial  incision,  the  radii 
of  which  were  about  half  an  inch  in  length ;  then  penetrating  still  deeper  into 
the  cerebral  substance,  I  worked  the  scissors  in  various  directions  so  as  to  break 
up  the  brain.  The  male  and  then  the  female  blade  of  the  embryotomy  forceps 
were  next  introduced,  and  locked  without  any  trouble,  as  also  without  pain  to 
the  patient.  The  articular  part  touched  the  vulva.  By  aid  of  the  vice,  I  next 
closed  the  instrument,  leaving  only  a  space  of  about  one  inch  between  the  ends 
of  the  handles,  and  tractions  were  then  made ;  but  I  soon  found  the  blades  slip- 
ping. It  was  necessary  to  begin  the  operation  anew,  and  the  same  accident 
occurred  again.     The  third  time  the  slipping  commenced,  and  I  only  succeeded 

43 


674  DYSTOCIA. 

in  arresting  it  by  suspending  the  tractions,  and  closing  the  forceps  more  firmly, 
when  the  head  was  finally  extracted ;  but  the  chest  was  arrested  at  the  superior 
strait,  and  considerable  efibrts  were  still  necessary  for  the  extraction  of  the  rest 
of  the  trunk.  The  delivery  of  the  after-birth,  being  immediately  effected,  pre- 
sented no  particular  difficulty. 

In  a  case  of  twin  labor,  the  particulars  of  which  were  communicated  to  me  by 
Dr.  Leflem,  of  Pontrieux,  the  second  child  presented  in  a  mento-pubic  position, 
complicated  with  procidentia  of  the  right  foot  and  right  hand,  the  heel  of  the 
foot  being  turned  toward  the  pubis.  It  is  true,  that  since  an  attempt  to  turn  had 
been  made  by  a  midwife,  it  is  impossible  to  know  whether  these  situations  of  the 
hand  and  foot  were  spontaneous,  or  the  result  of  awkward  manipulations.  How- 
ever this  may  be,  M.  Leflem  found  it  impossible  either  to  push  up  the  head  or 
to  use  the  foi'ceps  with  advantage.  Not  having  the  proper  instruments  for  per- 
forming embryotomy  at  hand,  he  was  obliged  to  leave  the  patient  for  a  few  hours, 
and  on  his  return  he  found  that  she  had  expired. 

It  is  possible  that,  if  after  having  discovered  the  impossibility  of  turning  occa- 
sioned by  the  contraction  of  the  uterus,  bleeding  to  syncope  had  been  practised, 
or  if  the  state  of  the  patient  did  not  allow  of  this,  large  doses  of  opiates  or 
an£Bsthetics  had  been  administered,  the  patient  might  have  been  delivered. 

The  unfolding  of  the  lower  limbs  in  the  positions  of  the  pelvic  extremity,  and 
the  stretching  out  of  the  arms  in  that  of  the  shoulder,  are  merely  concomitants 
of  the  principal  presentation,  and  should  not  be  looked  upon  as  an  unfavorable 
complication.  The  extension  of  the  arm,  or  the  presentation  of  the  hand  or  arm 
of  certain  authors,  has  been  considered  by  them  as  one  of  the  gravest  complica- 
tions of  labor;  but  it  has  already  been  shown,  in  the  article  on  Spontaneous 
Evolution,  that  a  descent  of  the  arm  rather  favored  this  latter  process  than  other, 
wise ;  and  we  shall  hereafter  see  that  it  is  only  from  circumstances  foreign  to  the 
presence  of  the  arm  itself,  that  the  version  is  at  times  rendered  more  difficult. 
(See  Pelvic  Version.) 


BOOK  III. 

OF  THE  DISEASES  AND  ACCIDENTS  THAT  MAY  COMPLICATE  LABOR, 
AND  REQUIRE  THE  INTERYENTION  OF  ART. 

The  numerous  causes  of  dystocia  that  have  just  been  studied,  are  not  the 
only  circumstances  which,  by  disordering  the  regular  course  of  nature,  may  re- 
quire an  artificial  termination  of  labor ;  for,  even  when  surrounded  by  the  most 
favorable  conditions,  it  may  possibly  be  complicated  by  the  occurrence  of  some 
accident  serious  enough  to  compromise  the  life  of  either  the  mother  or  the  child 
in  a  few  minutes.  The  accoucheur  should  render  himself  perfectly  familiar  with 
the  indications  presented  by  these  formidable  accidents,  because  their  suddenness 
and  danger  will  rarely  permit  him  to  reflect  long  on  the  choice  of  the  most  suit- 


PUERPERAL    HEMORRHAGE.  675 

able  means  to  be  employed ;  and  we  cannot,  therefore,  too  strongly  urge  practi- 
tioners to  make  them  a  subject  of  serious  and  profound  study. 


CHAPTER  I. 

OF   PUERPERAL   HEMORRHAGE. 

Hemorrhage  is  certainly  one  of  the  most  frequent  and  at  the  same  time 
most  dangerous  accidents  that  can  occur  to  puerperal  women,  whether  before, 
during,  or  after  parturition ;  for  it  is  most  generally  fatal  to  the  child,  when 
it  occurs  at  an  early  period  of  the  pregnancy,  and  always  subjects  the  mother 
to  the  greatest  dangers,  at  whatever  period  it  may  come  on.  Under  the  double 
aspect,  therefore,  of  the  mother's  safety,  and  the  child's  life,  it  constitutes  a 
pathological  phenomenon  which  should  interest  every  one  in  the  highest  de- 
gree ;  not  only  every  physician  who  devotes  himself  more  especially  to  the  prac- 
tice of  midwifery,  but  likewise  all  who  are  engaged  in  the  practice  of  medicine ; 
for  any  one  may  be  summoned  in  a  time  of  pressing  danger,  and  all  may,  by  ill- 
directed  or  proper  attentions,  compromise  or  save  the  lives  of  two  beings  equally 
dear.  The  importance  of  the  subject,  therefore,  will  justify  the  detail  into 
which  we  propose  entering. 

We  designate  as  puerperal  hemorrhage  (or  the  hemorrhage  that  occurs  in  the 
puerperal  state)  every  hemorrhagic  accident  that  pregnant  women  may  be  affected 
with,  either  during  gestation  or  in  the  course  of  the  labor  and  lying-in ;  thus, 
comprising  under  this  denomination,  not  only  the  losses  of  blood  that  have  their 
source  and  seat  in  the  genital  organs,  or  in  the  foetus  and  its  appendages,  but 
also  all  the  effusions  that  may  take  place  into  the  tissue  of  the  principal  viscera 
as  a  consequence  of  an  exaggeration  of  the  modifications  impressed  on  the  general 
circulation  by  pregnancy.  But  we  shall  devote  a  more  particular  attention  to 
the  discharges  that  have  their  source  in  the  vessels  of  the  uterus,  or  foetus,  or 
their  appendages.  As  to  the  other  hemorrhages,  whatever  be  their  origin,  or  the 
seat  of  effusion,  they  present  the  same  indications  for  treatment  in  the  puerperal 
state  as  at  any  other  period  of  life,  and  consequently  do  not  claim  our  attention 
here.  For,  during  the  labor,  whether  the  hemorrhage  takes  place  in  the  lungs, 
the  stomach,  or  the  brain,  the  only  thing  to  be  done  is  to  combat  it  by  the  usual 
means,  if  the  dilatation  of  the  os  uteri  is  not  sufiiciently  advanced  to  admit  of  an 
artificial  termination  of  the  labor.  But  in  the  contrary  case,  the  accoucheur 
should  apply  the  forceps  at  once,  or  resort  to  version,  and  thus  relieve  the  patient 
as  promptly  as  possible  from  the  danger  that  threatens  her. 

ARTICLE   I. 

OF   THE   CAUSES   OF   UTERINE  HEMORRHAGE. 

The  causes  of  uterine  hemorrhage  have  been  divided  into  the  predisposing, 
the  determining,  and  the  special  causes. 


676  DYSTOCIA. 

§  1.  Of  the  Predisposing  Causes. 

We  must  place  in  the  first  rank  of  the  predisposing  causes,  all  the  disorders 
in  the  general  circulation  that  are  induced  and  kept  up  by  pregnancy,  and  which 
are  manifested  by  palpitations  of  the  heart,  by  obstructed  respiration,  varicose 
swellings  of  the  veins  of  the  lower  extremities,  and  by  the  fulness  and  greater 
activity  of  the  pulse ;  but,  above  all,  it  is  important,  in  order  to  understand  the 
mode  of  action  of  tht  causes  described  below,  to  bear  in  mind  the  changes  that 
Lave  occurred  in  the  structure  of  the  womb  itself;  which  changes  have  been 
studied  in  detail,  when  describing  the  anatomical  phenomena  of  gestation,  but 
which  we  again  bring  forward  in  a  summary  way,  for  the  better  illustration  of  the 
subject  under  consideration. 

The  mere  fact  of  conception  produces  a  state  of  orgasm  in  all  the  genital 
organs,  the  uterus  particularly,  which  determines  a  considerable  afilux  towards 
these  parts.  In  some  women,  of  a  sanguineous  temperament,  this  state  of  irri- 
tation is  not  confined  to  the  hypertrophy  of  the  mucous  membrane,  but  the  deve- 
lopment of  its  vascular  apparatus  is  attended  or  followed  by  an  exhalation  of 
blood,  and,  in  the  course  of  a  few  days,  a  uterine  hemorrhage  takes  place  that 
seems  to  be  only  a  menstrual  return,  but  which,  in  reality,  interrupts  a  commen- 
cing pregnancy.  In  certain  cases,  this  fluxion  is  not  limited  to  the  uterine  ves- 
sels ;  for,  when  very  considerable,  it  causes  an  aneurismatic  or  a  varicose  swelling 
in  the  neighboring  parts,  such  as  the  vessels  of  the  broad  ligaments,  which  run 
to  the  tube  or  ovary.  These  trunks  occasionally  give  way,  and  produce  a  mortal 
hemorrhage,  as  Al.  Leroy  says  he  found  to  be  the  case  in  two  women  who  died 
a  few  days  after  marriage. 

During  the  first  month  of  its  intra-uterine  life  the  ovum  occupies  only  a  very 
small  portion  of  the  uterine  cavity,  all  the  rest  being  filled  with  the  pouch  formed 
by  the  epichorial  decidua  and  parietal  mucous  membrane ;  and  hence,  being  free 
and  floating,  and  having  as  yet  contracted  but  feeble  adhesions  with  the  walls  of 
the  organ,  the  product  of  conception  can  only  be  developed  by  imbibing  the 
juices  secreted  on  the  internal  surface  of  the  womb  (see  Nutrition  of  the  Foetus); 
which  secretion  requires  a  much  greater  activity  in  the  circulation  of  the  uterus, 
and  may  become  a  cause  of  flooding,  under  the  influence  of  the  least  disorder. 
Somewhat  later,  the  placenta  begins  to  be  developed,  and  with  it  those  numerous 
vessels  which,  coming  from  the  internal  surface  of  the  uterus  and  the  external 
one  of  the  chorion,  appear,  so  to  speak,  to  run  to  meet  each  other;  then  they 
interlace  without  inosculating,  and  ultimately  become  united,  forming  a  mass  that 
is  held  together  by  a  species  of  flaky  lymph,  a  product  of  the  uterine  secretion. 
Now,  who  does  not  see  in  this  process  of  vascular  organization,  in  this  copious 
secretion  that  is  constantly  going  on,  and  requiring  so  much  activity  in  the  cir- 
culation of  the  organ,  a  continual  predisposition  to  hemorrhage?  For,  if  any 
vivid  moral  impression,  or  any  violent  physical  commotion,  disturbs  the  harmony 
that  presides  over  this  new  creation  for  a  single  instant,  by  causing  a  derange- 
ment in  the  circulation,  the  just  relations  established  between  the  ovum  and  the 
womb  are  at  once  destroyed ;  and  the  blood,  being  forced  too  rapidly  into  these 
recently-formed  vessels,  overcomes  the  resistance  of  their  feeble  walls,  and  a 
flooding  results  in  consequence. 


PUERPERAL  nEMOR  PHAGE.  677 

At  a  still  more  advanced  period  of  the  gestation,  when  the  placenta  is  orga- 
nized, the  production  of  hemorragic  accidents  is  singularly  favored  by  the  double 
circulation  of  which  it  is  the  seat,  by  the  gi-eat  development  of  the  uterine  vas- 
cular apparatus,  and  by  the  peculiar  structure  of  the  utero-placental  vessels. 
Quite  recently,  M.  Jacquemier  has  carefully  studied  the  influence  of  each  of 
these  circumstances,  and  the  following  summary  will  serve  to  illustrate  the  results 
of  his  inquiries. 

When  we  examine  the  uterus  of  a  pregnant  woman  in  the  latter  periods  of 
gestation,  after  having  undergone  its  usual  transformations,  we  are  struck  with, 
the  development  of  its  vascular  system  ;  for  the  trunks  of  the  four  arteries  that 
nourish  the  organ  have  increased  in  size,  and  their  divisions  or  ramifications  in 
the  texture  of  the  womb  are  wonderfully  multiplied.  The  vessels  that  existed 
before  the  impregnation,  have  more  than  doubled  their  calibre,  and  a  great  num- 
ber of  others  that  did  not  exist,  or  rather  were  not  visible,  have  successively 
formed,  become  enlarged,  and  attained  a  considerable  size.  We  have  hitherto 
mentioned  (see  art.  Pregnancy)  the  extraordinary  development  of  the  uterine 
veins ;  and  it  is  only  necessary  to  recall  here  the  feebleness  of  their  walls,  which 
are  composed  of  a  single  coat,  their  adhesion  to  the  uterine  tissue,  and  the  nume- 
rous divisions  sent  by  them  into  the  cavity  of  the  organ,  which  penetrate  directly 
or  indirectly  into  the  substance  of  the  placenta  itself.  It  results  from  this 
arrangement  that,  in  the  arterial  system  of  the  womb,  the  blood  passes  from 
trunks  of  a  moderate  size  into  cavities  very  numerous  and  spacious  in  proportion 
to  the  volume  of  the  trunks ;  which  cavities  are  formed  by  the  numerous  ramifi- 
cations given  off  from  the  latter  in  the  substance  of  the  uterus ;  while,  in  the 
venous  apparatus,  a  much  greater  disproportion  exists  between  the  trunks  of  the 
uterine  and  ovarian  veins  and  their  branches,  so  that  the  blood  passes  from  very 
large  cavities  into  narrower  tubes. 

This  arrangement  has  been  considered  by  M.  Jacquemier  as  a  cause  of  the 
retardation  in  the  uterine  circulation,  and  as  being  calculated  to  produce  a  venous 
stasis,  followed  by  an  engorgement  of  this  system,  and,  as  a  consequence,  the 
rupture  of  the  vessels  and  hemorrhage ;  which  venous  rupture  is  further  favored 
by  the  want  of  resistance  on  the  part  of  the  utero-placental  veins.  According  to 
his  view,  all  the  causes  under  whose  influence  floodings  are  found  to  result, 
merely  act  by  producing  this  engorgement  of  the  uterine  venous  apparatus ;  and 
hence  the  immediate  cause  of  hemorrhage  is  the  rupture  of  one  of  the  vessels 
appertaining  thereto. 

But  we  cannot  fully  embrace  this  theory,  so  far,  at  least,  as  regards  the  hemor- 
rhages that  occur  during  gestation,  for  we  do  not  believe  that  the  retardation  in 
the  circulation  is  so  extensive  as  51.  Jacquemier  has  described.  Although  the 
blood  arriving  by  the  uterine  arteries  passes  into  the  larger  cavities  constituted 
originally  by  the  arterial  and  afterwards  by  the  venous  ramifications  (the  uterine 
sinuses),  yet  it  seems  to  us  that  this  cause  of  delay  would  be  compensated  by  the 
rapidity  with  which  the  blood  contained  in  these  venous  capillaries  must  pass 
into  the  trunks  where  they  empty ;  and  even  by  virtue  of  that  very  law  of 
hydraulics  quoted  by  M.  Jacquemier  in  favor  of  his  theory,  namely,  "  when  a 


678  DYSTOCIA. 

liquid  flows  in  full  stream  througli  a  tube,  the  quantity  of  this  liquid  which,  at  a 
given  moment,  traverses  the  different  sections  of  the  tube,  must  everywhere  be 
the  same.  Consequently,  as  the  tube  becomes  larger,  the  rapiditi/ diminishes ; 
hut  increases  as  the  tube  becomes  smaller."  If,  therefore,  the  course  of  the  blood 
is  slackened  in  the  arteries  by  its  passage  from  the  main  trunks  into  the  ramifi- 
cations, it  must  be  accelerated  in  the  veins  by  its  passage  from  the  ramifications 
into  the  trunks;  and  hence  there  must  be  a  compensation  in  its  rapidity. 

But  an  infinity  of  circumstances  may  destroy  this  harmony ;  and  which  series 
of  vessels  will  then  be  the  seat  of  the  congestion,  and  afterwards  of  the  rupture  ? 
M.  Jacquemier  supposes  that  some  point  of  the  venous  system  will  always  yield 
the  first;  for  he  says,  "Every  part  of  the  uterine  vascular  circle  is  not  equally 
exposed  to  this  species  of  rupture  ;  and  the  arteries  woxdd  even  be  wholly  exempt, 
unless  they  tcere  the  seat  of  some  morbid  lesion.  The  utero-placental  arteries 
themselves  would  rarely  be  a  primitive  seat  of  rupture  from  the  mere  impetus  of 
the  blood,  although  the  surrounding  delicate  tissue  in  which  they  ramify  supports 
them  in  a  much  less  perfect  manner  than  the  elastic  tissue  of  the  womb,  and 
besides  is  easily  torn ;  but  the  utero-placental  veins,  from  their  situation  and 
organization,  can  afford  but  a  very  moderate  resistance,  which  will  frequently  be 
overcome."  No  doubt,  the  venous  parietes  are  less  resistant  than  the  arterial 
ones;  but  which  of  the  two  has  the  greater  stress  to  bear?  Do  not  all  the  causes, 
under  whose  influence  the  uterine  congestions  and  subsequent  hemorrhages  are 
produced,  act  first  on  the  arterial,  before  being  perceptible  in  the  venous  system  ? 
And  is  not  the  plethoric  condition  first  manifested  by  a  fulness  of  the  pulse?  M. 
Jacquemier  supposes  that,  as  the  circulation  is  impeded  in  the  vena  cava  inferior, 
it  must  determine  a  reflux  of  the  blood  contained  in  these  vessels ;  which  reflux 
would  be  primarily  felt  in  the  uterine  veins,  and  then  in  their  ramifications ;  and 
that  this  would  likewise  be  favored  by  the  particular  structure  of  the  uterine 
veins  themselves,  lohich,  during  gestation  at  least,  are  destitute  of  valves. 

This  absence  of  valves  must  certainly  favor  the  reflux  of  the  venous  blood;  and 
it  is  possible  that,  under  the  influence  of  some  of  the  causes  enumerated  by  this 
writer,  a  congestion  and  then  a  venous  rupture  might  be  the  primitive  pheno- 
mena; but  we  cannot  admit  that  this  is  generally  the  case  in  the  hemorrhages 
that  occur  during  gestation.  And  whilst  acknowledging  that  our  friend  has  ren- 
dered an  important  service  to  the  profession,  by  calling  attention  to  a  particular 
variety  of  mechanism  in  the  production  of  uterine  hemorrhages,  we  must  persist 
in  considering  his  theory  as  being  only  applicable  to  a  small  number  of  cases. 
(^QQ  Archives  Ginh-ales  de  Midecine,  1839.) 

I  must  yet  bring  forward  another  anatomical  peculiarity,  which,  perhaps,  will 
serve  to  reconcile  two  conflicting  opinions.  It  has  been  said  by  some  persons 
that  all  uterine  hemorrhages  proceed  from  a  separation  of  the  placenta ;  while 
others  contend  that  many  of  them  result  simply  from  an  exhalation  of  blood  from 
that  portion  of  the  internal  surface  of  the  womb  not  occupied  by  the  placental 
insertion.  Doubtless,  the  floodings  that  occur  during  pregnancy  are  most  fre- 
quently caused  by  a  rupture  of  one  or  more  of  the  utero-placental  vessels;  but  it 
is  not  to  be  supposed  that  this  rupture  is  the  only  source  of  hemorrhage,  for  we 


PUERPERAL    HEMORRHAGE.  679 

have  already  seen  that,  in  the  early  months  of  gestation,  the  ovum  only  occupied 
the  uterus  in  part,  all  the  rest  of  its  cavity  being  filled  with  the  tumefied  and 
very  vascular  mucous  membrane,  and  that,  in  consequence  of  the  greater  activity 
of  the  circulation,  an  exhalation  of  blood  might  take  place  from  the  internal  sur- 
face of  the  womb.  This  fact  is  unquestionable ;  but  even  after  the  placenta  is 
completely  formed,  and  the  ovum  occupies  the  whole  cavity  of  the  womb,  there 
are  still,  as  elsewhere  desciibed,  some  arterial  and  more  particularly  some  venous 
radicles  found  existing  externally  to  the  placental  mass,  that  might  give  rise  to  a 
hemorrhage,  in  which  the  proper  utero-placental  relations  would  be  in  nowise 
concerned. 

From  the  foregoing,  it  would  appear  that  a  hemorrhage  may  take  place  during 
gestation  :  1st,  by  sanguineous  exhalation,  especially  during  the  early  stages;  2d, 
from  a  rupture  of  the  veins,  and  oftener,  of  the  utero-placental  arteries,  properly 
so  called ;  3d,  from  a  rupture  of  the  veins  and  arterioles  that  ramify  in  the  sub- 
stance of  the  decidua  beyond  the  placenta. 

Among  the  anatomical  modifications  impressed  on  the  uterus  by  gestation,  the 
development  of  its  muscular  structure  has  recently  been  pointed  out  by  M.  Gen- 
drin  as  a  predisposing  cause  of  hemorrhage.  At  the  close  of  pregnancy,  the 
womb  is  formed  of  two  evident  layers,  an  external  and  an  internal  one ;  and  it  is 
the  relation  of  these  two  muscular  laminaj  with  the  vascular  one  that  explains, 
according  to  his  view,  the  influence  that  it  has  over  the  production  of  flooding. 

This  double  muscular  layer,  may,  under  the  influence  of  various  external  or 
internal  irritants,  become  affected  with  spasms,  which  produce  irregular  contrac- 
tions in  some  part  of  the  organ.  He  states  that  such  spasmodic  contractions  are 
very  frequent  after  the  third  month,  and  that  they  are  often  noticed  after  exter- 
nal, moral,  or  physical  impressions,  or  the  tumultuous  movements  of  the  foetus, 
or,  indeed,  when  the  vitality  of  the  latter  has  ceased.  The  patient  first  becomes 
conscious  of  it  by  some  peculiar  sensations  and  movements  in  the  uterine  globe ; 
and  when  the  gestation  is  somewhat  more  advanced,  the  hand,  applied  on  the 
abdomen,  enables  us  to  ascertain  that  the  sense  of  movement  felt  by  the  woman 
is  dependent  on  a  real  contraction  of  the  uterine  walls ;  which  gives  rise  to  cer- 
tain irregular  elevations,  that  slip  about  and  become  displaced  under  the  hand 
by  something  like  a  peristaltic  movement,  of  which  the  patient  has  always  a  very 
distinct  perception.  These  contractions  frequently  accompany  the  hemorrhage, 
sometimes  they  precede  it,  and  seem  to  be  the  earliest  phenomena  that  succeed 
the  action  of  the  pathological  cause.  Although  they  may  be  considered  as  re- 
sulting in  the  fii-st  place  from  the  discharge  of  blood,  and,  possibly,  from  the  for- 
mation of  coagula,  whose  presence  incommodes  and  irritates  the  womb ;  yet,  in 
the  second,  they  must  be  regarded  as  an  active  cause  in  the  production  of  the 
flooding. 

In  fact,  it  is  impossible  for  any  contraction  to  take  place  in  the  external  mus- 
cular layer,  without  modifying  the  circulation  in  the  subjacent  vascular  one ; 
hence,  when  the  vascular  plexus  of  this  intra-uterinc  lamina  is  irregularly  com- 
pressed by  the  muscular  contractions  of  the  organ,  the  blood  must  flow  back  into 
some  part  of  the  placental  disk,  thereby  determining  a  partial  congestion,  which 


6S0  DYSTOCIA. 

lua}'^  cause  the  rupture  of  one  of  these  feeble  venous  ramifications,  and,  as  a  con- 
sequence, a  sanguineous  extravasation.  But  the  influence  of  the  spasmodic 
action  is  not  limited  to  this ;  for,  by  effecting  a  retraction  that  is  confined  esclu- 
sivel}'  to  segments  of  the  uterine  globe,  they  necessarily  draw  upon  the  placental 
adhesions,  and  may,  perhaps,  rupture  them. 

Besides  these  local  modifications,  whose  power  to  produce  hemorrhage  it  is 
impossible  to  deny,  there  are  still  numerous  other  circumstances  that  we  might 
point  out,  which  have  the  same  effect.  But  -let  it  suffice  to  recall  the  physiolo- 
gical and  pathological  changes  that  gestation  impresses  on  all  the  functions,  which 
have  already  been  studied  under  the  titles  of  the  Physiology  and  Pathology  of 
Pregnancy.  Let  us  remember  the  almost  constant  presence  of  serous  plethora, 
the  habitual  fulness  of  the  pulse,  flushing  of  the  face,  and  increased  activity  of 
nutrition  and  circulation  which  are  manifested  in  most  plethoric  women  during 
the  early  months ;  also,  that  susceptibility  which  the  least  emotion  excites  and 
irritates ;  that  delicacy  of  sensation  natural  to  most  nervous  females,  but  carried 
to  the  highest  degree  in  pregnant  ones ;  and,  finally,  let  us  recall  the  fact  that, 
during  the  gravid  state,  the  uterus  is,  as  it  were,  the  common  centre,  upon  which 
all  the  general  disorder  caused  by  any  moral  or  physical  excitement  is  directed. 
Then  we  will  understand  the  reason  why  most  authors  have  considered  a  ple- 
thoric constitution,  a  profuse  normal  menstruation,  and  the  lymphatic  tempera- 
ment, which  so  often  accompanies  great  nervous  irritability,  as  predisposing 
causes  of  puerperal  hemorrhage ;  why  plethoric  females  are  so  often  affected  with 
flooding  at  the  return  of  the  monthly  periods,  since  their  habit  determines  at 
these  times  a  greater  activity  and  a  more  intense  congestion  in  the  womb ;  why 
venereal  excesses  have  often  been  followed  by  a  profuse  flooding,  by  causing  a 
long-continued  and  over-excitation  in  all  the  genital  organs ;  and,  lastly,  why 
every  circumstance  calculated  to  determine  or  to  keep  up  an  unusual  activity  in 
the  general  circulation,  and  particularly  a  more  considerable  afflux  of  fluids  to- 
wards the  gestatory  organ,  has  been  at  all  times  considered  as  predisposing  the 
woman  to  hemorrhage ;  such,  for  instance,  as  fatigue,  the  frequentation  of  balls, 
of  plays,  and  crowded  assemblies,  where  the  air  is  impure  and  at  a  high  tempera- 
ture; prolonged  watching;  over-heating  diet,  and  the  use  of  alcoholic  drinks;  as 
well  as  all  local  irritants,  such  as  the  abuse  of  drastic  purgatives,  which,  by  pro- 
ducing excessive  irritation  of  the  intestines,  may  react  on  the  uterus ;  hip-baths, 
the  frequent  application  of  leeches  to  the  vulva,  the  existence  of  any  organic 
alteration,  or  an  acute  inflammation  in  the  neighboring  organs,  or  in  the  womb 
itself;  because  all  these  circumstances  are  calculated  to  maintain  an  habitual 
state  of  congestion  toward  the  womb. 

§  2.  Determining  Causes. 

The  prolonged  action  of  the  predisposing  causes  just  enumerated  may  even- 
tually produce  a  hemorrhage ;  and  thus,  after  having  acted  for  a  long  time  as  the 
predisposing,  finally  become  determining  causes.  But,  in  addition  to  these,  some 
other  circumstances  have  been  enumerated  by  authors,  which  might  be  desig- 
nated as  accidental  determininrj  causes.    These  are  so  numerous  and  varied  that, 


PUERPERAL  HEMORRHAGE.  681 

to  exhibit  them,  it  would  be  necessary  to  bring  forward  nearly  all  of  the  cases 
that  have  ever  been  published.  Besides,  all  these  causes  may  be  referred  either 
to  acute  moral  emotions,  or  to  physical  disturbances ;  for  example,  to  a  violent 
passion ;  the  sudden  arrival  of  some  unexpected  person  or  intelligence ;  a  fit  of 
anger;  sharp  bickerings,  &c. ;  to  the  jolting  of  a  rough  carriage;  to  riding  on 
horseback ;  a  fall  on  the  feet  or  nates ;  blows  on  the  abdomen ;  efforts  to  carry  or 
lift  some  burden;  to  cough,  vomiting,  &c.  &c.  &c.     (See  art.  Abortion.) 

But  these  causes,  the  list  of  which  I  might  have  lengthened  greatly,  do  not  all 
have  the  same  mode  of  action ;  for  some  of  them,  such  as  most  of  the  moral 
ones,  act  primarily  on  the  whole  organism,  and  only  react  on  the  womb  secon- 
darily ;  while  others,  like  the  generality  of  the  physical  causes,  are  addressed,  as 
it  were,  directly  to  the  gestatory  organ,  and,  by  the  shock  they  communicate, 
have  a  tendency  to  disturb  the  relations  existing  between  it  and  the  product  of 
conception.  It  is  generally  conceded  that  the  former  determine  a  more  consider- 
able afflux  of  blood  towards  the  uterus,  then  an  engorgement  of  the  utero-placen- 
tal  vessels,  and  finally  the  rupture  of  those  vessels ;  or,  if  the  pregnancy  is  but 
little  advanced,  the  afflux  of  blood  is  followed  by  a  sanguineous  exhalation  from 
the  internal  surface  of  the  organ.  But  how,  it  may  be  asked,  is  the  hemoi-rhage 
produced  after  a  fall,  blow,  or  any  physical  commotion  whatever,  especially  in  the 
latter  stages  of  the  gestation  ?  And  is  the  separation  of  the  placenta,  which  is 
then  a  very  common  occurrence,  the  primitive  phenomenon,  and  has  it  caused  a 
vascular  rupture  ?  Or,  indeed,  has  this  rupture  taken  the  precedence,  and  has 
the  eifusion  of  blood  between  the  after-birth  and  the  uterus  resulting  therefrom 
produced  the  separation  of  the  placenta?  The  latter  opinion  appears  to  me  the 
more  probable ;  for,  although  there  can  be  no  doubt  that  the  feeble  bonds  of 
union  which  attach  the  placenta  to  the  uterus  may  be  ruptured  at  once,  as  a  eon- 
sequence  of  some  very  violent  shock  or  fall  from  an  elevated  place,  since,  under 
like  circumstances,  the  very  substance  of  the  solid  organs,  the  liver  in  particular, 
has  been  lacerated,  yet  this  certainly  does  not  happen  in  a  large  majority  of 
cases  ;  because  the  ovum  forms  a  full  sac,  which  is  in  immediate  contact  with  the 
walls  of  the  cavity  that  encloses  it,  and  the  placenta  is  sustained  by  the  waters 
and  the  foetus  within  and  by  the  uterine  wall  without.  The  organ  and  its  con- 
tents constitute  a  whole,  that  cannot  be  separated  by  any  general  concussions 
unless  they  are  very  severe.  Wherefore,  so  long  as  the  membranes  remain  un- 
ruptured, it  is  difficult  to  conceive  that  the  separation  could  be  effected  otherwise 
than  by  the  effort  of  the  blood  to  escape  into  the  cavity  of  the  womb. 

In  conclusion,  although  these  phj-sical  and  moral  disturbances  are  enumerated 
by  authors  as  being  capable  of  producing  a  hemorrhage,  it  must  not  be  supposed 
that  they  constantly  have  this  unfortunate  result ;  indeed,  their  influence  is  far 
from  being  always  in  proportion  to  their  violence  and  intensity.  In  general, 
they  only  act  and  are  followed  by  flooding,  because  a  predisposition  exists  in  the 
patient  which  the  determining  cause  excites  and  brings  into  play.  I  might  men- 
tion individuals  in  whom  the  least  excitement  has  been  followed  by  a  hemorrhage 
that  proved  fatal  to  the  fcetus,  whilst  others  have  borne  the  most  severe  moral 
disturbances  without  accident;  and  several  cases  were  cited  in  the  article  on 


682  DYSTOCIA. 

Abortion,  ■whicli  prove  that  the  most  violent  physical  shocks  oftentimes  give  rise 
to  no  disorder  whatever.  We  must,  therefore,  admit  the  intervention  of  a  pre- 
disposing cause  in  the  majority  of  cases ;  a  cause  which  often,  indeed,  plays  the 
most  important  part  in  the  production  of  the  accident. 

§  3.  Special  Causes. 

Independently  of  the  general  causes  just  studied,  there  are  some  which  might 
be  termed  special  causes,  because  they  depend  on  certain  peculiarities  in  the  posi- 
tion and  structure  of  the  ovum  ;  and  the  influence  of  which  is  particularly  apt  to 
be  felt  at  an  advanced  stage  of  gestation.  AVe  allude  to  an  abnormal  insertion  of 
the  placenta,  to  a  rupture  of  the  umbilical  cord,  and  to  some  other  peculiarities 
about  to  be  mentioned. 

1.  Insertion  of  the  Placenta  iipon  the  Loicer  Segment  of  the  Uterus. — Nearly 
all  the  older  authors  detail  cases  in  which  the  placenta  was  found  inserted  over 
the  neck  of  the  womb  at  the  time  of  labor.  But  some  of  them  altogether  mis- 
understood the  cause  of  this  disposition,  and  supposed  that  the  placenta  had  been 
detached  in  totality  from  the  point  where  it  was  originally  inserted,  and  had 
fallen  from  mere  gravity  on  the  neck  of  the  womb ;  while  others,  who  had  ob- 
served it  to  be  still  adherent  by  one  margin  to  some  point  of  the  periphery  of  the 
cervix,  concluded  that  this  adhesion  was  only  accidental  and  merely  occasioned 
by  the  clotted  blood;  which,  says  Deventer,  sometimes  glues  the  placenta  so  closely 
to  the  orifice  that  it  might  be  taken  for  an  excrescence  of  the  part.  There  were 
others,  again,  who  had  noted  the  fact  with  much  care,  without  attempting  to  give 
any  explanation  of  it ',  Levret  was  among  the  first  to  direct  attention  to  this  im- 
portant point,  for  he  demonstrated  its  frequency  and  danger,  and  studied  the 
causes  and  proper  methods  of  detecting  it.  However,  this  abnormal  insertion 
had  been  pointed  out  long  before  the  time  of  Levret;  for  Giffart,  in  narrating  a 
case  of  hemorrhage,  wrote,  in  1730  :  "  I  cannot  receive  as  absolutely  true  the 
opinion  of  those  authors,  who  say  that  the  placenta  is  always  attached  to  the 
fundus  uteri,  for  in  this  case,  as  in  many  others,  I  have  every  reason  to  believe 
that  it  adhered  on  the  internal  orifice,  or  very  near  to  it ;  and  that,  in  dilating, 
the  latter  occasioned  the  separation  of  the  after-birth,  and  as  a  consequence  the 
hemorrhage."  (^Observ.,  115  et  IIG.)  Heister  (^Institutiones  Chirurgicales, 
chap,  cliv,  part  i)  likewise  says :  "  Some  moderns  think  that  the  adhesion  of  the 
placenta  over  the  neck  is  a  cause  of  hemorrhage ;  and,  therefore,  that  the  more 
the  OS  uteri  dilates  the  more  abundant  is  the  flooding."  As  we  detailed  the 
various  circumstances,  when  studying  the  anatomy  of  the  placenta,  which,  ac- 
cording to  most  authors,  determine  the  point  of  attachment  of  this  vascular  mass, 
it  will  be  unnecessary  to  revert  to  them  here. 

The  insertion  of  the  placenta  over  the  os  uteri  has  been  considered,  since  the 
days  of  Levret,  as  an  inevitable  cause  of  hemorrhage  during  the  last  three 
months  of  gestation,  and  in  the  course  of  the  parturition.  The  flooding  then, 
says  Gardien,  is  an  immediate  result  of  the  gestation,  and  particularly  of  the 
labor.  Most  modern  writers,  supposing  that  the  modifications  occasioned  by 
pregnancy  in  the  disposition  of  the  neck  towards  the  latter  months  are  the  sole 


PUERPERAL  HEMORRHAGE.  683 

cause  of  the  hemorrhages  that  then  occur,  have  adopted  the  same  opinion ;  and 
the  following,  in  their  view,  is  the  mechanism  whereby  the  discharge  is  produced. 
Up  to  the  fifth  month,  the  body  of  the  womb  undergoes  numerous  changes, 
but,  after  that  period,  the  neck  is  also  involved  and  participates  therein.  (See 
Pregnancy.)  The  diminution  in  its  length  is  accompanied  by  a  more  consider- 
able enlargement  of  its  base  on  a  level  with  the  internal  orifice.  The  placenta, 
being  fixed  and  immovable  on  the  spot  where  it  is  implanted,  cannot  follow  this 
spreading  out  of  the  upper  part  of  the  neck,  and  hence  the  bonds  of  union  which 
it  has  contracted  with  the  womb  necessarily  become  ruptured,  as  do  also  the 
utero-placental  vessels  j  and  this  rupture  produces  a  more  or  less  considerable 
discharge. 

But  it  is  only  necessary  to  recall  what  was  stated  in  the  article  on  Pregnancy, 
to  be  convinced  that  this  explanation,  which  is  founded  on  a  false,  though 
hitherto  admitted  fact,  ought  to  be  rejected ;  since  it  is  at  the  lower  part  of  the 
neck,  at  least  in  women  who  have  previously  borne  children,  that  the  eversion 
of  its  cavity  commences ;  and,  in  all,  the  internal  orifice  often  remains  closed 
until  the  last  few  weeks  of  gestation.  The  neck,  therefore,  does  not  spread  out 
at  its  superior  part,  and,  consequently,  we  are  not  to  search  there  for  the  cause 
that  produces  the  hemorrhage,  when  the  placenta  is  inserted  over  the  cervix. 
The  following  explanation  appears  to  me  more  plausible :  During  the  first  six 
months  of  gestation  the  uterus  is  developed  more  especially  at  the  expense  of  the 
fibers  of  the  superior  part  of  the  body  or  fundus  of  the  organ ;  while  in  the  last 
three  months,  the  fibres  appertaining  to  the  lower  third  of  the  womb  are  de- 
veloped in  a  rapid  manner,  and  the  cavity  of  the  organ  is  enlarged  in  conse- 
quence of  the  distension  and  growth  of  this  lower  part ;  a  proof  of  which  is, 
that  the  body  of  the  uterus,  which  was  pyriform  in  the  earlier  months,  is  per- 
fectly ovoidal  in  shape  towards  the  close  of  pregnancy ;  and  I  will  further  re- 
mark, that  the  development  of  the  placenta  is  far  more  rapid  in  the  first  six  than 
in  the  last  three  months.  Now,  this  double  circumstance  seems  to  me  quite 
sufficient  to  account  for  the  production  of  hemorrhage ;  for  when  the  placenta 
is  attached  to  the  fundus,  its  growth  is  simultaneous  with  the  enlargement  of 
that  portion  of  the  uterine  walls  on  which  it  is  implanted,  and  it  is  evident  that 
no  hemorrhage  need  occur ;  but  when  the  after-birth  is  inserted  over  the  cervix 
uteri,  or  on  some  adjacent  point,  the  contrary  must  necessarily  ensue,  becaiise 
the  growth  of  the  placenta  is  nearly  completed,  whilst  a  more  considerable  ex- 
tension of  the  lower  third  of  the  womb  has  yet  to  take  place.  Of  course,  the 
placenta  can  no  longer  participate  in  this  rapid  development,  by  conforming  to 
the  increase  of  the  uterus,  and  by  following  the  extension  of  the  wall  on  which 
it  is  inserted;  and  hence  it  spreads  out  from  the  centre  towards  its  circum- 
ference, the  fissures  between  the  cotyledons  become  larger,  and  its  different 
lobes  are  thus  widely  separated ;  but  the  growth  of  the  inferior  wall  of  the 
uterus  is  so  rapid  in  the  latter  months,  that  this  mechanical  enlargement  of  the 
placenta,  on  which  M.  Jacquemier  has  particularly  insisted,  is  no  longer  sufficient 
to  prevent  the  tension  of  the  utero-placental  vessels,  or  of  the  cellular  tissue  in 
which  they  ramify;  and  this  tension  being  ultimately  carried  to  an  extreme,  all 


684 


DYSTOCIA. 


of  these  cellulo-vascular  adhesions  give  way  and  become  ruptured,  and  thus 
give  rise  to  the  production  of  hemorrhage.  If  this  be  the  true  explanation, 
there  is  no  necessity  for  invoking  a  diminution  in  the  length,  and  a  spreading 
out  of  the  upper  part  of  the  neck,  which  really  does  not  take  place.  By  it  we 
can  also  comprehend  the  possibility  of  a  circumstance  that  is  inexplicable  under 
the  theory  generally  received, — I  allude  to  the  hemorrhages  that  occur  when  the 
placenta  is  attached  to  the  lower  part  of  the  womb,  on  some  point  adjacent  to 
the  internal  orifice  ;*  for  it  is  not  because  the  after-birth  is  implanted  over  the 
cervix  that  a  flooding  takes  place  during  the  latter  months  of  pregnancy,  but  be- 
cause it  is  in  relation  with  the  inferior  third  of  the  uterus. 

The  explanation  usually  given,  is  true  only  with  regard  to  those  sanguineous 
discharges  that  come  on  in  the  latter  weeks  of  gestation  or  during  the  parturition  ; 
for  then,  the  spreading  out  of  the  cervix  uteri,  and  its  complete  effacement? 
must  necessarily  have  a  great  influence  over  the  production  and  profuseness  of 
the  flooding,  in  those  cases  where  some  point  of  the  circumference  of  the  pla- 
centa is  in  immediate  relation  with  the  neck ;  but  still  more  especially  in  those 
where  the  insertion  takes  place,  as  it  is  said,  centre  for  centre. 

The  hemorrhages  of  which  we  are  speaking  occur,  besides,  most  frequently  in 
the  latter  weeks  or  during  the  labor. 

Although  a  hemorrhage  is  usually  considered  to  be  inevitable  under  such 
circumstances,  yet  it  may  not  appear  even  during  the  labor ;  and  the  dilatation 
of  the  OS  uteri  may  be  effected  without  the  loss  of  a  drop  of  blood.  This  absence 
of  discharge  is  doubtless  a  rare  circumstance;  but  its  authenticity  at  the  pre- 
sent day  is  well  established  by  numerous  cases ;  authors  only  difi"ering  as  to  the 
explanation  given  of  it.  Thus  Walter  supposes  that  in  cases  of  this  kind  there 
is  probably  a  larger  and  more  easy  communication  between  the  venous  and 
arterial  radicles  of  the  uterus  than  usual,  whereby  the  blood  may  pass  from  the 
arteries  into  the  veins  without  escaping  externally;  and  M.  Mercier  imagines 
that  the  exhalant  vessels  of  the  womb  are  then  in  a  state  of  constriction,  of  per- 

'  It  affords  me  pleasure  to  acknowledge  that  M.  Jacquemier,  in  his  excellent  Memoire  sur 
le  Mecanisme  des  Hcmorrhagies,  has  anticipated  me  in  describing  the  part  which  the  successive 
development  of  the  fundus  and  the  lower  portion  of  the  uterus  performs  in  the  production  of 
certain  hemorrhages;  but,  unfortunately,  he  does  not  avail  himself  of  it  to  explain  the  flood- 
ing in  the  cases  where  the  placenta  is  inserted  over  the  cervix  uteri ;  for  he  says,  "  As  to 
the  latter,  the  explanation  given  by  Levret,  and  since  adopted  by  nearly  all  observers,  is 
perfectly  correct."  I  believe,  on  the  contrary,  it  is  wholly  erroneous  ;  for  whilst,  acconling  to 
M.  Jacquemier,  the  tardy  development  of  the  lower  portion  of  the  body  of  the  uterus  can 
only  explain  the  accident  when  the  placenta  is  inserted  in  such  a  way  that  its  margin  is 
quite  near  to  the  orifice  of  the  womb,  I  consider  it  the  only  cause  of  hemorrhage  during  the 
gestation,  even  when  the  placenta  is  inserted,  centre  for  centre,  directly  over  the  internal 
orifice. 

So  decided  a  declaration  left  no  doubt  in  my  mind  as  to  the  opinion  held  by  M.  Jacque- 
mier in  1839.  It  appears,  however,  that  I  misunderstood  my  honorable  cOHfrbre,  since  he 
claims  at  present  the  priority  of  the  theory  which  I  believed  I  was  the  first  to  give  in  1840. 
"  Though,"  M.  Jacquemier  said  to  me,  "the  explanation  is  not  clearly  expressed  in  my 
memoir,  it  certainly  was  in  my  mind."  I  am  willing  to  believe  it,  since  M.  Jacquemier  says 
so ;  but,  it  must  at  least  be  allowed  that  I  committed  the  plagiarism  unwittingly. 


PUERPERAL    HEMORRHAGE.  685 

version  of  their  sensibility,  which  is  sufficient  to  retard  the  course  of  the  blood ; 
but  these  two  explanations  appear  to  me  inadmissible.  M.  Moreau  remarks  that, 
in  the  reported  cases,  the  children  were  dead,  and  perhaps  had  been  so  for 
several  days ;  now,  says  he,  as  soon  as  the  inflint  dies  in  the  womb,  the  cessation 
of  the  fcetal  circulation  occasions  changes  in  that  of  the  organ  ;  the  blood  being 
arrested  in  the  vessels  coagulates  there ;  the  latter  retract,  or  even  become  ob- 
literated, and  no  more  blood  reaches  the  womb  than  what  is  necessary  to  its 
nutrition,  since  the  stimulus  that  heretofore  determined  a  greater  quantity  to  it, 
no  longer  exists ;  and  hence  the  dilatation  of  the  orifice  may  be  effected  without 
hemorrhage,  notwithstanding  the  vessels  are  torn  that  united  its  borders  to  the 
placenta.     This,  in  my  opinion,  is  the  more  rational  view. 

Lastly,  if  the  rupture  of  the  membranes  should  occur  at  the  commencement  of 
labor,  it  is  possible  that  the  uterine  retraction,  which  would  naturally  follow  a 
discharge  of  the  waters,  and  the  compression  that  would  be  made  by  the  head  on 
the  part  left  uncovered  by  the  separation  of  the  placenta,  might  entirely  oblite- 
rate the  lacerated  vessels,  and  thus  put  an  end  to  the  hemorrhage ;  and  yet  the 
foetus  be  living. 

2.  Rupture  of  the  Cord,  or  of  one  of  its  Vessels. — It  is  now  an  incontrover- 
tible fact,  that  a  rupture  of  the  umbilical  vessels,  or  of  the  omphalo-placental 
trunk  itself,  may  take  place;  and,  inexplicable  as  it  may  seem,  it  can  no  longer 
be  called  in  question,  since  it  has  been  successively  observed  by  such  men  as 
Delamotte,  Levret,  Baudelocque,  Naegele,  &c.  This  rupture,  and  the  hemor- 
rhage to  which  it  inevitably  gives  rise,  may  be  occasioned  either  by  some  disease 
of  the  vascular  tunics,  by  a  particular  arrangement  of  the  vessels  of  the  cord,  or  by 
a  brevity  of  the  latter,  whether  this  be  natural  or  dependent  on  numerous  turns 
made  around  different  parts  of  the  foetus. 

A.  "The  umbilical  vessels,"  says  M.  Velpeau,  ''are  sometimes  ruptured :  I  am 
in  possession  of  several  examples  of  the  kind ;  but  it  is  because  they  were  pre- 
viously in  a  diseased  state."  In  a  case  reported  by  M.  Deneux,  the  blood 
escaped  through  the  umbilical  vein,  which  was  varicose  at  several  points.  The 
subjoined  curious  instance,  which  I  reported  in  my  Inaugural  Thesis,  might  pro- 
bably be  attributed  to  a  state  of  disease  in  the  ramifications  of  the  vessels  of  the 
cord ;  in  this  case,  the  hemorrhage  occurred  between  the  chorion  and  the  foetal 
surface  of  the  placenta,  in  consequence  of  a  rupture  of  all  the  ramifications  of  the 
umbilical  vessels.  This  case,  which  I  believe  is  unique,  and  hitherto  but  little 
known,  has  generally  been  misinterpreted  by  those  who  have  referred  to  it,  and  I 
therefore  feel  justified  in  republishing  it  here.^    I  must  confess,  that  it  is  not  with- 

'  Rocqnes-Marie-Joseph  Herce,  aged  twenty-nine  years,  pregnant  for  the  fifth  time,  and 
advanced  to  the  seventh  month  of  gestation,  was  brought  to  the  Hotel-Dieu  on  the  fifth  of 
May,  at  midnight.  The  midwife  tliat  accompanied  her  informed  us  that  she  had  liad  sharp 
pains  since  five  oclock  in  the  evening.  The  patient  appeared  much  enfeebled ;  her  face 
was  pale  and  slightly  jaundiced ;  and  this  debility  had  been  caused,  the  midwife  further 
told  us,  by  a  hemorrhage  that  had  lasted  since  the  fourth  month  of  pregnancy.  The  flood- 
ing had  considerably  increased  from  the  moment  the  pains  began;  and  it  was  owing,  added 
the  attendant,  to  an  implantation  of  the  placenta  over  the  os  uteri.     The  patient  was  phti.'ed 


686  DYSTOCIA. 

out  some  hesitation  that  I  attribute  the  flooding,  in  this  instance,  to  a  previous 
disease  and  rupture  of  the  umbilical  vessels.     For,  might  not  such  a  rupture  be 

in  the  ward  of  Saint-Benjamin,  where  we  made  a  vaginal  examination,  the  result  of  which 
was  as  follows :  the  os  uteri  was  dilated  to  the  size  of  a  five-franc  piece,  and  the  cervix  was 
soft,  wholly  effaced,  and  did  not  contract  at  all.     The  finger,  having  been  introduced  into 
the  uterine  orifice,  detected  a  hard,  resistant,  ovoid  body,  which  we  recognized  as  the  fostal 
head  in  the  first  position.     No  soft  body  whatever  was  interposed  between  our  finger  and 
the  cranial  teguments,  and  we  concluded  that,  if  the  placenta  were  inserted  over  the  neck, 
it  was  not  at  least  by  its  centre.     By  carrying  the  semi-flexed  finger  around  th£  internal 
periphery  of  the  neck,  we  endeavored  to  ascertain  whether  the  after-birth  was  not  attached 
to  one  of  the  lips  of  the  orifice ;  but  as  we  found  nothing  of  the  kind,  the  error  of  the  mid- 
wife was  manifest,  and  though  unable  to  determine  the  cause  of  the  hemorrhage,  we  did 
not  hesitate  to  reject  her  opinion.     The   finger  being  still  in  the  orifice,  we  felt  the  womb 
contracting  moderately,  in  consequence,  probably,  of  the  irritation  produced  by  the  touch. 
The   hemorrhage  was  arrested,  the  head  engaged  at  the   superior  strait,  and  the  patient, 
though  feeble,  still  retained  a  sufficient  degree  of  strength  to  second  the  efforts  of  nature. 
We  thought  there  was  nothing  further  to  be  done  than  to  encourage  the  woman  about  her 
condition,  and  to  persuade  her  to  aid  the  uterine  contractions,  that  began  to  be  developed 
quite  strongly,  as  much  as  possible.     In  fact,  the  labor  advanced  very  well,  without  a  return 
of  the  hemorrhage,  and  at  four  o'clock  in  the  morning  she  was  delivered  of  a  dead  child  of 
seven  months,  which  was  pale  and  colorless,  but  exhibited  no  signs  of  putrefaction.     Its  de- 
livery was  followed  by  the  expulsion  of  three  large  clots  of  blood,  each  of  which  was  as  big 
as  the  fist ;  but  the  flooding  was  not  again  renewed  ;  the  cord  was  about  the  usual  length,  and 
there  was  no  circulation  in  it ;  but  we  were  not  a  little  surprised,  after  having  cut  it,  to  find 
that  it  was  no  longer  attached  to  the  mother ;  but  that  it  exhibited,  on  what  should  have 
been  the  placental  extremity,  a  kind  of  membrane,  in  the  centre  of  which  it  seemed  |o  be 
implanted.     The  membrane  was  nearly  as  large  as  an  ordinary  placenta,  aud  was  evidently 
continuous  with  the  debris  of  the  bag  of  waters;  and  we  at  first  supposed  it  to  be  one  of 
those  membranous  placentas  spoken  of  by  authors.     This  view  appeared  the  more  probable, 
as  .''ome  vessels,  evidently  arising  from  the  termination  of  the  cord,  ramified  in  its  substance. 
We  then  thought  the  opinion  of  the  midwife  might  possibly  be  correct,  as  the  want  of  thick 
ness  in  the  i^lacenta  might  have  prevented  us  from  recognizing  it.     When  we  returned  to 
the  patient,  at  eight  o'clock  in  the  morning,  we  found  her  doing  very  well ;  but  what  was 
our  astonishment,  when  the  nurse  brought  forward  a  placenta,  which  the  woman  had  ex- 
pelled after  our  departure.     Thenceforth  all  our  suppositions  were  groundless,  and  it  was 
necessary  to  resort  to  an   examination  of  the  pieces  for  a  better  explanation  of  the  pheno- 
mena offered  by  this  patient.     The  following  was  the  result,  as  all  the  members  of  the  Ana- 
tomical Society  have  since  been  enabled  to  verify :  the  uterine  face  of  the  placenta  was 
smooth  and  normal,  but  its  fcetal  surface  was  entirely  deprived  of  the  portion  of  chorion  that 
ought  to  cover  it,  and  was  irregular,  nodulated,  and  clearly  exlnbited  the  anfractuosities  that 
separate  the  cotyledons.     It  was  covered  over  by  thick  clots,  and  the  debris  of  the  torn  and 
separated  vessels  that  ordinarily  ramify  on  its  surface  could  readily  be  detected;  the  loose 
extremity  of  some  of  these  vessels  was  an  inch  long.     By  a  further  careful  examination  of 
that  portion  of  the  pouch  hanging  to  the  cord,  which  we  had  taken  for  a  memfcranous  pla- 
centa, we  were  enabled  to  detect  on  the  surface  that  covered  the  after-birth,  some  vascular 
debris,  which  had  been  continuous  with  those  observed  on  the  fcetal  surface  of  the  placental 
mass.     The  cavity  of  these  vessels  was  patulous,  and  some  were  obstructed  by  fibrinous 
coagula  of  recent  formation.     The  principal  divisions  were  intact  and  permeable  to  the 
blood. 

From  that  examination,  we  felt  authorized  to  conclude:   1.  That  the  placenta  was  not 
inserted  over  tlie  neck ;  2.  That  the  hemorrhage  was  not  produced  by  a  detachment  of  the 


PUE^RPERAL  HEMORRHAGE.  087 

consecutive  to  an  effusion  of  blood  proceeding  from  one  of  the  utero-placcntal 
vessels,  the  ramifications  of  which,  as  elsewhere  demonstrated,  get  beneath  the 
membranes  that  cover  the  placenta  ?  This  effusion  would  have  produced  a  sepa- 
ration of  the  chorion,  and  then  a  rupture  of  the  umbilical  vessels.  The  profuse- 
ness,  and  the  return  of  the  hemorrhage,  and  the  continuance  of  the  child's  life 
up  to  the  commencement  of  the  labor,  would  certainly  be  more  easily  explained 
by  this  latter  hypothesis  than  by  the  former.  An  attempt  has  been  made  to 
misconstrue  this  case  since  its  first  publication ;  and  it  has  been  said  that  nume- 
rous loops  of  the  cord  probably  existed,  or  else  that  some  artificial  tractions  had 
been  made  upon  it;  but  I  can  affirm  that  nothing  of  the  kind  took  place,  and 
that  the  circumstance  occurred  just  as  I  have  described  it. 

B.  The  abnormal  distribution  of  the  umbilical  vessels,  which  was  pointed  out 
in  the  description  of  the  cord,  may  also  produce  a  hemorrhage  fatal  to  the  foetus, 
during  the  parturition.  The  subjoined  case,  described  by  M.  Cenckiser  as  oc- 
curring at  the  clinique  of  M.  Na?gele,  can  leave  no  doubt  on  this  point. ^ 

uterine  surface  of  the  after-birth ;  but  that  it  resiUted  from  a  separation  of  that  portion  of  the 
bag  of  waters  that  was  attached  to  the  after-birth ;  that  this  separation  was  eifected  at  first 
on  some  point  of  the  fcetal  surface  of  tlie  placenta,  then  over  a  greater  extent,  and  finally  se- 
parating this  mass  altogether  from  the  foetal  envelopes ;  3.  That,  becoming  more  and  more 
considerable,  this  separation  had  produced  a  gradual  increase  of  the  hemorrhage;  and  it  was 
only  when  the  detachment  had  been  completed,  and  the  bleeding  had  become  excessive, 
and  all  communication  being  interrupted  between  the  mother  and  child,  that  the  pains  were 
manifested,  and  the  abortion  took  place.  This  examination  likewise  enabled  us  to  account 
for  the  cessation  of  hemorrhage  from  the  time  of  the  patient's  arrival  at  the  hospital,  as  also 
for  the  quantity  of  coagulated  blood  that  escaped  after  the  delivery  of  the  child.  In  fact,  as 
soon  as  we  touched  the  woman  at  the  time  of  her  entrance,  the  head  began  to  engage  in  the 
pelvic  excavation,  thus  acting  the  part  of  a  tampon  and  preventing  an  external  discharge; 
but  the  blood  did  not  the  less  continue  to  escape  and  to  accumulate  internally,  thus  giving 
rise  to  the  formation  of  coagula,  and  their  discharge  after  the  delivery. 

'  A  countrywoman,  about  twenty-six  years  of  age,  was  admitted  into  the  hospital  in  No- 
vember, 1830.  Her  labor  commenced  on  the  seventh  of  December  at  noon  ;  by  three  o'clock 
the  OS  uteri  was  dilated  to  the  extent  of  an  inch,  and  the  tumor  formed  by  the  bag  of  waters 
could  readily  be  felt.  While  exploring  with  the  finger,  an  abnormal  cord,  about  the  size  of 
a  writing-quill,  was  detected  in  the  substance  of  the  membranes,  running  from  behind  for- 
wards, and  exhibiting  no  pulsation.  After  the  rupture  of  the  bag,  the  waters  escaped,  and 
were  followed  by  a  few  drops  of  blood.  The  head  was  found  in  the  excavation  in  the  first 
position,  and  it  then  appeared  that  a  fold  of  the  cord  had  become  placed  between  it  and  the 
right  sacro-iliac  symphysis :  but  a  very  feeble  pulsation  could  be  distinguished  in  it,  and  at- 
tempts to  push  it  up  were  made  to  no  purpose.  As  the  labor  was  progressing  actively.  Pro- 
fessor Na-gfele  terminated  the  labor  by  the  forceps.  When  the  right  blade  was  applied,  a 
large  quantity  of  water  mixed  with  blood  came  away;  indeed,  this  latter  fluid  had  not  ceased 
to  flow  during  the  four  hours  that  elapsed  between  the  rupture  of  the  sac  and  the  termina- 
tion of  the  labor,  and  the  patient  must  have  lost  six  or  eight  ounces  of  it;  the  delivery  of  the 
placenta  took  place  half  an  hour  afterwards.  The  child,  though  pale  and  colorless,  still  pre- 
sented some  evidences  of  life,  but  it  died  in  the  course  of  a  few  minutes;  it  weighed  six 
pounds  and  a  quarter.  At  the  autopsy,  the  fcetus  exhibited  signs  of  anemia,  and  everything 
evinced  that  its  death  had  been  caused  by  hemorrhage.  An  examination  of  the  after-birth 
discovered  the  source  of  the  bleeding ;  the  placenta  had  its  usual  form  and  texture,  but  the 
membranes  were  somewhat  thicker  and  more  dense,  and  their  laceration  was  just  sufiicient 


688  DYSTOCIA. 

c.  The  brevity  of  the  cord  may  prove  a  cause  of  its  laceration,  not  only  after 
the  rupture  of  the  membranes,  but  even  before  the  commencement  of  the  labor 

to  permit  the  child's  escape  ;  the  umbilical  cord  was  attached  to  the  membranes  at  about  two 
inches  from  the  placental  border;  and,  starting  from  this  point,  the  vessels  of  the  cord  were 
no  longer  held  together,  but  they  separated  and  ramified  in  different  directions  on  the  mem- 
branes; and  then,  after  these  divers  ramifications  of  the  arteries  and  vein  had  run  over  their 
internal  surface  for  a  more  or  less  considerable  extent  (though  variable  for  each,  from  two 
inches  up  to  ten),  they  entered  the  placenta,  some  at  its  centre,  but  the  greater  number  by 
its  margin. 

The  author  of  the  thesis  alluded  to,  carefully  describes  the  course  and  disposition  of  these 
various  branches;  but,  as  the  limits  of  this  work  do  not  permit  me  to  give  his  description  in 
detail,  I  will  only  quote  the  principal  points.  The  first  branch,  arising  from  the  division  of 
the  umbilical  vein  at  the  point  of  its  insertion  in  the  membranes,  ran  towards  the  right,  tra- 
versed a  considerable  portion  of  their  internal  surface,  and  was  ultimately  prolonged  to  the 
opposite  border  of  the  placenta;  the  rupture  of  the  membranes  took  place  just  in  this  route 
at  its  most  distant  point  from  the  placenta,  and  this  had  necessarily  produced  a  rupture  of 
the  venous  trunk  just  described  ;  and  to  it,  without  any  doubt,  must  be  referred  the  flooding 
that  occasioned  the  child's  death,  as  proved  by  the  autopsy.  The  mere  descent  of  the  cord 
could  have  no  influence  on  its  death  ;  for,  in  cases  dependent  on  that  cause,  the  opening  of 
the  dead  body  exhibits  the  symptoms  of  congestion. 

Dr.  Panis,  Professor  of  Midwifery  in  the  Medical  School  of  Reims,  has  kindly  furnished 
rae  with  a  similar  case  : 

"Madame  H ,  of  Reims^ thirty-six  years  of  age,  has  had  four  children  ;  her  labors  were 

fortunate,  and  the  children  were  large  and  living.  I  was  called  to  her  in  her  fifth  labor 
about  six  o'clock,  on  the  morning  of  the  17th  of  January  last.  I  learned,  on  my  arrival,  that 
the  waters  were  discharged  at  five  o'clock,  and  that  they  were  accompanied  with  blood. 

The  motions  of  the  child  were  felt  the  day  before  until  evening.     Mad.  H had  slept  all 

night,  and  was  only  awakened  by  the  rupture  of  the  membranes.  On  examination,  I  found 
the  vertex  in  the  left  posterior  occipito-iliac  position,  and  the  os  uteri  dilated  to  the  extent  of 
an  inch  and  a  quarter.     At  first,  the  labor  advanced  regularly  though  rather  slowly;  blood 

continued  to  flow,  though  in  small  quantity,  and  at  ten  a.m..  Mad.  H was  delivered  of 

a  dead  child,  which  was  disengaged  in  an  anterior  position. 

"Being  surprised  at  the  death  of  the  child,  whose  face  was  but  slightly  colored  and  its  de- 
velopment perfect,  and  whose  motions  had  ceased  to  be  felt  only  at  the  time  the  mother  fell 
asleep,  I  sought  for  the  cause  of  the  accident,  and  found  it  in  the  umbilical  cord  as  soon  as 
I  had  extracted  the  placenta.  The  cord  was,  in  fact,  inserted  upon  the  membranes,  at  the 
distance  of  about  three  inches  from  the  placenta.  The  vessels  composing  it  were  separated, 
and,  after  traversing  the  membranes,  entered  the  circumference  of  the  placenta.  One  of 
these  vessels  belonging  to  the  umbilical  vein,  was  ruptured  at  the  distance  of  about  an  inch 
and  a  quarter  from  its  insertion  in  the  placenta,  precisely  at  the  spot  where  the  membranes 
themselves  had  been  torn.  I  immediately  concluded  that  death  had  been  caused  by  the 
hemorrhage  following  tlie  rupture  of  the  vein.  It  also  explained  why  the  discharge  of 
blood  had  occurred  at  the  instant  the  membranes  gave  way.  I  have  preserved  the  specimen, 
which  will  be  placed  in  the  Museum  of  the  Medical  School  of  Reims." 

Although  cases  of  this  kind  are  very  rare,  they  may  nevertheless  occur  again,  since  this 
disposition  of  the  vessels  in  the  cord  has  already  been  reported  quite  a  number  of  times;  but 
it  can  only  endanger  the  child  when  the  rupture  of  the  sac  takes  place  in  the  course  of  one 
of  the  venous  or  arterial  ramifications.  Where  the  vascular  trunk  exists  on  the  portion  of 
the  membranes  engaged  in  the  os  uteri,  as  in  the  case  under  consideration,  we  might  antici- 
pate the  consequences ;  but  what  measures  should  then  be  emi)loyed  to  prevent  the  flood- 
ing ?     It  would  appear  to  us  advisable  to  retard  the  rupture  of  the  membranes  as  much  as 


PUERPERAL    HEMORRHAGE.  6^9 

and  the  discharge  of  the  waters ;  and  thus  produce  that  variety  of  hemorrhage 
■which  has  been  designated  as  the  intra-amniotic.  I  repeat  again,  that  I  am  un- 
willing to  reject  any  fact,  however  extraordinary  it  may  be,  when  it  is  advanced 
by  experienced  and  conscientious  observers,  who  declare  they  have  taken  every 
precaution  to  avoid  all  sources  of  error;  consequently,  I  admit  that  this  rupture 
may  take  place,  Madame  Lachapelle  and  Boivin,  and  M.  Velpeau,  to  the  con- 
trary notwithstanding.  In  such  cases,  the  rupture  has  doubtless  been  favored  by 
an  abnormal  weakness  in  the  vascular  walls,  and  by  the  diminished  resistance  of 
the  sheath  that  surrounds  the  vessels;  but  it  maybe  more  particularly  attributed 
to  the  tensions  on  the  cord  itself,  that  are  probably  produced  before  the  mem- 
branes give  way,  by  the  immoderate  movements  of  the  foc'tus ;  which  movements 
are  probably  excited  by  the  annoj-ance  that  the  turns  of  the  cord  occasion  it. 
After  the  discharge  of  the  waters,  and  during  the  expulsion  of  the  child,  the 
shortened  cord  becomes  stretched,  and  its  tension  augments  as  the  head  ap- 
proaches the  vulva;  when,  as  a  general  rule,  its  rupture  alone  can  permit  the 
expulsion  to  be  effected.' 

According  to  most  accoucheurs,  this  unusual  shortness  of  the  cord  may  give 
rise  to  flooding  by  determining  a  premature  detachment  of  the  placenta.  But  it 
appears  to  me  that  such  a  separation  can  scarcely  occur  from  a  mere  dragging  on 
the  cord,  because,  during  the  uterine  contraction,  the  placenta  is  strongly  pressed 
by  the  womb  externally,  and  by  the  amniotic  liquid  internally,  or,  still  more, 
after  the  escape  of  the  waters,  by  the  body  of  the  child.  Now,  these  parts  must 
evidently  react  on  the  foetal  surface  of  the  after-birth  with  all  the  force  of  impul- 
sion communicated  by  the  contraction ;  of  course,  the  fcjctus  can  only  advance, 
and,  consequently,  the  tension  of  the  cord  can  only  take  place  under  the  in- 
fluence of  this  contraction ;  and  I  repeat  that,  while  it  lasts,  the  placenta  is 
moulded  on  and  forcibly  pressed  against  the  parts  contained  within  the  sac,  and, 
of  necessity,  cannot  be  separated  from  the  womb.  I  believe,  therefore,  that  a 
separation  of  the  placenta  from  a  tension  of  the  cord  is  almost  impossible  during 
the  continuance  of  the  contraction;  but  it  may  take  place  before  or  during  the 
labor,  and  prior  to  the  escape  of  the  waters,  if  the  cord  be  very  short  and  the 
movements  of  the  foetus  are  very  active.  As  to  those  cases,  in  which  it  is  com- 
monly said  the  child  is  born  with  a  caul,  that  is,  where  the  head  pushes  the 
membranes  before  it,  it  may  happen  that  the  dragging  to  which  these  latter  are 
subjected,  being  communicated  to  the  placenta,  may  occasion  its  premature  sepa- 

possible,  if  they  be  still  whole,  and  to  terminate  the  labor  immediately  after  their  rupture. 
In  the  former  case,  the  os  uteri  should  be  permitted  to  dilate  sufRcienlly ;  but,  in  the  latter, 
an  attempt  ought  to  be  made  to  terminate  the  labor  before  the  discharge  has  been  profuse 
enough  to  cause  the  infant's  death.  These  measures  would  evidently  be  more  urgent  if 
instead  of  a  venous  trunk  without  pulsation,  it  should  be  an  arterial  one,  recognizable  by  its 
throbbing,  which,  from  its  position  on  the  membranes,  was  threatened  with  laceration. 

'  For  further  details  relative  to  the  rupture  of  the  cord,  see  the  observations  of  Portal, 
Pratique  des  Accouchemenls,  p.  267 ;  Lamotte,  Traite  des  ^crouchetnents,  p.  oG2 ;  Levret,  Ac- 
couchement s  Laborieux,  p.  199;  Baudelocque,  i?en/ei7  Periodique  de  la  Societe  de  Medecine  de 
Paris,  t.  iii,  p.  1 ;  Niegele,  jlnnales  Cliniques  d' Heidelberg,  1826;  and  of  Busch,  Siebold's  Jour- 
nal, ann.  1828. 

44 


690  DYS|OCIA. 

ration  and  give  rise  to  uterine  hemorrhage;  more  particularly  where  this  body  is 
not  attached  directly  to  the  fundus  of  the  organ. 

§  4.  KAriD  Contraction  op  the  Uterus. 

A  sudden  and  rapid  contraction  of  the  womb  may  likewise  produce  a  disas- 
trous hemorrhage,  by  destroying  the  cellulo-vascular  attachments  of  the  placenta; 
for  this  contraction,  which,  when  restricted  to  proper  limits,  is  a  physiological 
condition  of  labor,  becomes  a  cause  of  premature  separation  of  the  placenta,  when 
it  takes  place  too  rapidly  or  at  too  early  a  period  of  the  travail.  This  is  apt  to 
occur  in  cases  of  a  dropsy  of  the  amnios,  where  a  large  quantity  of  the  waters 
escapes  at  once ;  for  the  uterus  then  passes  from  an  enormous  bulk,  to  a  much 
more  circumscribed  volume  than  what  comports  with  the  dimensions  of  the  foetus 
on  which  it  is  applied.  It  likewise  happens  after  the  expulsion  of  the  first  child 
in  twin  pregnancies ;  for  the  contraction  that  follows  this  process  may,  by  sepa- 
rating the  placenta  appertaining  to  the  other  twin,  cause  a  flooding  that  might 
prove  fatal  to  both  mother  and  child;  if  a  long  interval  should  elapse  between  the 
two  deliveries. 

The  hemorrhages  that  so  often  complicate  a  rupture  of  the  body  or  neck  of  the 
womb,  and  those  which  constitute  the  thrombus  of  the  vulva  and  vagina,  have 
already  been  considered  in  separate  articles,  and  we  shall  not  again  revert  to 
them  here. 

ARTICLE   II. 

SY3IPT0MS   OF   UTERINE    HEMORRHAGE. 

The  symptoms  of  uterine  hemorrhage  may  be  divided  into  general  and  heal. 

1.  General  Si/mptoms. — In  some  cases,  the  flooding  commences  in  so  sudden 
and  rapid  a  manner  that  the  discharge  of  blood  is  the  first  symptom  manifested; 
this  is  more  apt  to  occur  in  those  instances  where  the  hemorrhage  follows  the 
violent  action  of  some  external  cause.  Most  generally,  the  woman  experiences, 
during  the  few  days  preceding  the  accident,  some  uneasiness  in  her  limbs,  a 
general  and  unusual  malaise,  a  sensation  of  weight  and  of  numbness  in  the  pelvis, 
and  a  dull  and  obscure  pain  in  the  loins,  in  the  upper  part  of  the  thighs  and 
groins,  which  is  augmented  by  the  erect  position,  by  strainings  at  stool,  and  by 
the  act  of  urinating;  and,  in  many  cases,  there  is  a  constant  desire  to  pass  the 
urine.  These  phenomena,  which  arc  characteristic  of  a  local  uterine  congestion, 
are  accompanied  by  the  symptoms  of  general  plethora;  that  is  to  say,  by  pains 
in  the  head,  vertigo,  dimness  of  vision,  flushing  of  the  face,  and  by  frequency 
and  fulness  of  the  pulse.  After  these  general  disorders  have  lasted  some  days, 
it  is  not  unusual  for  the  active  movements  of  the  foetus  to  die  away,  and  to  be- 
come very  feeble,  or,  perhaps,  not  at  all  perceptible  to  the  patient.  After  the 
lapse  of  some  time,  varying  from  a  few  hours  to  several  days,  these  precursory 
phenomena  give  way  to  the  general  symptoms  of  hemorrhage,  which  are  the 
same  as  accompany  every  loss  of  blood ;  namely,  pallor  of  the  skin,  feebleness  of 
the  pulse,  and  coldness  of  the  extremities;  the  intensity  of  which,  it  is  needless 


PUERPERAL    HEMORRHAGE.  G91 

to  add,  varies  according  to  the  abundance  and  rapidity  of  the  flooding,  the 
strength  of  the  woman,  &c.  &c. 

2.  Local  Symptoms. — With  regard  to  the  local  symptoms  that  characterize 
its  existence,  uterine  hemorrhage  has  been  divided  into  the  external  and  the  in- 
ternal. The  flooding  is  called  external,  when  the  blood  flows  to  the  exterior, 
and  internal,  when  it  is  effused  into  the  cavity  of  the  organ;  but  we  shall  here- 
after see  that  it  may  be  both  external  and  internal  at  the  same  time. 

A.  External  Flooding. — A  discharge  of  blood  externally,  is  of  itself  a  suffi- 
cient sign  of  hemorrhage  during  pregnancy  or  parturition  ;  but  there  are  certain 
peculiarities  dependent  on  the  various  causes  indicated  above,  that  demand 
attention,  and  which  will  be  pointed  out  in  detail  in  the  following  article. 

B.  Internal  Flooding. — An  internal  discharge  may  take  place  during  the 
earlier  months  of  pregnancy,  and  yet  may  escape  detection ;  if,  however,  the 
amount  of  blood  should  be  considerable,  the  clot  formed  by  its  coagulation  con- 
stitutes a  foreign  body,  whose  presence  excites  colicky  gripings,  and  pains  in 
the  loins,  and  a  feeling  of  weight  about  the  fundament ;  and  these  symptoms 
obstinately  persist  until  a  miscarriage  takes  place.  Besides  which,  as  M.  Bau- 
delocque  remarks,  there  are  some  instances  where  the  symptoms  of  occult 
hemorrhage  are  either  preceded,  accompanied,  or  followed  by  an  external  dis- 
charge of  blood.  In  the  former  case,  the  blood,  finding  a  free  issue  outwardly, 
continues  to  escape  until  its  further  passage  is  prevented  by  the  formation  of 
a  coagulum,  which  forces  it  to  accumulate  internally;  in  the  latter,  the  eS"usioa 
of  blood  into  the  cavity  constantly  goes  on,  until  it  reaches  the  orifice  of  the 
womb  by  gradually  separating  the  membranes ;  while,  in  the  third  case,  an  ex- 
ternal discharge  will  accompany  the  occult  hemorrhage  whenever  one  part  of  the 
blood  has  a  free  issue,  but  the  other  collects  in  the  cavity  of  the  organ. 

At  an  advanced  stage  of  the  gestation,  when  the  hemorrhage  is  more  profuse, 
we  must  add  to  the  precursory  signs  before  mentioned  a  considerable  and  rapid 
development  of  the  belly,  and  a  greater  resistance,  tension,  and  hardness  of  the 
uterus  than  usual ;  sometimes  even  it  presents  a  very  irregular  form,  seeming  to 
be  divided  into  two  parts,  one  of  which  is  occupied  by  the  ovum,  and  the  other 
by  the  eff"used  blood ;  and  most  generally  the  active  movements  of  the  foetus 
disappear.     In  some  few  cases,  a  well-marked  fluctuation  has  been  detected. 

Finally,  when  the  flooding  is  first  manifested  in  the  course  of  the  labor,  the 
interval  of  each  pain  is  characterized  by  the  escape  of  clots  of  blood  in  greater 
or  less  profusion.  This  discharge  of  coagula  can  be  explained  by  the  fact  that, 
during  the  interval,  the  child's  head  does  not  seal  up  the  neck  hermetically,  and 
thus  its  orifice  is  left  comparatively  free,  and  the  blood  is  permitted  to 
escape. 

Seat  of  the  Effusion. — The  point  at  which  the  accumulation  of  blood  takes 
place  in  those  internal  hemorrhages  that  come  on  at  an  advanced  period  of  ges- 
tation must  necessarily  vary,  according  to  the  part  of  the  utcro-fcetal  vascular 
apparatus  which  has  been  the  source  of  the  flooding.     For  instance — 

1.  The  blood  may  be  primarily  eflfused  between  the  uterine  face  of  the  pla- 
centa and  the  corresponding  uterine  wall ;  as  the  discharge  progresses,  it  ordi- 


G92  DYSTOCIA. 

narily  dissects  oif  the  placenta  towards  some  one  point  of  its  circumference,  and 
is  then  effused  all  around  the  ovum,  by  displacing  the  membranes.  But  it  may 
also  happen  that  the  whole  placental  circumference  remains  adherent  to  the 
womb,  whilst  its  central  portion  is  entirely  detached,  the  effusion  being  limited 
by  the  margins  of  this  mass ;  and  the  hemorrhage  may  be  copious  enough  in 
such  instances  to  kill  the  patient  promptly,  as  the  case  of  Laforterie  (whatever 
may  be  said  of  it)  fully  proves. 

The  reader  will  likewise  find,  in  the  New  Medical  and  Physical  Journal 
(1813,  No.  38,  p.  535),  the  following  case,  which,  though  less  known  in  France 
than  the  one  of  Laforterie,  is  not  the  less  extraordinary :  "  A  lady,  of  a  weakly 
constitution  and  delicate  habit,  was  attacked  in  the  latter  months  of  pregnancy 
with  a  slight  discharge  of  blood  from  the  vagina,  not  amounting  altogether  to 
half  an  ounce,  accompanied  with  alarming  symptoms  of  exhaustion  and  debility. 
The  OS  uteri  was  scarcely  dilated  to  the  size  of  a  sixpence,  and  was  in  such  a  state 
of  rigidity,  as  precluded  the  possibility  of  affording  any  manual  assistance.  The 
lady  in  consequence  died ;  and,  on  examination  after  death,  it  was  found  that  a 
separation  of  the  centre  of  the  placenta  from  the  parietes  of  the  uterus  had  taken 
place,  whilst  its  edges  were  completely  adherent,  forming  a  kind  of  cul-de-sac 
into  which  blood  had  been  poured,  to  the  amount  of  a  pint  and  a  half,  which 
had  become  coagulated  within  the  cafity  thus  formed. '^ 

2.  The  blood  may  be  effused  into  the  proper  tissue  of  the  placenta,  and 
thereby  constitute  those  sanguineous  collections  which  have  been  designated  of 
latter  time  as  placental  apo-[>lfxy .  The  woman's  life  is  never  compromised  by  a 
discharge  of  this  nature,  but  the  death  of  the  foetus,  and,  as  a  consequence,  its 
premature  expulsion,  most  generally  result  therefrom. 

3.  The  blood  may  be  effused  on  the  foetal  surface  of  the  placenta,  as  in  the 
case  referred  to  above;  but  the  flooding  here  evidently  must  have  been  internal 
before  it  was  external.  Indeed,  several  observers  have  reported  that  they  found 
coagula  lying  between  the  chorion  and  a  portion  of  this  foetal  aspect  of  the  pla- 
centa, 

4.  The  numerous  observations  detailed  in  the  memoir  of  M.  C.  Baudelocque, 
prove  that  blood  may  be  effused  between  the  various  membranous  lamiuaj  that 
constitute  the  amniotic  sac,  at  all  stages  of  pregnancy. 

5.  Lastly,  notwithstanding  the  strictures  which  the  cases  narrated  by  Dela- 
motte,  Levret,  Nasgele,  Baudelocque,  and  others  have  been  subjected  to,  they 
constrain  us  to  believe  that  both  a  partial  and  a  complete  rupture  of  the  umbilical 
cord  may  take  place ;  in  consequence  of  which  an  effusion  of  blood  is  made  into 
the  cavity  of  the  amnios. 

ARTICLE    III. 

DIAGNOSIS. 

A.  External  Discharge. — The  difficulties  hitherto  described  (see  Diagnosis 
of  Abortion),  as  complicating  the  diagnosis  of  hemorrhage  during  the  first  six 


PUERPERAL    HEMORRHAGE.  603 

months  of  pregnancy,  are  scarcely  ever  met  with  at  a  more  advanced  period.  In 
fact,  it  is  so  rare  to  find  women  reguhir  as  late  as  the  last  three  months,  that 
every  discharge  of  blood  from  the  vulva  at  that  period  may  be  considered  as  a 
symptom  requiring  immediate  attention;  for,  at  the  most,  we  could  only  confound 
a  vei-y  slight  hemorrhage  with  a  return  of  the  menstrual  discharge,  and,  in  both 
cases,  the  precautions  to  be  taken  would  be  the  same ;  or,  at  least,  if  indifferent 
in  the  one,  they  might  prove  very  serviceable  in  the  other. 

When  a  hemorrhage  does  come  on  in  the  course  of  the  last  three  months  of 
gestation,  or  during  labor,  the  question  arises,  what  is  its  cause?  But  this 
question,  though  very  important  both  as  regards  the  prognosis  and  the  treatment, 
is  sometimes  exceedingly  difficult  to  answer.  It  has  been  shown  that  often, 
perhaps  even,  according  to  certain  authors,  the  most  frequently,  it  is  owing  to 
an  insertion  of  the  placenta  either  over  the  os  uteri,  or  on  some  adjacent  point; 
and  most  of  them  go  further,  and  endeavor  to  point  out  the  signs  whereby 
this  abnormal  situation  of  the  after-birth  may  be  recognized. 

The  signs  that  announce  the  existence  of  this  anomaly  may  be  divided  into  the 
rational  and  the  sensible.  The  first  are  derived  from  the  mode  of  development 
of  the  accident,  and  its  attendant  circumstances;  while  the  second  are  furnished 
by  the  touch. 

When  the  flooding  comes  on  at  an  advanced  stage  of  the  gestation,  more  par- 
ticularly in  a  woman  who  has  previously  borne  children,  it  is  most  generally 
possible  to  detect  the  presence  of  the  placenta  over  the  internal  orifice  by  the 
touch.  In  this  case,  says  Levret,  there  is  sometimes  difficulty  in  finding  the 
neck,  notwithstanding  it  be  in  a  measure  within  reach  of  the  finger;  for  a  great 
quantity  of  coagula,  a  part  of  which  is  .adherent,  is  ordinarily  found  in  the  vagina, 
and  their  detachment  augments  the  hemorrhage;  beyond  all  these,  a  soft,  fleshy, 
and,  as  it  were,  a  pulpy  tumor  is  detected.'  When  the  accoucheur  examines 
this  tumor  with  the  extremity  of  his  finger,  it  feels  as  if  he  were  touching  the 
head  of  a  small  caulifiower,  and  he  recognizes  there  the  anfractuosities  peculiar 
to  the  external  surfece  of  the  placenta;  then,  by  searching  out  the  circumference 
of  the  tumor,  the  uterine  orifice,  which  surrounds  it  towards  its  superior  part,  is 
made  out;  but  all  attempts  to  pass  the  finger  between  the  tumor  and  the  orifice 
will  prove  unsuccessful  without  a  resort  to  violence,  and  a  detachment  of  the 
tumor  at  the  point  where  the  index  is  passed  up ;  or  if  one  place  should  hap- 
pen to  be  free,  the  same  would  not  be  true  around  the  whole  periphery  of  the 
cervix. 

A  somewhat  voluminous  coagulum,  situated  in  the  os  uteri,  might  be  mistaken 

'  In  general,  this  examination  has  to  be  made  with  the  greatest  possible  care,  because  the 
separation  of  the  clots  often  causes  a  return  of  the  hemorrhage.  Where  the  os  uteri  is  not 
sufficiently  dilated  to  permit  the  introduction  of  the  finger  without  difficulty,  it  would  be 
proper  to  wait  until  the  discharge  had  continued  long  enough  to  produce  its  relaxation. 
Indeed,  unless  the  flooding  be  profuse  enough  to  render  a  premature  labor  inevitable,  and 
unless  there  be  an  actual  commencement  of  the  labor,  or  the  patient  be  very  near  her  full 
term,  all  explorations  of  this  kind  should  be  suspended,  and  the  general  measures  calculated 
to  subdue  the  symptoms  be  employed  instead. 


694  DYSTOCIA. 

for  the  after-birth ;  but,  by  a  little  attention,  it  will  generally  be  found  that  the 
clot  is  much  less  resistant,  more  friable  and  movable  than  the  placental  mass, 
which  latter  can  scarcely  be  changed  in  position,  and  whose  parts  are  separated 
with  much  more  difficulty.  Sometimes,  quite  a  thick  layer  of  coagulated  blood 
covers  the  external  surface  of  the  after-birth,  and  prevents  the  finger  from  reach- 
ing its  proper  tissue,  though  the  clot  can  always  be  detached  by  a  slight  effort 
and  the  intervals  between  the  cotyledons  be  made  out. 

As  stated  above,  the  flooding  may  be  dependent  on  an  improper  insertion  of 
the  placenta,  and  the  latter  be  so  far  removed  from  the  internal  orifice  that  the 
finger,  introduced  into  the  os  uteri,  can  only  detect  the  naked  membranes;  if  the 
patient  be  examined  during  labor,  the  extremity  of  the  index  should  be  passed 
over  all  the  parts  adjacent  to  the  orifice,  when  the  margin  of  the  after-birth  will 
most  generally  be  felt,  or,  at  least,  the  membranes  will  be  found  thicker  than 
common  ;  or,  still  more  likely,  an  epichorion  that  is  softer,  and  of  a  triple  or 
quadruple  thickness,  will  be  detected  towards  that  side  of  the  os  uteri  where  the 
placenta  is  inserted. 

In  certain  cases,  the  diagnosis  may  be  further  facilitated  by  an  examination  of 
the  lower  part  of  the  uterine  tumor,  even  where  the  cervix  does  not  permit  the 
introduction  of  a  finger.  Thus,  for  instance,  in  a  woman,  used  in  my  course  for 
the  practice  of  the  "  touch,"  who  had  advanced  to  the  fifth  month  of  her  gesta- 
tion, I  observed  the  following  condition  of  things :  All  the  superior  part  of  the 
excavation  was  occupied  by  a  thick,  fleshy,  and  comparatively  soft  tumor,  which 
was  very  nearly  of  the  consistence  of  the  uterine  walls  at  the  second  or  third 
month  of  gestation.  Towards  whatever  part  of  the  superior  strait  I  carried  the 
finger,  it  still  encountered  the  same  resistance,  and  I  found  it  impossible  to 
detect  any  portion  of  the  foetus,  or  to  perform  the  ballottement.  From  this 
single  fact,  I  suspected  an  insertion  of  the  placenta  over  the  os  uteri,  but  was 
unable  to  verify  my  diagnosis  ;  though  I  have  since  ascertained  that  she  was  deli- 
vered, six  weeks  subsequently,  after  a  moderate  flooding. 

M.  Gendrin  has  made  a  similar  observation ;  for  he  says  that,  in  cases  of  im- 
plantation of  the  after-birth  over  the  os  uteri,  the  only  unusual  phenomenon  that 
can  be  recognized  is  the  absence  of  the  ballottement. 

When  the  hemorrhage  takes  place  either  in  a  woman  with  her  first  child,  or  at 
an  early  stage  of  the  gestation,  when,  in  a  word,  the  cervix  uteri  is  not  sufficiently 
dilated  to  permit  the  introduction  of  a  finger,  we  might  still  be  enabled  to  deter- 
mine the  cause  of  the  flooding  by  the  following  signs,  namely : 

1,  A  hemorrhage  caused  by  insertion  of  the  placenta  over  the  internal  orifice 
never  occurs  before  the  end  of  the  sixth  month  ;  and,  most  frequently,  not  until 
the  last  four  or  six  weeks  of  gestation.  Besides,  it  is  highly  probable  that  the 
period  at  which  the  flooding  comes  on,  is  usually  subordinate  to  the  greater  or 
less  extent  of  the  placenta  corresponding  to  the  neck ;  that,  in  cases  of  insertion, 
centre  for  centre,  it  is  manifested  much  sooner  than  whei-e  only  one  of  its  mar- 
gins is  in  apposition  with  the  orifice.  Nevertheless,  there  are  numerous  excep- 
tions to  this  (as  M.  Nrogele  considers  it)  nearly  general  rule;  for,  in  a  large 


PUERPERAL    HEMORRHAGE.  G05 

number  of  the  cases  of  central  insertion,  the  hemorrhage  is  not  devcloj^ed  prior 
to  the  commencement  of  labor. 

2.  It  commences  spontaneously,  without  an  appreciable  cause,  and  without 
any  precursory  phenomena ;  the  woman  being  often  suddenly  aroused  in  the 
middle  of  the  night  by  the  escape  of  blood  from  the  genital  parts. 

3.  When  manifested  for  the  fii^st  time,  it  is  generally  inconsiderable  in 
amount,  and  soon  over;  but,  after  having  disappeared  altogether,  it  returns, 
sometimes  in  the  course  of  a  few  hours,  at  others,  not  for  several  days ;  but,  at 
each  reappearance,  the  discharge  is  a  little  more  abundant,  and  lasts  somewhat 
longer. 

4.  The  cervix  uteri  (considering  the  period  of  gestation)  is  usually  thicker, 
softer,  and  more  spongy,  because  the  placenta,  by  becoming  fixed  over  this  point, 
determines  there  a  more  considerable  afflux  of  blood. 

5.  If  the  labor  has  commenced,  and  the  membranes  are  still  intact,  the  flood- 
ing constantly  augments  during  the  uterine  contractions,  and  diminishes  in  the 
intervals.  But  the  contrary  is  observed  when  the  discharge  is  occasioned  by  a 
separation  of  the  placenta  attached  to  any  other  point;  for  then  the  womb,  by 
contracting,  obliterates  the  vessels,  either  by  a  retraction  of  its  own  proper  tissue, 
or  by  the  compression  they  are  subjected  to  from  the  parts  enclosed  within  its 
cavity;  but,  in  the  case  under  consideration,  the  contractions  that  effect  the  dila- 
tation of  the  cervix,  destroy  the  vascular  adhesions  which  unite  it  to  the  placenta, 
more  and  more,  and  thus  multiply  the  sources  of  hemorrhage.  This  sign  is  one 
of  great  value  before  the  membranes  are  ruptured ;  but,  after  the  waters  are  dis- 
charged, the  child's  head  presses  on  the  orifice  during  the  contraction,  and  pre- 
vents the  blood  from  escaping. 

6.  The  bag  of  waters  does  not  form  as  in  an  ordinary  labor ;  for  the  insertion 
of  the  placenta  over  the  neck  closes  its  orifice,  and  prevents  the  lower  segment 
of  the  ovum  from  engaging  therein,  and  from  being  accessible  to  the  finger. 

7.  Lastly,  according  to  Dewees,  the  blood  has  a  brighter  color  at  the  onset  of 
the  hemorrhage  than  when  it  comes  from  the  fundus,  and  coagula  never  come 
away,  excepting  when  the  discharge  has  lasted  for  some  time,  or  is  on  the  point 
of  disappearing. 

In  the  case  I  have  reported,  where  the  flooding  was  produced  by  a  rupture  of 
the  umbilical  vessels,  itself  caused  by  a  separation  of  the  chorion  from  the  foetal 
surface  of  the  placenta,  the  symptoms  were  very  similar  to  those  which  accom- 
pany a  hemorrhage  induced  by  insertion  of  the  placenta  over  the  os  uteri.  Thus, 
the  discharge  commenced  towards  the  middle  of  pregnancy,  was  several  times 
renewed  at  irregular  intervals,  and  always  in  increasing  abundance ;  and  it  was 
manifested  anew  at  the  onset  of  labor.  The  vaginal  examination  could  alone 
determine  the  diagnosis,  by  enabling  us  to  ascertain  the  absence  of  the  placenta 
from  the  internal  orifice. 

Finally,  in  the  case  detailed  by  Benckiser,  there  was  something  like  a  cord 
that  crossed  the  opening  in  the  neck  at  an  acute  angle,  and  this  was  detected 
before  the  rupture  of  the  membranes.  This  cord  was  devoid  of  pulsations,  but  it 
certainly  would  have  exhibited  them  if,  instead  of  a  venous  branch,  it  had  been 


696  DYSTOCIA. 

one  of  the  ramifications  of  the  umbilical  arteries.  Should  another  case  of  the 
kind  be  met  with,  the  presence  of  such  a  vascular  trunk  on  the  membranes  ought 
to  receive  attention,  and  arouse  a  suspicion  of  the  possibility  of  a  hemorrhage 
from  its  rupture. 

B.  Internal  Discharge. — The  diagnosis  of  the  internal  hemorrhages  becomes 
more  easy  as  the  gestation  advances.  The  general  phenomena  that  accompany 
all  profuse  discharges  would  first  attract  attention;  while  the  unusual  and  rapid 
development  of  the  abdomen,  and  occasionally  it^  irregular  form,  would  confirm 
the  surmise.  The  hemorrhage  can  alwaj's  be  recognized  whenever  it  is  abundant 
enough  to  endanger  the  mother;  though  it  must  be  acknowledged  that  a  quan- 
tity of  blood  may  be  effused  between  the  womb  and  the  placenta,  which  may 
effect  nearly  an  entire  separation  of  the  latter,  or  destroy  the  child,  without  giving 
rise  to  any  other  phenomena  than  a  manifestation  of  labor. 

A  considerable  enlargement  of  the  belly  is  a  sign  of  the  fii'st  importance ;  but 
it  must  not  be  forgotten  that  this  may  be  occasioned  by  an  entirely  different 
cause.  Thus,  for  instance,  a  tympanitis  of  the  abdomen  or  a  dropsy  of  the  amnios 
may  give  rise  to  it ;  however,  the  sonoreity  in  the  former  case,  and  the  slowness 
of  the  development  of  the  abdomen  in  the  latter,  conjoined  with  the  absence  of 
any  general  phenomena,  will  always  prove  suflBcient  to  avoid  an  error.  Again, 
the  patient  may  be  affected  with  a  syncope  during  the  labor  that  is  wholly  foreign 
to  any  discharge  of  blood ;  but  then  the  size  of  the  abdomen  will  not  increase. 

On  the  whole,  therefore,  the  general  phenomena  that  accompany  all  losses  of 
blood,  and  a  rapid  enlargement  of  the  belly,  are  the  two  characteristic  signs  of 
internal  hemorrhage,  whether  it  occurs  in  the  latter  stages  of  pregnancy  or  during 
the  parturition. 

Finally,  internal  hemorrhage  during  labor  is  frequently  followed  by  weakening 
or  even  suspension  of  the  pains.  The  abdomen  sometimes  becomes  painful 
(Levret),  and,  in  some  cases,  an  obscure  fluctuation  can  be  detected.   (Leroux.) 

Nevertheless,  M.  Ilenning  has  observed  that,  under  certain  circumstances,  the 
abdominal  swelling  may  be  altogether  wanting,  and  yet  the  .syncope  be  dependent 
on  an  internal  discharge.  Thus,  he  says,  the  patient  is  taken  at  first  with  violent 
uterine  pains,  that  reappear  at  certain  intervals,  and  each  one  of  which  is  followed 
by  a  slight  issue  of  blood  from  the  vulva ;  then,  at  a  moment  when  least  ex- 
pected, the  symptoms  of  a  most  alarming  syncope  come  on,  though  but  little 
blood  can  be  found  upon  the  cloths,  and  the  uterus  is  scarcely  distended.  But, 
by  making  a  careful  examination,  the  accoucheur  will  find,  that  although  this 
oro-an  may  enclose  but  an  inconsiderable  coagulum,  and  although  the  blood  does 
not  escape  freely  to  the  exterior,  yet  it  is  because  the  vagina  is  distended  by  an 
enormous  clot  as  large  as  a  child's  head.  I  deem  it  necessary,  he  adds,  to  insist 
on  the  presence  of  uterine  pains,  in  these  cases  of  intra-vuijinal  hemorrhage; 
for  they  are  generally  regarded  as  an  evidence  that  nothing  is  to  be  feared  from 
the  discharge,  whilst,  in  reality,  they  are  often  a  distinctive  character  of  the 
hemorrhage  in  quesiion. 


PUERPERAL    HEMORRHAGE.  GOT 

AETICLE  IV. 

PROGNOSIS. 

As  a  general  rule,  the  prognosis  of  uterine  hemorrhage  is  unfavoi'able ;  though, 
perhaps,  in  a  single  instance,  the  discharge  occurring  in  a  pregnant  female  may 
prove  advantageous — it  is  where  the  patient  is  harassed  by  all  the  symptoms  of 
a  general  or  local  plethora,  and  a  moderate  discharge  takes  place  that  relieves 
her  of  the  surplus  that  gave  rise  to  all  these  symptoms.  But  as  we  cannot 
always  moderate  a  flooding  at  will  that  has  already  commenced,  it  would  be  better 
both  to  relieve  the  patient  and  to  prevent  the  monorrhagia  by  resorting  to  vene- 
section. 

The  gravity  of  the  prognosis  depends  very  much  on  the  amount  of  the  dis- 
charge, and  the  period  at  which  the  hemorrhage  takes  place,  being  always  so 
much  the  more  dangerous  both  for  the  mother  and  child  as  the  blood  escapes  in 
larger  quantities.  Other  things  being  equal,  the  infant's  existence  will  be  more 
seriously  compromised  when  the  flooding  comes  on  at  an  early  stage  of  gestation ; 
that  of  the  mother,  on  the  contrary,  will  be  the  more  endangered  when  it  occurs 
nearer  the  term  of  pregnancy. 

During  childbirth,  this  accident  will  be  more  serious  both  for  the  mother  and 
child  when  it  is  manifested  at  an  early  stage  of  the  process;  and  it  will  be  still 
more  dangerous  in  a  primiparous  woman  than  in  one  who  has  previously  borne 
children.  For  it  must  be  evident  that,  if  the  flooding  should  occur  at  the  com- 
mencement of  labor,  that  is,  long  before  the  dilatation  of  the  os  uteri  is  efi"ected, 
and  befoi'e  the  external  parts  of  generation  are  suitably  prepared  for  the  free  and 
easy  passage  of  the  foetus,  the  means  adequate  to,  and  calculated  for,  the  termi- 
nation of  the  labor,  will  be  of  much  more  difiicult  application,  and  more  delayed; 
and,  consequently,  a  larger  quantity  of  blood  might  escape. 

As  regards  the  cause  producing  the  hemorrhage,  that  variety  which  is  depen- 
dent on  an  implantation  of  the  placenta  over  the  inferior  segment  is  the  gravest 
of  all :  to  the  mother,  because  it  is  renewed  several  times  during  the  latter 
months  of  her  gestation  in  a  constantly  increasing  amount,  and  because,  being 
always  present  during  the  labor,  it  usually  requires  the  intervention  of  art;  to 
the  child,  because  such  an  intervention  is  not  without  danger  to  it,  and  the  in- 
terruption of  the  utero-placental  circulation,  resulting  from  the  detachment  of 
the  placenta,  produces  an  asphyxia  that  oftentimes  proves  speedily  fatal.'      The 

'  The  fcEtus  then  dies  by  asphyxia  and  not  by  hemorrhage,  as  has  been  asserted,  and 
again  repeated,  in  the  recent  work  of  M.  Gendrin.  For  the  foetus  can  only  lose  its  blood 
when  the  source  of  the  hemorrhage  is  in  a  lesion  of  the  umbilical  vessels;  while,  in  a  case 
of  simple  detachment  of  the  uterine  surface  of  the  placenta,  the  child  dies  only  because  the 
circulation  is  interrupted  in  the  uteroplacental  vessels,  and  its  respiration  can  no  longer  take 
place.  (See  Functions  of  the  Foetus.)  The  blood,  being  shut  up  in  the  umbilical  vessels, 
cannot  come  any  more  into  the  usual  mediate  contact  with  the  maternal  blood,  and  the  infant 
is  then  in  the  same  condition  as  an  acUilt  deprived  of  respirable  air,  and  like  him  must  die 
asphyxiated.  Besides,  the  autopsical  examination  in  such  cases  exhibits  the  anatomo-patho- 
logical  characters  of  asphyxia. 

There  are  some  rare  cases  reported,  in  which  die  child's  head,  being  forcibly  urged  on  by 


698  DYSTOCIA. 

following  statistics  by  Dr.  Simpson,  prove  the  danger  of  this  complication, 
namely,  of  399  women  in  whom  this  misplaced  insertion  of  the  placenta  was  ob- 
served, 134  perished. 

"When  the  placenta  is  inserted  over  the  neck,  centre  for  centre,  the  hemorrhage 
would  evidently  be  much  more  profuse,  than  in  the  cases  in  which  it  is  in  con- 
tact with  the  orifice  by  one  part  of  its  circumference  only. 

A  singular  circumstance  sometimes  takes  place  in  cases  of  central  insertion. 
The  gradual  dilatation  of  the  cervix  may  effect  the  complete  detachment  of  the 
placenta,  which  may,  perhaps,  be  entirely  expelled  through  the  vulva  several 
hours  before  the  expulsion  of  the  child.  This  accident,  which,  at  first  view, 
would  seem  likely  to  have  the  most  disastrous  consequences,  is  nevertheless 
proved  by  experience  rarely  to  compromise  the  mother's  life,  though  it  is  gene- 
rally fatal  to  the  child. ^ 

the  powerful  contractions  of  the  womb,  has  perforated  the  placenta  near  the  middle,  and 
thus  opened  for  itself  a  passage  through  this  central  opening.  This  occurred  in  Portal's 
twenty-ninth  observation:  and  W.  White  reports  that,  in  a  case  where  the  placenta  appeared 
to  be  inserted  over  the  os  uteri,  centre  for  centre,  the  patient  suffered  two  or  three  very  in- 
tense pains,  during  which  the  head  perforated  the  after-birth  and  was  delivered.  The  child 
was  stillborn,  but  the  woman  recovered. 

'  Chapman  relates  an  instance  in  which  the  after-birth  was  thus  expelled  four  hours  in 
advance  of  the  child;  and  Perfect  furnishes  a  very  similar  case.   (Cases,  vol.  ii,  page  288.) 

"  I  was  once  consulted,"'  says  Merriman,  "  by  a  very  careful  and  judicious  practitioner,  re- 
specting a  woman,  who,  when  I  first  saw  her,  was  rapidly  sinking  under  peurperal  fever. 
In  this  case,  the  placenta  was  expelled  many  hours  before  the  child  was  born,  and  no  ex- 
traordinary means  were  used  to  expedite  the  delivery  of  the  child ;  a  physician-accoucheur, 
who  was  consulted  on  the  occasion,  having  deemed  it  more  prudent  to  leave  the  case  to 
nature.  The  fatal  event,  however,  would  lead  one  to  doubt  whether  it  was  wise,  under  such 
circumstances,  to  decline  the  interference  of  art.''    (Synopsis,  page  126.) 

Smellie  has  reported  three  cases  of  the  same  kind  ;  Lamotte,  three  (06s.  321,  322,  323)  ; 
Lee,  three  (Med.  Gaz.,  1S39)  ;  Ramsbotham,  .Sr.,  five  (Practical  Obs.,  Case  153) ;  Baudelocque 
and  Barlow,  each  one;  and  Dr.  Collins  (Practical  Treatise,  page  91)  narrates  an  instance  in 
which  the  placenta  was  expelled  about  eighteen  hours  before  the  fcetus ;  the  membranes 
were  ruptured,  and  the  waters  escaped  two  weeks  before  the  entrance  of  the  patient  into  the 
hospital:  from  that  time  until  the  eve  of  her  admission,  the  flooding  had  continued  with 
more  or  less  abundance.  We  satisfied  ourselves,  says  he,  that  the  placenta  had  been  ex- 
tracted the  evening  before  by  the  midwife  who  attended  her.  This  woman  recovered  per- 
fectly, and  left  the  hospital  on  the  thirteenth  day. 

Cases  of  this  kind  are  much  more  common  than  might  be  supposed;  thus,  Dr.  Simpson 
has  collected  141  authentic  observations,  and,  in  order  the  better  to  appreciate  the  effect  of 
this  premature  separation,  he  has  divided  them  into  four  categories.  In  the  first,  47  in  num- 
ber, there  were  41  stillborn  children,  and  10,  of  whose  condition  nothing  could  be  learned, 
but  all  the  women  except  three  recovered.  In  all,  the  hemorrhage  diminished  greatly,  or 
ceased  altogether,  immediately  after  the  expulsion  of  the  placenta,  although  an  interval  of 
ten  hours  at  the  most,  and  of  ten  minutes  at  the  least,  had  elapsed  between  the  expulsion  of 
the  after-birth  and  the  birth  of  the  child.  In  the  second,  are  placed  24  cases.  In  all  of 
these,  rather  less  than  ten  minutes  intervened  between  the  expulsion  of  the  placenta  and 
that  of  the  fcEtus;  9  of  the  children  were  stillborn,  2  were  putrefied,  and  11  were  alive;  no 
information  respecting  the  two  others;  all  the  mothers  but  three  recovered.  The  third 
contains  29  observations,  in  which  the  expulsion  of  the  child  followed  that  of  the  after-birth 
immediately;  14  stillborn,  and  11  hving  children;  no  information  respecting  the  others;  all 


PUERPERAL    HEMORRHAGE.  699 

In  some  rai'e  cases,  it  has  happened  that  the  head,  under  the  influence  of 
powerful  contractions,  perforated  the  centre  of  the  placenta,  and  was  expelled 
through  the  passage  thus  formed.  Portal's  twenty-ninth  observation  relates  to  a 
case  of  this  kind ;  and  W.  White  informs  us  that  in  an  instance  of  apparently 
central  insertion  upon  the  neck,  the  woman  had  two  or  three  very  strong  pains, 
during  which  the  head  perforated  the  placenta,  and  was  expelled.  The  child 
was  stillborn,  but  the  mother  recovered. 

When  the  placenta  is  situated  only  in  the  vicinity  of  the  neck,  the  hemoi'- 
rhage  may  not  appear  during  the  labor,  although  it  may  have  occurred  several 
times  in  the  latter  stages  of  pregnancy ;  for,  should  the  membranes  rupture  pre- 
maturely, and  the  head  be  presenting,  it  is  possible  that  its  engagement  might 
compress  the  torn  vessels  sufficiently  to  prevent  the  discharge  of  blood.' 

The  internal  hemorrhage  is  generally  more  dangerous  than  the  external,  be- 
cause it  often  takes  place  imperceptibly  in  the  commencement  of  gestation,  and 
thus  destroy  the  foetus ;  while,  at  a  more  advanced  period,  it  compromises  the 
mother's  life,  before  having  given  rise  to  any  symptom  whereby  its  existence 
could  be  positively  recognized,  so  that  the  accident  is  often  detected  too  late  to 
be  remedied. 

Where  the  blood  collects  in  the  uterine  cavity,  the  accumulation  cannot  take 
place  without  detaching  a  new  portion  of  the  placenta,  and  this  secondary  sepa- 
ration becomes  a  fresh  cause  of  vascular  rupture,  and,  as  a  consequence,  aug- 
ments the  chances  of  flooding.  For  even  suppose  the  hemorrhage  were  arrested, 
whether  spontaneously  or  under  the  influence  of  the  measures  employed,  there 
does  not  the  less  remain  a  voluminous  coagulura  in  the  uterus,  a  veritable  foreign 
body,  whose  presence  will  irritate  its  walls,  will  determine  there  a  more  con- 
siderable sanguineous  fluxion,  and  will  excite  premature  contractions,  and  thus 
become  perhaps  the  cause  of  another  discharge. 

Lastly,  during  the  parturition,  the  internal  hemorrhage  is  less  to  be  feared 
before  than  after  the  membranes  are  ruptured  ;  because,  in  the  former  case,  the 
womb,  being  already  occupied  by  the  amniotic  liquid,  will  yield  less  readily  to 
a  new  distension,  and,  consequently,  will  prevent  a  great  eff"usion  of  blood. 
Besides  this,  the  integrity  of  the  membranes  will  admit  of  their  artificial  rupture, 

the  mothers  recovered,  except  one.  Finally,  in  10  cases,  the  time  between  the  birth  of  the 
child  and  the  delivery  of  the  placenta  was  not  noted.  Only  three  mothers  died,  and  9  chil- 
dren survived. 

Thus,  according  to  these  facts,  the  premature  separation  of  the  placenta,  which  does  not 
appear  to  have  had  a  very  serious  etTect  upon  the  mothers,  is  extremely  dangerous  to  the 
child,  since  all  the  children  of  the  first  series  died;  half  only  of  the  second,  and  eleven  of  the 
third  category,  survived. 

We  shall  refer  to  these  figures  hereafter,  in  order  to  appreciate  the  practical  consequences 
which  Dr.  Simpson  thinks  himself  able  to  deduce  from  them. 

'  When,  saysPlenck,  the  orifice  is  half  covered  by  the  adherent  placenta,  the  case  should 
be  left  to  nature ;  for  the  head  of  the  child  pushes  the  presenting  part  of  the  placenta  aside, 
compresses  the  bloodvessels,  and  thus  ])revents  hemorrhage.  This  precept,  though  too 
absolute,  at  least  proves  that  Plenck  had  made  the  same  observation  that  we  have  just 
mentioned. 


700  DYSTOCIA. 

wliicb,  by  tlie  salutary  retraction  that  follows  it,  is  one  of  the  most  valuable  re- 
sources of  our  art  in  these  unfortunate  cases;  and  of  which,  it  is  unnecessary  to 
add,  we  are  deprived,  when  the  waters  escape  prematurely. 

But  the  dangers  that  threaten  the  woman  whilst  the  hemorrhage  lasts,  are  not 
the  only  ones  to  be  dreaded ;  for  her  constitution  and  health  may  be  broken 
down  for  a  long  time  by  these  grave  accidents.  For  even  when  the  patients 
have  the  good  fortune  to  escape  with  their  lives,  they  ordinarily  suffer  for  a  con- 
siderable period;  they  ai'e  tormented  with  constant  pains  in  the  head;  their 
digestion  is  painful,  their  vision  and  hearing  are  defective  ;^  and  there  are  often 
wandering  pains  in  the  limbs,  trembling,  &c.  &c.  Most  frequently  the  labor  is 
lingering,  the  pains  are  short  and  distant,  and  inertia  of  the  uterus  results  from 
this  general  weakness.  Those  females  who  have  been  afflicted  with  profuse 
hemorrhages  are  far  more  disposed  than  others,  during  the  lying-in,  to  acute  in- 
flammations, and  to  peritonitis  especially;  which  inflammations  then  advance 
more  rapidly  to  a  fatal  termination,  because  the  general  condition  of  the  patient 
does  not  permit  an  active  resort  to  the  antiphlogistic  treatment. 

The  cephalalgia  noticed  by  all  observers,  and  which  I  have  frequently  had 
opportunities  of  verifying  myself,  only  disappears  after  a  very  long  time,  and  not 
until  the  reparation  of  the  blood,  and  the  re-establishment  of  the  strength,  have 
taken  place.  M.  Baudelocque  supposes  that  the  pain  is  particularly  apt  to  be 
seated  in  the  hinder  part  of  the  head.  Lerous  attributes  this  aifection  to  a 
diminution  in  the  quantity  of  blood  contained  in  the  vessels  of  the  brain,  which 
occurs  as  an  immediate  consequence.  I  would  rather  explain  it  like  Baudelocque, 
by  the  direct  influence  which  the  loss  of  blood  must  exercise  over  the  nervous 
system. 

The  child's  death  does  not  necessarily  result  from  the  hemorrhage ;  for,  when 
the  latter  is  inconsiderable,  the  gestation  continues  its  regular  course.  The  loss 
of  blood  has  even  been  carried  to  an  extent  calculated  to  inspire  just  fears  for 
the  mother's  life,  and  yet  without  being  followed  by  abortion. 

But  although  the  foetus  may  have  resisted  the  violence  of  the  first  accidents, 
it  must  not  be  supposed  that  it  experiences  no  injurious  effects  therefrom. 
Though  but  a  small  portion  of  the  j^lacenta  may  have  been  separated,  the  foetus 
is  nevertheless  deprived  thereby  of  a  portion  of  its  means  of  respiration  and  of 
nutrition,  and  this  deprivation,  though  partial,  may  eventually  prevent  its  com- 
plete development,  and  even  destroy  it  before  the  termination  of  pregnancy. 
Therefore,  when  born  alive,  it  is  often  emaciated,  and  weaker  than  under  ordi- 
nary circumstances,  and  this  congenital  debility,  which  is  generally  regarded  by 
authors  as  a  consequence  of  the  anaemic  condition  of  the  mother,  should,  in  my 
opinion,  be  attributed  to  the  partial  separation  of  the  placenta. 

When  the  mother  has  had  the  good  fortune  to  escape  the  danger  that  menaced 
her,  and  the  pregnancy  continues,  how  then  is  the  hemorrhage  arrested  ?  The 
mode  of  termination  varies  somewhat,  according  to  the  cause  that  has  determined 

'  In  a  case  reported  by  Ingleby,  tlie  patient  became  suddenly  blind  ;  for  five  days  she 
could  not  distinguish  anything  at  all,  and  her  sight  was  not  perfectly  restored  till  six  months 
afterwards. 


PUERPERAL    nEMORRHAGE.  701 

the  accident.  Thus,  when  the  flooding  has  been  preceded  by  general  plethora, 
or  by  uterine  congestion,  it  may  happen  that  the  escape  of  blood  removes  this 
condition,  and  thus  remedies  the  symptoms  itself;  and  this  must  nearly  always 
be  the  case,  where  the  discharge  resulted  from  a  sanguineous  exhalation.  But 
where  there  is  a  rupture  of  one  of  the  utero-placental  vessels,  it  is  possible  that 
the  flow  of  blood,  by  relieving  their  distension,  will  permit  these  vessels  to  be- 
come flattened  down  and  depressed,  from  the  double  pressure  of  the  ovum  and 
womb,  and  then  the  hemorrhage  is  arrested.  Again,  where  the  placenta  has 
been  detached  from  the  womb  to  a  moderate  extent,  the  bleeding  can  only  be 
checked  by  the  formation  of  a  coagulum,  which  creates  an  obstacle  to  the  ulterior 
issue  of  the  blood,  by  being  placed  between  the  uterus  and  the  placenta;  for, 
"  while  the  blood  is  endeavoring  to  glide  towards  the  os  uteri,"  says  M.  Velpeau, 
''  a  more  or  less  extensive  portion  of  the  placental  mass  becomes  fully  saturated 
•with  it :  first  one  clot  forms,  then  a  second,  then  a  third,  and  these  several 
layers,  of  various  thickness,  soon  become  sufficiently  numerous,  provided  the 
energy  of  the  hemorrhagic  afHuxion  becomes  diminished,  to  exert  such  a  degree 
of  pressure  as  to  retain  the  blood  within  its  own  vessels."  All  the  vascular 
tubes  corresponding  to  the  point  where  this  coagulum  is  formed,  are  thenceforth 
rendered  useless  to  the  utero-placental  circulation,  which  can  only  be  kept  up 
through  those  that  have  not  been  lacerated. 

The  authors  of  the  Dictionnaire  de  Medecine  (art.  Hemorragie  Uterine)  seem 
to  admit,  from  a  case  reported  by  Noortwyk,  that  the  detached  portion  of  pla- 
centa may  contract  new  adhesions  with  the  uterine  wall ;  but  from  what  has  just 
been  said  respecting  the  formation  of  the  coagulum,  which,  by  its  presence,  puts 
an  end  to  the  symptoms,  it  is  impossible  to  admit  that  this  re-attachment  can 
take  place  without  the  intervention  of  a  fibrinous  clot,  which  evidently  precludes 
the  re-establishment  of  the  circulatory  relations.  Besides,  this  matter  is  satis- 
factorily proved  at  the  time  of  labor;  for,  by  examining  the  uterine  surface  of 
the  placenta,  we  can  then  detect  one  or  more  fibrinous  laminae,  of  a  variable  size, 
and  difiiering  from  each  other  in  the  degree  of  degeneration,  according  to  the 
period  at  which  the  separation  was  effected ;  in  addition  to  which,  the  portion 
of  placenta  that  had  been  detached  is  often  atrophied  and  deprived  of  juices ; 
in  a  word,  the  corresponding  placental  cotyledons  have  withered  away  completely. 

ARTICLE   V. 

TREATMENT. 

The  management  of  uterine  hemorrhage  may  be  subdivided  into  the  preventive 
and  the  curative  treatment.  The  prophylactic  measures  are  as  numerous  as  the 
predisposing  causes,  and  they  consist  in  preventing  the  action  of  those  causes ; 
hence,  to  furnish  a  detailed  account  of  them,  it  would  be  necessary  to  enter  into 
a  series  of  repetitions.  Besides,  they  are  included  in  the  hygienic  and  general 
therapeutic  management  of  pregnancy,  and,  therefoi'e,  we  need  not  dwell  further 
upon  them  here.  But  if,  notwithstanding  all  the  preventive  means  employed,  or 
if/  from  the  influence  of  any  unforeseen  causes,  a  hemorrhage  is  developed,  what 


702  DYSTOCIA. 

course  shall  we  adopt  to  subdue  it?  The  frequency  of  this  accident,  and  its 
great  danger  in  many  cases,  have  at  all  times  claimed  the  attention  of  practi- 
tioners; and,  with  a  view  of  facilitating  the  study  of  the  numerous  measures 
that  have  been  recommended,  we  shall  divide  them  into  the  general  and  the 
special  ones.  The  first,  being  applicable  in  all  cases,  are  nearly  always  the  same; 
but  the  second  vary  according  to  whether  the  flooding  takes  place  in  the  course 
of  the  gestation  or  during  parturition,  and  according  to  the  abundance  or  the 
trifling  character  of  the  discharge. 

§  1.  General  Therapeutic  Measures, 

Whenever  an  accoucheur  is  summoned  to  a  pregnant  woman  who  is  aff"ected 
with  flooding,  he  should  immediately  attend  to  certain  precautions  that  we  are 
about  to  point  out,  namely — 

The  woman  ought  to  be  kept  in  a  horizontal  position,  care  being  taken  to  have 
the  pelvis  elevated  somewhat  higher  than  the  rest  of  the  body.  All  feather  beds 
must  be  proscribed,  and,  whenever  possible,  she  should  lie  on  a  hair  mattress 
that  is  rather  hard.  The  bed  is  to  be  placed  in  a  large,  well-ventilated  chamber, 
80  as  to  be  easily  accessible  on  all  sides ;  in  the  summer  season,  the  room  might 
even  be  sprinkled ;  and  the  woman  is  to  be  lightly  covered.  It  is  desirable  to 
have  the  chamber  somewhat  darkened,  and  the  attendants  should  be  advised  to 
discharge  their  respective  duties  without  making  any  unnecessary  noise.  He 
should  endeavor  to  satisfy  the  patient  as  to  her  condition,  and  to  remove  all 
sources  of  vexation  and  opposition  ;  for  calmness  of  mind  is  not  less  essential 
than  rest  of  the  body ;  especially,  when  the  discharge  has  been  occasioned  by 
violent  passions  or  acute  moral  aff"ections. 

Cold  drinks,  slightly  acidulated  with  vinegar,  gooseberry,  or  lemon  syrup,  or 
even  with  lime  or  orange  juice,  are  the  most  suitable.  We  should  endeavor 
to  obviate  the  strainings  the  patient  might  make  on  the  close  stool,  because  they 
might  po.ssibly  increase  the  flooding ;  for  this  purpose,  the  bowels  are  to  be  kept 
free  by  injections,  or,  if  these  are  not  sufiicient  to  remedy  the  constipation,  by 
mild  laxatives ;  and,  lastly,  if  the  woman  has  the  least  difficulty  in  urinating,  it 
would  likewise  be  necessary  to  empty  the  bladder  by  the  catheter. 

§  2.  Special  Therapeutic  Measures. 

These  vary,  as  stated,  according  to  the  abundance  or  trifling  character  of  the 
discharge,  and  according  to  whether  the  latter  is  manifested  in  the  course  of 
the  gestation,  or  during  the  labor.  We  shall  first  examine  them  during  preg- 
nancy. 

A.  Moderate  Hemori'liage,  occurring  in  the  last  three  months. — If  the  flooding 
has  been  preceded  by  the  general  phenomena  of  plethora,  and  if  at  the  time  when 
the  woman  is  examined  the  pulse  be  found  full,  strong,  and  developed,  the  face 
flushed,  &c.,  in  a  word,  if  the  hemorrhage  appears  to  be  owing  to,  or  kept  up  by, 
the  plenitude  or  morbid  action  of  the  vessels,  it  is  necessary  to  have  recourse  to 
general  venesection,  which  will  act  both  as  a  revulsive  and  as  an  antiphlogistic ; 
but  this  measure  is  recommended  in  those  cases  only  in  which  labor  has  not  yet 
commenced,  and  where  the  discharge  is  inconsiderable,  and  has  lasted  but  a 


PUERPERAL  HEMORRHAGE.  703 

short  time.  Bloodletting  must  be  proscribed  under  the  opposite  circumstances, 
as  also  in  those  instances  where  the  flooding  is  not  associated  with  plethora. 

When  the  hemorrhage  is  not  very  abundant,  and,  as  a  consequence,  when  there 
is  some  reason  to  hope  that  the  pregnancy  will  continue  on  its  regular  course, 
opiates  may  be  administered ;  they  might  be  given  by  the  mouth,  but  it  is  much 
better,  in  general,  to  exhibit  them  by  injection,  in  the  dose  of  twenty  drops  of 
Sydenham's  laudanum,  diffused  in  a  small  quantity  of  some  mucilaginous  vehicle; 
and  this  may  be  repeated  three  or  four  times,  at  intervals  of  an  hour  or  more, 
where  the  first  have  not  been  sufficient  to  arrest  the  symptoms.  A  long  expe- 
rience, says  Burns,  enables  me  to  recommend  this  measure  in  all  cases  where 
bloodletting  is  not  practicable.  For  the  first  twenty-four  hours,  the  patient  must 
be  subjected  to  a  strict  regimen. 

Such  are  the  measures  to  be  employed  in  cases  of  moderate  hemorrhage  occur- 
ring in  the  last  three  months  of  gestation ;  and  they  should  be  continued  until  it 
has  entirely  disappeared. 

After  the  symptoms  are  wholly  subdued,  the  woman  ought  to  take  the  greatest 
precautions  to  avoid  a  relapse,  by  keeping  in  bed  for  a  week  at  least,  eating  but 
little,  and  that  of  non-succulent  articles,  especially  if  the  discharge  had  been 
attributed  to  plethora,  &c.  &c. 

B.  Profuse  HenwrrhaQe  occurring  in  the  last  three  months.  —  Where  the 
flooding  is  more  abundant,  the  remedies  to  be  employed  are  also  more  active; 
and,  to  the  measures  already  enumerated,  except  venesection,  which,  as  before 
stated,  must  be  rejected  when  the  discharge  is  very  profuse,  we  may  now  add  : 

1.  The  application  of  compresses,  steeped  in  some  very  cold  liquid,  to  the 
upper  part  of  the  thighs,  hypogastrium,  or  loins  (in  one  instance,  M.  Gendrin 
successfully  administered  an  opiate  injection  at  the  temperature  of  melting  ice); 
and,  where  the  heat  is  very  great,  cold  sponging  over  the  legs,  arms,  and  even 
the  body.  But  the  action  of  cold  is  not  to  be  resorted  to  without  discrimination ; 
nor,  as  a  general  rule,  should  it  be  kept  up  for  a  very  long  time;  because, 
although  its  application  may  be  useful  at  the  commencement  of  the  attack,  when 
the  phenomena  of  local  congestion  are  manifest,  it  would  certainly  prove  inju- 
rious if  a  very  copious  and  persistent  flooding  had  already  enfeebled  the  patient, 
and  if  there  was  reason  to  fear  the  powers  of  life  were  giving  way,  and  that  the 
woman  was  likely  to  sink  into  a  state  of  complete  prostration. 

When  the  skin  is  cold,  and  the  pulse  small  and  feeble,  the  refrigerants  are 
not  indicated,  and  they  should  be  suspended  at  once,  if  already  in  use. 

2.  In  this  latter  case,  if  the  flooding  continued  and  the  prostration  augmented, 
it  would  be  necessary  to  have  recourse  to  revulsives  applied  to  the  superior  parts. 
I  have  seen,  says  M.  Baudelocque,  a  profuse  hemorrhage  suspended  almost  in- 
stantaneously by  placing  the  hands  in  very  hot  water. 

Under  the  title  of  revulsives  it  has  been  recommended,  since  the  days  of  Hip- 
pocrates, to  apply  cups  either  above  or  just  under  the  breasts,  and  between  the 
shoulders. 

M.  Velpeau  advises  the  employment  of  a  sinapism  at  the  upper  part  of  the 
back;  for  he  has  found  this  remedy  beneficial  in  a  great  number  of  instances, 
and  at  all  stages  of  gestation;  "nevertheless,"  he  says  himself,  "there  would  be 


704  DYSTOCIA. 

little  wisdom  in  relying  upon  it  to  completely  suppress  a  hemorrhage  that  had 
already  become  serious  and  alarming."  It  is,  however,  an  auxiliary  measure 
that  should  never  be  neglected,  for  it  can  have  no  disastrous  tendency;  but,  in 
my  opinion,  the  same  cannot  be  said  of  revulsives  applied  to  the  breasts,  since 
it  is  by  no  means  certain  that  they  may  not  prove  injurious.  Indeed,  many 
authors,  relying  on  the  sympathy  existing  between  the  uterus  and  the  mammae, 
have  supposed  that  every  stimulant  applied  to  the  latter  must  excite  the  action 
of  the  former,  and,  consequently,  tend  to  renew,  or  to  keep  up,  the  hemorrhage. 

3.  If  the  measures  hitherto  enumerated  be  not  sufficient  to  arrest  the  flooding, 
the  ergot  might  be  exhibited  in  the  dose  of  half  a  drachm  divided  into  three 
pai'ts,  one  of  which  is  to  be  taken  every  ten  minutes.  This  medicine,  which  is 
recommended  by  M.  P.  Dubois  under  such  circumstances,  appears  to  him  to 
have  nothing  more  than  a  hemostatic  action;  "for,  if  it  be  objected,"  says  he, 
"  that  this  remedy  might  excite  uterine  contractions,  and  thus  provoke  a  prema- 
ture labor,  we  answer  that,  up  to  the  present  time,  not  a  single  well-founded 
observation  proves  that  the  spurred  rye  has  the  property  of  ]irovoJi:ln(j  the  ute- 
rine contractions;  though,  where  these  exist  already,  it  increases  them,  or 
restores  them  when  suspended;  but  it  does  not  cause  them  to  appear  if  the 
uterus  is  in  a  state  of  perfect  rest.  On  the  other  hand,  even  supposing  that  it 
had  this  virtue,  that  would  not  be  a  just  ground  of  exclusion,  for  it  must  not  be 
forgotten  that  the  question  is  before  us  of  arresting  a  serious  accident,  one  which 
cannot  continue  without  prejudice  to  both  mother  and  child ;  and  that  the  only 
other  resource  is  the  use  of  the  tampon,  which,  even  more  than  the  ergot,  would 
expose  her  to  the  hazard  of  a  delivery  before  term."  (Journ.  de  Med.  et  de 
Chir.  Pratique,  1836.) 

4.  But  it  sometimes  happens  that,  notwithstanding  the  employment  of  refri- 
gerants and  ergot,  the  flooding  continues,  the  woman  becomes  pale  and  colorless, 
the  pulse  small  and  thread-like,  and  she  has  vertigos,  c*cc. ;  and  the  violence  of 
the  symptoms  endangers  the  lives  of  both  mother  and  child.  Under  these  grave 
conditions,  the  accoucheur  has  only  to  choose  between  an  application  of  the  tam- 
pon and  a  provocation  of  the  labor  by  rupturing  the  membranes. 

A.  Use  of  (he  Tampon. — When  speaking  of  the  natural  termination  of  those 
hemorrhages  that  come  on  during  pregnancy,  we  stated  that  the  discharge  was 
arrested  in  consequence  of  the  formation  of  coagula,  which,  by  becoming  applied 
over  the  orifices  of  the  vessels,  perhaps  even  by  being  continued  into  these  ori- 
fices, prevented  a  subsequent  discharge  of  blood;  and  that  it  is  on  the  formation 
of  these  salutary  coagula  that  we  must  found  our  hope,,  so  long  as  there  is  a 
chance  of  preserving  the  infant.  It  was  with  this  view  that  the  older  physicians 
resorted  to  the  use  of  astringent  injections,  and  more  especially  to  pessaries  made 
of  some  old  linen  saturated  with  such  liquids.  But  they  did  not  depend  upon 
the  coagulating  and  astringent  properties  of  these  substances  alone;  but  also 
relied  on  their  mechanical  eff"ect  in  retaining  the  blood.  For  this  purpose,  there- 
fore, Leroux,  of  Dijon,  proposed  his  tampon  in  177G.  This  remedy,  says  he,  is 
exceedingly  simple ;  it  consists  in  the  creation  of  an  obstacle  to  the  escape  of  the 
blood  by  filling  up  the  vagina  with  balls  of  linen  or  tow,  saturated  with  pure 
vinegar.     Desormeaux  thought  it  was  better  to  first  double  a  large  piece  of  fine 


PUERPERAL  HEMORRHAGE.  705 

linen,  and  then  carry  up  the  fold  to  the  fundus  of  the  vagina;  and  afterwards  to 
fill  the  pocket,  thus  formed  by  the  linen,  with  bits  of  charpie,  or  tow,  or  any 
other  soft  substance  that  may  be  at  hand.  M.  Moreau  condemns  this  procedure, 
because,  he  remarks,  it  is  difficult  and  painful,  and  it  would  be  almost  impossible 
not  to  leave  some  space  between  the  tampon  and  the  cervix  uteri.  He  recom- 
mends the  mode  of  application  to  be  altered  to  suit  the  particular  case  :  for  in- 
stance, if  the  OS  uteri  is  a  little  dilated,  he  advises  the  use  of  a  roller,  wound 
tightly  in  the  form  of  a  cone,  and  well  fastened;  then  the  conical  extremity  of 
this  plug  is  introduced  into  the  uterine  orifice  itself,  and  is  retained  there  by  the 
finger.  "When  the  dilatation  is  somewhat  more  advanced,  he  makes  use  of  a 
lemon,  having  the  rind  pared  off  at  one  extremity,  and  he  introduces  this  into 
the  neck  of  the  womb,  where  its  bulk  obliterates  the  orifice,  and  its  juice  irritates 
the  organ ;  and  lastly,  when  the  os  uteri  is  freely  dilated,  he  recommends  the 
vagina  to  be  crammed  with  lint  steeped  in  vinegar,  and  the  whole  to  be  secured 
with  a  T  bandage.  Leroux  was  also  in  the  habit  of  saturating  the  tampon  with 
vinegar.  The  astringents  were  considered  useless  by  Desormeaux ;  for,  he  says, 
it  is  only  on  the  mechanical  action  of  the  tampon  that  we  can  rely,  and  not  upon 
the  irritation  which  its  contact,  and  that  of  the  acids  with  which  some  persons 
saturate  it,  may  have  on  the  uterine  wall.  It  would  be  very  fortunate,  indeed, 
if  the  only  effect  of  the  tampon  was  to  prevent  the  issue  of  the  blood,  and  to  de- 
termine its  coagulation ;  for  then,  by  arresting  the  hemorrhage,  we  might  preserve 
the  life  of  the  foetus  much  oftener  than  is  now  done.  But,  unhappily,  it  has  yet 
another  effect,  that  is,  it  frequently  irritates  the  organ  by  mere  presence,  and  by 
forcing  the  blood  to  coagulate  in  the  uterine  cavity,  whereby  a  more  or  less  volu- 
minous coagulum  is  formed  there,  which  further  adds  to  the  irritation  produced 
by  the  tampon  itself;  contractions  are  excited,  and,  in  most  cases,  the  womb 
soon  drives  out  the  tampon,  coagulated  blood,  and  foetus  altogether.  This,  we 
may  observe  in  passing,  is  the  most  serious  objection  that  can  be  urged  against 
the  use  of  the  tampon,  a  reproach  that  it  often  merits,  especially  when  it  is  satu- 
rated with  vinegar. 

But,  after  all,  notwithstanding  these  disadvantages,  the  tampon  is  a  remedy 
that  cannot  be  dispensed  with  in  practice ;  and  we  do  not  know  how  to  better 
describe  the  cases  in  which  it  may  be  resorted  to  with  advantage,  than  by  fur- 
nishing the  following  extract  from  the  memoir  published  by  Gardien,  in  the  ninth 
volume  of  Leroux,  Boyer,  and  Corvisart's  Journal. 

The  tampon  may  be  applied :  1.  To  arrest  any  hemorrhage  that  might  arise 
from  the  rupture  of  a  varix  on  the  uterine  neck,  or  in  the  vagina;  2.  In  a  case 
of  laceration,  occurring  at  the  orifice  of  the  womb  during  labor,  and  when  there 
is  any  inertia,  by  a  direct  application  to  the  torn  surface ;  3.  In  cases  where  the 
placenta  is  inserted  over  the  os  uteri  centre  for  centre ;  the  blood,  being  retained 
by  the  tampon,  forms  a  coagulum  which  is  compressed  between  it  and  the  after- 
birth, whereby  the  serous  part  is  expressed,  and  a  concretion  takes  place  which 
contracts  adhesions  with  the  adjacent  parts,  and  suspends  the  discharge  until  the 
rupture  of  some  other  vessel  renews  the  hemorrhage.  Nothing  is  to  be  feared 
in  these  cases  from  an  internal  bleeding ;  for,  although  we  have  quoted  some 

45 


706  DYSTOCIA. 

examples  of  the  kind,  these  ai-e  so  rare  that  they  cannot  counterbalance  all  the 
advantages  of  the  tampon ;  besides,  the  mere  fact  of  its  employment  docs  not 
dispense  with  the  necessity  of  carefully  watching  the  patient;  4.  It  is  likewise 
serviceable  in  the  floodings  attending  the  abortions  which  take  place  in  the 
course  of  the  first  three  months,  whether  before  or  after  the  delivery  of  the 
after-birth ;  before,  because  Puzos'  method  might  render  this  delivery  impos- 
sible, or  at  least,  very  difficult ;  and  after,  because  there  would  be  no  cause  to 
fear  an  internal  hemorrhage,  for  the  reasons  before  given ;  5.  It  might  answer  in 
those  instances  where  there  is  no  dilatation  of  the  os  uteri,  or  when  this  is  im- 
possible, and  consequently  where  it  would  be  impracticable  to  pierce  the  mem- 
branes ;  6.  And  lastly,  where  the  flooding  continues  after  the  membranes  have 
been  punctured,  and  it  is  impossible  to  eS'ect  a  forced  delivery;  as  in  the  cases 
reported  by  Lamotte  and  Smellie.  Nevertheless,  its  employment  then  should 
always  be  watched  over  with  the  greatest  possible  attention ;  for  the  uterus,  in 
which  a  void  is  created  after  the  discharge  of  the  waters,  is  susceptible  of  be- 
coming distended,  and  an  internal  hemorrhage  might  take  place.  Under  such 
circumstances,  an  artificial  delivery  must  be  resorted  to. 

But  the  tampon  should  be  rejected :  1,  whenever  we  might  reasonably  hope 
to  prevent  an  abortion  ;  for  even  Leroux  himself  made  use  of  the  ordinary  means 
before  resorting  to  this  measure;  because,  by  retaining  within  the  womb  the 
blood  that  would  otherwise  escape,  it  distends  this  organ  by  forming  a  coagulum, 
which  may  increase  the  detachment  of  the  membranes  and  placenta,  and  may 
likewise  irritate  the  womb  by  its  presence,  and  thus  bring  on  the  contractions; 
and,  2,  whenever  (as  hitherto  stated)  the  placenta  is  inserted  over  the  os  uteri, 
and  the  labor  is  far  advanced. 

B.  Rupture  of  the  Membranes. — When  the  hemorrhage  is  profuse,  and  has 
made  its  appearance  during  the  latter  months  of  gestation,  more  especially  if  the 
labor  has  already  begun,  a  rupture  of  the  membranes  should  generally  be  prefei'- 
red  to  the  use  of  the  tampon.  The  child's  life  is  then  almost  as  precious  as  the 
mother's,  and  we  must  endeavor  to  remove  it  from  the  threatened  danger.  It 
was  with  this  view  that  our  predecessors  resorted  to  an  artificial  labor  under  such 
circumstances.  But  Puzos  has  proposed  a  measure  which  conjoins  the  advan- 
tages of  the  natural  with  those  of  a  forced  delivery.  It  is  necessary  for  this 
purpose,  he  says,  to  introduce  one  or  more  fingers  into  the  uterine  orifice,  by 
which  an  attempt  is  made  to  dilate  it  with  a  degree  of  force  proportioned  to  its 
resistance;  this  gradual  dilatation,  which  is  interrupted  by  intervals  of  rest  from 
time  to  time,  excites  the  pains ;  the  womb  contracts,  and  during  its  contraction 
the  membranes  become  tense,  and  engage  a  little  at  the  upper  part  of  the  cervix, 
and  these  latter  are  ruptured  as  soon  as  possible,  in  order  to  effect  a  discharge  of 
the  waters.  The  presenting  part,  particularly  if  this  happens  to  be  the  head, 
should  be  carefully  pressed  up  by  the  finger  for  some  moments,  so  as  to  permit 
the  liquid  to  escape.  The  objects  to  be  accomplished  are  obviously  to  encourage 
a  discharge  of  the  waters,  to  arouse  the  contractility  of  the  uterine  tissue  by  their 
evacuation,  and  to  solicit  its  retraction ;  whereby  the  vessels  situated  in  the  thick- 
ness of  its  walls  would  undergo  certain  modifications  favorable  to  an  arrest  of  the 


PUERPERAL     IlEMORP  il  AG  E.  707 

hemorrhage.  Further,  when  the  womb  is  well  contracted  on  the  body  of  the 
chikl,  and  some  portions  of  the  hitter  are  forcibly  applied  against  the  patulous 
vessels  that  furnish  the  blood,  the  compression  thereby  produced  must  evidently 
arrest  the  flooding. 

This  method,  which  has  been  adopted  by  Dr.  High}',  of  England,  has  been 
severely  criticised  by  his  countryman,  Duncan  Steward,  who  endeavors  to  sup- 
port his  own  opinion  by  the  following  observations  :  by  rupturing  the  membranes 
before  the  uterus  is  dilated,  we  retard  rather  than  accelerate  the  expulsion  of  the 
child ;  and,  besides,  it  is  by  no  means  certain,  as  experience  has  demonstrated, 
that  this  measure  will  arrest  the  hemorrhage ;  while  it  often  diminishes  the 
chance  of  saving  the  life  of  the  mother  and  child,  by  rendering  the  version 
much  more  difficult,  if  this  operation  should  subsequently  become  necessary'. 

Notwithstanding  these  objections,  which,  after  all,  have  no  great  force,  the 
rupture  of  the  membranes  is  advocated  by  most  of  the  teachers  of  the  present 
day,  in  cases  of  profuse  flooding,  occurring  at  an  advanced  stage  of  gestation. 
Nearly  all  te^ch,  however,  that  a  regular  commencement  of  labor,  manifested  by 
evident  uterine  contractions,  should  precede  its  performance ;  but,  as  M.  P. 
Dubois  remarks,  it  is  important  to  bear  in  mind  that,  when  a  considerable  hemor- 
rhage takes  place,  the  contractions  of  the  womb  are  often  feeble,  and  that  the 
labor  may  actually  be  progressing  though  the  pains  have  not  clearly  marked  its 
onset ;  while,  on  the  other  hand,  the  discharge  of  a  large  quantity  of  blood  and 
the  escape  of  voluminous  coagula,  both  relax  and  dilate  the  uterine  orifice ;  and 
these  circumstances,  which  are  doubtless  joined  to  some  non-painful  contractions, 
may  dilate  the  os  uteri,  without  the  knowledge  of  the  patient  or  the  suspicion  of 
the  accoucheur.  This  phenomenon  is  not  at  all  unusual,  especially  in  women 
who  have  previously  borne  children;  and,  therefore,  whatever  be  the  condition 
of  the  body  of  the  uterus,  and  whether  there  be  any  apparent  contractions  or 
not,  he  should  carefully  ascertain  the  state  of  the  os  uteri.  In  cases  of  profuse 
flooding,  this  will  most  frequently  be  found  sufficiently  dilated  to  permit  the  in- 
troduction of  a  finger,  at  least;  and  the  membranes  will  then  be  felt  tense  and 
protruding  at  intervals  ;  which  protrusion  is  a  certain  proof  that  the  womb  begins 
to  contract,  and  the  rupture  of  the  membranes  will  then  be  eff"ected  to  the  greatest 
advantage.  Besides,  this  operation  does  not  exclude  the  employment  of  the 
various  stimulants  calculated  to  excite  the  contractions ;  thus  abdominal  frictions 
might  be  resorted  to,  and  the  finger,  when  introduced  into  the  neck,  should  first 
titillate  and  irritate  this  part  before  making  the  rupture ;  and  it  would  even  be 
prudent  to  administer  two  or  three  doses  of  ergot  to  the  patient,  provided  the 
neck  is  softened,  and  it  seems  to  oifer  no  marked  resistance  to  the  dilatation. 

Most  accoucheurs  advise  the  application  of  the  tampon,  when  the  discharge  is 
produced  by  an  insertion  of  the  placenta  over  the  cervix ;  but  M.  P.  Dubois 
teaches  that  the  course  to  be  pursued  in  such  cases  will  vary  according  to  the 
degree  of  this  insertion.  For  instance,  where  it  takes  place  centre  for  centre,  or 
in  other  words,  when  the  placenta  covers  all  the  superior  part  of  the  internal 
orifice,  and  the  membranes  are  inaccessible,  or  can  only  be  reached  by  detaching 
some  portion  of  the  circumference  of  the  still  adherent  placenta,  we  should  have 
recourse  to  the  tampon ;  but  where  the  placenta  corresponds  to  the  orifice  by  only 


708  DYSTOCIA. 

one  of  its  borders,  and  particularly  where  it  is  inserted  at  some  point  adjacent  to 
this  orifice,  he  likewise  recommends  an  artificial  rupture  of  the  membranes ;  being 
satisfied  that,  after  the  waters  have  escaped,  the  child's  head,  by  becoming  ap- 
plied on  the  detached  portion  of  the  placenta,  will,  by  compressing  it,  put  an  end 
to  the  flow  of  blood. 

Quite  recently,  M.  Gendrin  has  entertained  the  idea  of  adopting  Puzos' 
method,  even  in  those  cases  in  which  the  after-birth  corresponds  to  the  os  uteri 
centre  for  centre.  Under  almost  identical  circumstances,  Rigby  had  deemed  it 
advisable  to  push  his  finger  through  the  centre  of  the  placenta,  and  thus  pass 
directly  into  the  amniotic  cavity.  The  following  are  the  observations  of  M. 
Gendrin  on  this  subject :  Authors,  he  says,  have  advised  that  labor  should 
be  induced  by  direct  manipulations,  which  consist  in  forcing  the  dilatation  of 
the  OS  uteri  and  passing  into  the  womb  through  the  placenta,  or  by  detaching 
this  organ  from  one  portion  of  the  neck  ;  out  these  manoeuvres  occupy  much 
time,  and  besides  are  very  difficult,  and,  if  the  blood  continues  to  flow,  the 
enfeebled  patient  may  become  prostrated.  We  propose  instead  t^ie  following 
process,  which  has  the  great  advantage  of  keeping  up  the  relation  between  the 
after-birth  and  the  uterus,  as  long  as  possible.  It  consists  in  evacuating  the 
waters,  by  making  a  puncture  with  a  female  catheter,  which  is  directed  along 
the  finger  previously  introduced  into  the  os  uteri,  and  is  passed  into  the  mem- 
branes through  that  portion  of  the  placenta  lying  over  the  neck.  In  the  two 
cases  in  which  he  adopted  this  plan,  the  hemorrhage  disappeared  immediately ; 
and  this  measure  may,  therefore,  be  employed,  when  the  amount  of  the  discharge 
indicates  a  resort  to  the  method  of  Puzos,  and  when  the  presence  of  the  placenta 
is  the  only  obstacle. 

We  think,  however,  that  if  the  woman  is  pregnant  for  the  first  time,  and  the 
dilatation  but  slight,  the  tampon  had  better  be  applied,  and  the  puncture  of  the 
ovum  be  deferred  somewhat  later. 

Internal  Hemorrhayc. — We  can  only  expect  to  overcome  those  internal  dis- 
charges that  are  serious  enough  to  compromise  the  mother's  life,  by  emptying 
the  womb  and  terminating  the  labor.  Two  different  conditions  may  then  be  met 
with,  viz.,  one,  in  which  the  labor  has  not  yet  commenced,  the  neck  is  still  un- 
dilated,  and  its  margins  hard  and  thick ;  in  the  other,  on  the  contrary,  there  are 
some  labor  pains,  the  cervix  is  softened,  and  is  more  or  less  dilated.  In  the 
latter  case,  the  indications  for  treatment  are  obvious;  that  is,  to  rupture  the 
membranes  and  employ  all  the  various  measures  which  are  calculated  to  hasten 
the  contractions  (such  as  abdominal  frictions,  titillations  of  the  orifice,  and 
ergot),  and  to  watch  the  state  of  the  womb  after  this  rupture  attentively.  Such 
is  the  course  to  be  pursued  when  the  dilatation  is  inconsiderable;  but,  on  the 
other  hand,  when  the  os  uteri  is  either  dilated  or  dilatable,  the  delivery  should 
be  effected  at  once  by  turning,  or  by  an  application  of  the  forceps,  according  to 
circumstances  (see  Version,  and  art.  Forceps).  But  where  the  symptoms  occur 
a  short  time  before  the  full  term  of  gestation,  particularly  in  a  woman  with  her 
first  child,  the  complete  obliteration  of  the  cervix  may  constitute  an  insurmount- 
able obstacle  to  the  introduction  of  the  smallest  instrument.  In  these  grave 
cases,  after  having  employed  the  usual  means  to  moderate  the  efl"usion  of  blood 


PUERPERAL     IIEMOKRHAGE.  709 

without  benefit,  such  as  irritations  made  on  the  neck  and  over  the  fundus  of  the 
womb,  with  a  view  of  bringing  on  its  contractions,  it  will  be  absolutely  neces- 
sary to  perforate  the  membranes,  and  if  the  hemorrhage  continues,  and  the 
woman  becomes  weaker  and  weaker,  and  is  threatened  with  death,  to  have  re- 
course to  a  forced  introduction  of  the  hand.  Generally  speaking,  the  slightest 
efforts  will  be  sufficient  to  overcome  the  resistance ;  since  it  is  scarcely  possible 
for  a  considerable  effusion  of  blood  to  take  place  in  the  cavity  of  the  uterus, 
without  causing  a  development  of  some  pains,  or  at  least,  a  marked  diminution 
in  the  resistance  of  the  cervix.  But  if  it  should  unfortunately  happen  that  this 
resistance  cannot  be  surmounted,  I  think  that  multiple  incisions  ought  to  be  made 
on  the  neck  itself.  If  the  symptoms  were  not  very  urgent,  it  would  be  better 
perhaps  to  have  recourse  to  compression  of  the  abdomen,  which  would  prevent  the 
womb  from  becoming  inordinately  distended.  This  procedure  has  so  often  appeared 
successful,  that  its  employment  under  like  circumstances  would  be  justifiable. 

C.  Moderate  Hemorrhage  during  Labor. — When  the  flooding  occurs  during 
labor,  the  indications  it  presents  likewise  vary  according  to  the  intensity  of  the 
symptoms  and  the  degree  of  dilatation  of  the  os  uteri.  When  the  blood  escapes 
in  small  quantities,  and  the  accoucheur  is  satisfied  that  it  does  not  accumulate 
within  the  organ,  he  will  employ  here  the  same  means  as  were  recommended  for 
the  slight  hemorrhages  occurring  in  the  latter  stages  of  gestation  ;  except  the 
bloodletting,  which  should  only  be  practised  when  evident  phenomena  of  plethora 
exist,  and  also  excepting  the  opium,  which  would  here  be  attended  with  the 
serious  inconvenience  of  suspending  the  uterine  contractions.  These  general 
measures  will  usually  prove  sufficient  when  the  neck  is  but  little  dilated,  and 
the  discharge  is  inconsiderable. 

But,  should  the  cervix  be  freely  opened,  or  be  so  softened  as  to  off"er  no  re- 
sistance, we  should  rupture  the  membranes,  if  they  are  yet  intact ;  and  if  the 
flooding  still  continued  after  this  rupture,  the  labor  lingered,  and  the  pains, 
though  at  first  energetic,  became  gradually  feeble,  and  the  intervals  between 
them  longer,  they  should  be  aroused  by  the  administration  of  ergot. 

D.  Profuse  Hemorrhage  during  Labor. — Whether  the  hemorrhage  be  internal 
or  external  at  the  time  of  labor,  it  always  ofi'ers  the  same  indications  for  treat- 
ment ;  and  these  latter  are  also  based  on  the  variable  degree  of  dilatation  of  the 
neck  of  the  uterus.  For,  if  this  is  but  little  advanced,  that  is,  if  the  cervix  be 
neither  dilated  nor  dilatable,  the  remedies  we  have  advised  for  the  profuse  hemor- 
rhages occurring  in  the  latter  months  of  pregnancy  should  again  be  brought  into 
service ;  that  is,  the  refrigerants,  the  ergot,  and  a  rupture  of  the  membranes,  if 
still  intact.  Should  the  flooding  continue  after  the  rupture,  and  the  retraction 
of  the  OS  uteri  render  an  introduction  of  the  hand  absolutely  impossible,  the 
tampon  should  be  applied  at  once ;  and  the  precaution  be  taken  to  make  com- 
pression over  the  anterior  surface  of  the  abdomen,  particularly  if  there  is  any 
inertia  of  the  womb,  so  as  to  prevent  an  accumulation  of  blood  within  the  organ. 
And,  where  the  flooding  persists,  notwithstanding  these  measures,  there  would 
be  no  other  resource  than  a  forced  delivery. 

Professor  Simpson  has,  in  consequence  of  these  facts,  proposed  to  separate 
completely,  and  bring  away  the  placenta,  whenever  its  insertion  upon  the  neck 


710  DYSTOCIA. 

lias  given  rise  to  a  hemorrliage  which  threatens  the  life  of  the  mother.  Although 
rather  too  absolute  at  the  outset,  Mr.  Simpson  has  finally  yielded  to  the  nume- 
rous and  valid  objections  made  to  his  precept,  so  far  as  to  confine  its  application 
to  the  following  conditions :  1.  "When  the  flooding  has  resisted  the  principal 
measures,  and  especially  the  evacuation  of  the  waters  ;  2.  When  the  slight  dilata- 
tion or  development  of  the  cervix,  or  contraction  of  the  pelvis,  render  turning  or 
any  mode  of  artificial  delivery  dangerous  or  impossible  ;  3.  When  the  death  or 
immaturity  of  the  foetus  restricts  the  duty  of  the  accoucheur  to  caring  for  the 
safety  of  the  mother.  It  is,  therefore,  especially  with  primiparous  females,  in 
cases  of  premature  labor,  or  rigidity  of  the  cervix  and  of  its  spasmodic  contrac- 
tion, of  organic  narrowing  of  the  pelvis  or  of  the  genital  passages,  of  the  death 
or  non-viability  of  the  foetus,  and,  finally,  of  extreme  exhaustion  of  the  mother, 
that  the  artificial  separation  may  be  practised.  It  is  to  be  understood,  he  adds, 
that  in  cases  of  separation  or  of  extraction  of  the  placenta,  the  foetus  should  be 
withdrawn  immediately,  unless  the  hemorrhage  should  cease,  which  it  does  in 
the  great  majority  of  cases. 

Even  with  this  reservation,  we  cannot  approve  of  the  advice  of  Mr.  Simpson ; 
for  WG  think  that  when  the  flooding  continues  after  the  evacuation  of  the  waters, 
and  when  the  neck  does  not  allow  the  hand  to  be  introduced,  there  is  some 
chance  left  of  saving  both  mother  and  child  by  applying  the  tampon. 

We  also  think,  that  when  an  obstacle  dependent  on  the  neck,  the  soft  parts,  or 
the  pelvis,  prevents  the  termination  of  the  labor,  the  tampon  may  be  applied 
with  advantage  until  the  dilatation  of  the  neck  allows  of  the  intervention  of  art; 
for  I  cannot  see  in  what  way,  under  these  circumstances,  the  extraction  of  the 
placenta  could  fiicilitate  that  of  the  foetus,  which  Mr.  Simpson  recommends  to  be 
practised  immediately  afterward.  The  obstacles  which  preve:pted  earlier  action 
exist  none  the  less  afterward.  It  is,  therefore,  only  when  caring  very  little  for 
the  life  of  the  child,  in  case  of  the  death  or  non-viability  of  the  latter,  that  one 
could  undertake  to  separate  and  extract  the  placenta,  if  the  hemorrhage  were 
dangerous,  in  order  to  spare  the  mother  the  pain  of  applying  the  tampon. 

Finally,  it  is  hardly  necessary  to  add,  that  if  the  neck  is  sufiiciently  dilated, 
the  delivery  should  be  effected  as  soon  as  possible,  either  by  turning  or  by  the 
forceps.  When  describing  these  two  operations,  we  shall  point  out  carefully  the 
cases  in  which  one  or  the  other  should  be  preferred. 

A  host  of  other  remedies  have  been  successively  extolled,  but  I  have  not 
spoken  of  them,  because  I  have  never  had  an  opportunity  of  employing  nor  of 
seeing  them  employed;  besides,  their  mode  of  action  appears,  on  theoretical 
grounds,  to  be  of  little  value;  and  hence,  in  my  opinion,  their  enumeration  would 
uselessly  burden  the  memory  of  students. 

I  do  not  know  better  how  to  conclude  my  remarks  concerning  the  hemorrhages 
that  may  afi'ect  females,  in  the  course  of  the  latter  months  of  pregnancy,  and 
during  labor,  than  by  placing  before  the  reader  a  short  summary  of  their  treat- 
ment, which  M.  P.  Dubois  caused  to  be  distributed  among  the  students  that 
attended  his  clinique ;  for,  as  the  Professor  states,  this  table  may  be  considered 
as  a  kind  of  vade  mecum.  Besides,  the  reader  will  see  by  it  how  far  I  have 
conformed  to  his  ideas,  in  the  treatment  of  hemorrhages  just  given. 


PUERPERAL     HEMORRHAGE. 


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712  DYSTOCIA. 


CHAPTER   II. 

OF   PUERPERAL   CONVULSIONS. 

Among  the  various  convulsive  diseases  that  may  appear  during  pregnancy, 
parturition,  or  the  lying-in,  there  is  one  which  has  such  well-marked  charac- 
teristics, and  whose  physiognomy  is  so  peculiar,  that  I  can  scarcely  comprehend 
the  want  of  accuracy  that  still  exists  in  most  of  our  classic  works  on  this  sub- 
ject. This  confusion  evidently  arises  from  the  fact  that  the  authors  who  have 
written  on  puerperal  convulsions  have  included  under  this  title  all  the  affections 
whose  striking  character  is  a  convulsion ;  forgetting  that  the  epithet  puerperal 
should  be  applied,  not  to  every  disease  which  is  developed  before,  during,  or  after 
labor,  for  then  we  might  admit  a  puerperal  pneumonia  or  pleurisy,  but  simply  to 
one  that  is  intimately  associated  with  that  state,  and  which  is  only  produced 
during  its  continuance.  This  confusion  is  further  caused,  in  my  opinion,  by 
designating  as  convulsions  some  affections  that  do  not  merit  the  name. 

These  two  propositions  will  be  easily  sustained  by  an  expose  of  the  distinctions 
admitted  by  some  authors.  According  to  them,  the  convulsions  that  occur  during 
gestation  may  be  either  partial  or  general.  Under  the  name  of  partial  convul- 
sions, they  have  described  those  affections  whose  principal  character  is  a  rapid, 
abnormal,  and  involuntary  contraction  of  one  or  more  muscular  organs,  and  which, 
consequently,  are  convulsive ;  but  which  are  otherwise  so  different  from  what  has 
usually  been  comprised  under  the  denomination  of  the  convulsions  of  pregnant 
women,  that  it  is  with  some  hesitation,  and  only  to  avoid  the  reproach  of  having 
omitted  any  important  facts,  that  I  allude  to  them  here.  Thus,  to  give  an  ex- 
ample, those  violent  contractions  of  the  stomach,  observed  in  certain  women  who 
are  affected  with  severe  and  obstinate  vomitings  during  gestation,  as  also  the  pal- 
pitations of  the  heart  experienced  by  some  others,  have  been  classed  among  the 
puerperal  convulsions. 

M.  P.  Dubois  relates  having  seen  the  walls  of  the  belly  contract  with  such 
force,  in  a  woman  in  the  fifth  or  sixth  month  of  her  pregnancy,  that  the  uterus 
was  completely  pressed  back  into  the  excavation ;  and  the  organ  was  afterward 
observed  to  return  briskly  to  its  place,  and  to  rebound  like  an  elastic  ball  when 
thrown  on  the  ground.  Some  other  tumefactions  appeared  in  the  flanks,  in  the 
epigastrium,  and  umbilical  region,  which  seemed  to  depend  as  much  on  the  spas- 
modic contraction  of  the  viscera  as  on  that  of  the  walls  of  the  abdomen.  Never- 
theless, this  woman  recovered  without  aborting. 

M.  Velpeau  states,  in  his  excellent  thesis,  from  which  I  extract  the  foregoing 
case,  that  a  countrywoman,  aged  twenty-two  years,  was  much  alarmed  on  the 
tenth  day  after  her  delivery  by  movements  that  took  place  in  her  belly ;  some- 
thing like  a  globe  was  observed  through  the  integuments  and  muscles,  which 
would  travel  sometimes  towards  the  excavation,  at  others  towards  the  flanks,  and 
again  in  the  direction  of  the  umbilicus.     This  species  of  ball  would  transform 


PUERPERAL    CONVULSIONS.  713 

itself  at  times  into  several  lumps,  which  traversed  the  abdomen  with  a  rumbling 
noise ;  but  the  walls  of  this  cavity  always  seemed  to  preserve  their  normal  sup- 
pleness. This  woman  died  insane  two  years  afterwards,  icitliout  these  sinijular 
movements  ever  liavimj  altocjether  disappeared.  Can  such  a  case  be  referred, 
with  truth,  to  puerperal  convulsions  ? 

According  to  certain  accoucheurs,  the  vaginal  parietes  are  occasionally  so  vio- 
lently contracted,  as  to  prevent  the  escape  of  the  child,  and  even  to  benumb  the 
hand  of  the  attendant  by  their  spasmodic  action.  Bat  of  all  the  partial  convul- 
sions, those  of  the  uterus  are  the  least  questionable.  We  have  already  treated  of 
the  spasmodic  contraction  of  the  external  and  internal  orifices  of  the  neck,  which 
are  capable  of  retarding  the  labor  greatly  in  ordinary  cases,  and,  in  breech  pre- 
sentations, may  cause  extension  of  the  head,  and  thus  render  its  extraction  diffi- 
cult; and  we  shall  see,  hereafter  (art.  Delivery  of  the  Placenta),  what  influence 
this  retraction  of  the  orifices,  which  is  evidently  due  to  a  convulsive  contraction 
at  the  superior  or  inferior  part  of  the  cervix,  as  well  as  the  partial  one  of  some 
of  the  fibres  in  the  body  of  the  womb,  may  have  over  the  delivery  of  the  after- 
birth. 

We  shall  only  mention  here,  that  other  cases,  similar  to  those  detailed  by  M. 
Dubois,  have  been  reported,  in  which  the  uterus  has  been  observed  to  pass 
rapidly  upwards,  downwards,  and  towards  the  sides  of  the  abdomen  ;  and  even 
to  descend  with  such  violence  towards  the  vulva,  that  it  was  necessary  to  sustain 
the  latter  with  the  fingers  to  prevent  it  from  escaping;  but,  for  further  particu- 
lars, we  refer  the  reader  to  the  essays  of  Baudelocque  and  Miquel. 

The  instances  just  referred  to,  doubtless  resemble  some  of  the  features  of  the 
disease  we  are  about  to  describe  under  the  name  of  eclampsia,  in  being  charac- 
terized by  a  rapid,  abnormal,  and  involuntary  contraction ;  but  they  differ  from 
it  so  much,  in  the  triple  aspect  of  symptoms,  prognosis,  and  treatment,  that  we 
cannot,  in  my  opinion,  class  them  under  the  same  denomination,  without  con- 
founding things  that  are  essentially  dissimilar. 

The  question  now  recurs,  what  is  the  state  of  the  case  as  regards  the  general 
convulsions  of  pregnant  women  ?  Hysteria,  tetanus,  catalepsia,  and  even  apo- 
plexy, have  been  observed  during  pregnancy  and  parturition,  and  have,  on  that 
account  alone,  been  forthwith  denominated  as  puerperal  diseases;  and  although 
these  aff"ections  offered  the  same  symptoms  as  when  they  occur  in  the  non-gravid 
state,  though  they  were  essentially  different  from  eclampsia,  properly  so  called, 
yet  they  were  considered  as  mere  varieties,  or  particular  forms,  of  this  latter 
complaint.  True,  there  can  be  no  doubt  that  hysteria,  tetanus,  &c.,  are  modified 
by  the  peculiar  condition  of  the  pregnant  female ;  and,  as  in  all  other  diseases 
that  occur  during  the  puerperal  period,  the  danger  to  which  they  expose  the 
patient  is  increased  by  that  to  which  they  subject  the  foetus;  but  the  hysteria 
does  not  thereby  become  less  an  hysteria,  and  the  tetanic  convulsion  has  not  the 
less  its  characteristic  persistence.  These  are  evidently,  therefore,  distinct  afiec- 
tions. 

I  ought,  however,  to  add,  that  the  form  of  the  convulsion  may  var}',  and  that 
an  attack  which  at  the  outset  presented  all  the  characters  of  eclampsia,  might 


714 


DYSTOCIA. 


finally  assume  the  tetanic  or  even  the  cataleptic  form.  Supposing  that  no  error 
of  diagnosis  has  been  committed,  the  latter  are  exceptional  cases,  in  regard  to 
which  it  is  difficult  to  say  whether  the  same  disease  has  assumed  two  different 
physiognomies  successively,  or  whether  one  disease,  catalepsy,  has  succeeded  to 
another,  eclampsia.  Dr.  Schmidt,  of  Paderborn,  and  31.  Danyau,  have  each 
published  a  case  of  this  kind  of  transformation.    (Juuni.  de  Chirxinjic,  18-44.) 

Apoplexy  may  occur  in  the  puerperal  state,  either  as  the  principal  disease  or 
as  a  termination  or  complication  of  eclampsia.  Often,  indeed,  as  stated  below, 
the  puerperal  convulsions  determine  a  cerebral  effusion ;  but  then  it  is  an  effect, 
and  not  a  cause,  of  the  accident.  There  are  likewise  some  cases  in  which  the 
general  circulation,  as  an  effect  of  the  remarkable  modifications  it  undergoes 
during  pregnancy,  is  strongly  determined  towards  the  brain,  and  may  even  result 
in  an  effusion ;  and  if  so,  the  latter  is  sometimes  preceded  by  slight  convulsions, 
or  a  tetanic  stiffness  in  one  or  more  limbs ;  but  these  soon  pass  away  and  do  not 
reappear.     Here,  then,  the  apoplexy  is  the  disease ;  but  it  is  nothing  more. 

In  my  opinion,  therefore,  it  must  be  admitted  that,  during  the  gestation,  the 
parturition,  or  the  lying-in,  women  may  have  attacks  of  hysteria,  of  tetanus,  or 
catalepsy,  or  may  be  struck  with  apoplexy ;  but  these  are  so  many  distinct  affec- 
tions, having  but  one  common  symptom  with  eclampsia, — the  convulsion.  "We 
hope  that  the  details,  into  which  we  are  about  to  enter,  will  illustrate  the  nume- 
rous differences  between  them. 

For  myself,  I  understand  by  the  term  eclampsia  an  affection  characterized  by 
a  series  of  fits,  in  which  nearly  all  the  muscles  of  relation,  and  often,  also,  those 
of  the  organic  life,  are  contracted  convulsively,  and  which  fits  are  usually  accompa- 
nied with  or  followed  by  a  more  or  less  complete  suspension  of  the  sensorial  and 
intellectual  faculties  for  a  variable  period. 

General  convulsions  (eclampsia,  properly  so  called),  constitute  a  quite  rare 
disease.  M.  Yelpeau  did  not  observe  a  single  case  in  a  thousand  labors  super- 
intended by  him  at  the  Clinique.  It  is  "probable,  however,  that  this  proportion 
is  too  small ;  for,  by  consulting  the  statements  furnished  by  Madame  Lachapelle, 
Merriman,  Ryan,  Pacoud  de  Bourg,  &c.,  it  appears  that  there  was  one  case  of 
convulsion  in  about  two  hundred  deliveries.  On  the  other  hand,  the  practice  of 
the  principal  accoucheurs  of  Great  Britain  would  furnish  one  case  of  eclampsia 
in  four  hundred  and  eighty-five  labors,  nearly.^ 

'  Bland,                 in            .....       1,897  women,  met  with 
Joseph  Clarke,  " 10,387        «  « 


Merriman, 
Granville, 
Cusack, 
Maunsell, 
Collins, 
Beatty, 
Ashwell, 
Mantell, 
Churchill, 


2,947 
640 
398 
848 
10,414 
399 

i.'^ee 

2.510 
600 


2  cases. 
19     " 

5  " 

1  case. 

6  cases. 
4     " 

30     " 

1  case. 

3  cases. 
6     " 

2  " 


38,300  79  cases. 

Thus  we  have  79  cases  of  convulsions  in  38,300  labors,  or  1  in  485,  nearly. 


PUERPERAL     CONVULSIONS.  7l5 

It  is,  liuwever,  almost  impossible  to  ascertain  an  exact  proportion  by  consult- 
ing the  praelioe  of  any  sinule  man,  since  great  variations  arc  observed  in  different 
years;  in  uiy  own  experience,  for  example,  I  met  with  but  three  cases  in  two 
thousand  deliveries  occurring  under  my  care  at  Hotel  Dieu  and  the  hospital  of 
La  Faculte,  whilst  house  physician  at  those  institutions,  whilst  on  the  other  hand, 
I  met  with  seven  cases,  within  the  months  of  July,  August,  September,  and 
October,  184G,  whilst  in  service  at  La  Clinique. 

Eclampsia  appears  indifferently  at  all  seasons  of  the  year ;  although  some 
authors  have  seemed  to  consider,  improperly,  I  think,  that  certain  atmospherical 
conditions  are  not  altogether  foreign  to  its  production,  and  that  it  occurs  more 
frequently  in  some  seasons  than  in  others.  Madame  Laehapelle,  who  appears 
quite  disposed  to  adopt  this  opinion,  notwithstanding  the  summary  she  furnishes 
sustains  her  views  but  very  imperfectly,  relies  upon  the  fact  that  at  the  hospital 
of  La  Maternite,  several  individuals  are  nearly  always  affected  at  the  same  time. 
But  I  am  strongly  disposed  to  believe  this  circumstance  is  rather  owing  to  imita- 
tion than  to  the  influences  of  the  atmosphere. 

This  affection  is  very  unusual  in  the  early  months  of  gestation  :  M.  Danyau, 
Sr.,  however,  met  with  it  in  a  young  girl,  who  had  only  reached  the  sixth  week, 
and  in  whom  nothing  but  the  extraction  of  the  ovum  could  remove  the  symptoms. 
The  eclampsia  came  on  again  in  her  next  pregnancy,  about  the  same  period,  and 
was  followed  by  an  abortion  ;  but,  in  this  instance,  the  fits  continued  for  some 
time  after  the  abortion. 

A  lady  of  Ferrara,  about  twenty-eight  years  of  age,  of  a  bilious  temperament, 
and  the  mother  of  three  children,  was  periodically  attacked  by  convulsions  as 
soon  as  she  had  conceived,  and  these  attacks  were  renewed  every  two  weeks 
throughout  gestation ;  so  that  there  appearance  constituted  in  her  a  sign  of  preg- 
nancy. As  a  general  rule,  they  are  quite  rare  prior  to  the  sixth  month;  they 
are  particularly  frequent  during  parturition;  and  they  appear  somewhat  oftener 
after  the  delivery  than  during  the  gravid  state. 

The  period  at  which  they  are  liable  to  occur  after  delivery  varies  greatly; 
though  the  eclampsia  most  commonly  appears  a  few  hours,  or  sometimes  even  a 
few  days,  after  delivery,  examples  are  not  wanting  of  its  being  postponed  for 
eight,  ten,  or  even  twelve  days. 

§  1.  Cal'Ses. 

The  causes  of  eclampsia  have  been  divided  into  predisposing  and  determining 
causes. 

Upon  a  careful  investigation  of  the  individual  conditions  under  which  eclampsia 
is  generally  found  to  occur,  we  are  forcibly  struck  with  a  singular  circumstance, 
which  entirely  escaped  the  notice  of  the  older  observers :  this  circumstance  is 
the  almost  constant  presence  of  albumen  in  the  urine  of  eclamptic  women. 
I  say  almost  constant,  for  with  the  exception  of  six  or  seven  cases  mentioned  by 
M.  Depaul  and  Mascarel,  in  reference  to  which  we  shall  have  more  to  say  here- 
after, I  am  aware  of  nothing  to  limit  the  assertion.  This  very  remarkable  co- 
incidence, which  is  at  present  well  determined  by  the   observations  of  many 


716  DYSTOCIA. 

physicians,  and  which  I  have  invariably  remarked  in  all  the  cases  which  have 
come  under  my  own  notice  within  the  last  eight  years,  evidently  seems  to  be  the 
dominant  foot  in  the  etiology  of  puerperal  convulsions.  Since  the  presence  of 
albumen  is  discovered  almost  constantly  in  cases  of  eclampsia,  the  severest  mind 
can  hardly  avoid  establishing  a  more  or  less  intimate  relation  of  causality  between 
the  two  facts. 

But,  it  has  been  observed,  the  presence  of  albumen  in  the  urine  does  not  con- 
stitute a  disease ;  it  is  but  the  symptomatic  expression  of  a  local  lesion,  or  of  a 
general  affection  of  the  economy.  The  latter,  are  doubtless  capable  of  producing 
eclampsia  as  they  had  already  caused  albuminuria ;  but  most  frequently,  their 
influence  is  limited  to  the  modification  of  the  urinary  secretion  without  producing 
any  nervous  disorder.  This  is  true,  and  M.  Blot  was  right  so  far  as  he  considered 
these  two  morbid  conditions  as  merely  concomitant,  and  not  that  one  was  a  con- 
sequence of  the  other.  M.  Blot's  remark  has  not,  however,  in  a  clinical  point 
of  view,  all  the  importance  that  has  been  attributed  to  it.  Though  the  cause  of 
eclampsia  be  attributed  to  an  organic  lesion  of  the  kidneys  or  to  an  alteration  of 
the  fluids  of  which  albuminuria  is  the  symptom,  it  is  nevertheless  true,  that  as 
both  these  general  or  local  lesions  are  to  be  detected  with  great  difiiculty  during 
gestation,  whilst  the  presence  of  albumen  may  always  be  discovered  with  ea^e,  it 
was  judicious  to  insist  upon  the  importance  of  the  albuminuria,  which  is  alone 
capable,  in  most  instances,  of  exciting  a  suspicion  of  the  organic  condition  to 
which  the  eclampsia  is  apparently  due. 

Since  albuminuria  is  present  in  the  immense  majority  of  eclamptic  women,  it, 
or  rather  the  disease  of  which  it  is  the  symptom,  may  be  rightfully  regarded  as 
the  predisposing  cause  of  eclamptic  convulsions.  I  say  the  only  known  predis- 
posing cause;  for,  since  attention  has  been  fixed  upon  this  point,  of  all  pregnant 
women,  those  only  who  are  affected  with  albuminuria  (a  few  cases  excepted)  have 
been  known  to  be  attacked  with  convulsions. 

Though  all  eclamptic  patients  have  albuminuria,  it  does  not  follow  that  albu- 
minuria, however  severe,  necessarily  gives  rise  to  convulsions.  Happily,  it  is  by 
no  means  uncommon  for  pregnant  women  to  have  the  urine  highly  charged  with 
albumen  without  presenting  a  single  convulsive  symptom.  Of  41  women  with 
albuminous  urine,  observed  by  M.  Blot,  but  7  had  convulsions;  and  of  20  men- 
tioned by  MM.  Devilliers  and  Regnault,  11  only  were  affected  with  them.  The 
latter  gentlemen,  it  is  true,  examined  the  urine  of  such  women  only  as  were 
dropsical,  and  it  is  very  certain  that  many  cases  of  albuminuria  are  not  attended 
with  infiltration.  Still,  by  taking  the  mean  between  these  different  results,  and 
having  regard  to  my  own  observations,  I  think  that  I  come  near  the  truth  in 
saying,  that  one  out  of  every  four  or  five  patients  with  albuminuria  will  be  affected 
with  convulsions. 

The  amount  of  albumen  in  the  urine  increases  greatly  during  the  convulsive 
attack,  and  generally  diminishes  after  it.  This  peculiarity  has  led  some  persons 
to  inquire  whether  the  eclampsia,  instead  of  being  due  to  the  alteration  of  the 
urine,  might  not  be  the  cause  of  it.  I  can  understand  why  there  might  be  hesi- 
tation in  regard  to  this  point,  if  a  single  case  could  be  cited  in  which  it  had  been 


PUERPERAL  CONVULSIONS.  717 

proved  that  the  urine  was  entirely  free  from  albumen  for  several  weeks  before 
the  appearance  of  the  accidents :  this,  I  believe,  has  never  been  done,  but  often, 
on  the  other  hand,  albuminuria  has  been  known  to  be  present  for  some  time  before 
the  convulsions  occurred.  Besides,  when  we  come  to  reflect  upon  the  obstruc- 
tion to  the  venous  circulation  produced  by  eclampsia,  we  can  very  readily  account 
for  the  active  congestion  with  which  the  internal  organs,  and  the  kidneys  in  par- 
ticular, may  be  affected  during  the  attack.  Now,  it  is  well  known  that  renal 
congestion  increases  the  secretion  of  albumen. 

The  organic  conditions  which  produce  albuminuria  are  certainly  the  most,  I 
would  even  say  the  only  ones,  favorable  to  the  production  of  eclampsia.  This 
proposition,  which  is  at  present  incontestable,  explains  the  influence  of  certain 
circumstances  which  most  authors  have  mentioned  as  predisposing  causes  :  thus, 
among  the  latter  has  been  classed  as  one  of  the  most  active,  oedema  of  the  lower 
extremities,  when  considerable,  but,  above  all,  general  infiltration,  invading  suc- 
cessively the  body,  upper  extremities,  and  face.  It  is  now  a  well-ascertained 
fact,  that  this  general  oedema  is  almost  always  connected  with  an  alteration  of 
the  urinary  secretion,  and  that  only  when  accompanied  with  albuminuria  does 
it  appear  to  give  rise  to  eclampsia. 

If  it  be  true,  as  M.  Rayer  thinks,  that  the  compression  exerted  by  the  deve- 
loped uterus  upon  the  renal  vein,  may  eventually  produce  hyperasmia,  and  then 
an  inflammation  of  the  kidneys,  we  are  able  to  understand  the  mode  of  action  of 
all  the  circumstances  capable  of  increasing  this  compression.  Thus,  we  can  ex- 
plain the  possible  effect  of,  1,  the  extreme  distension  of  the  uterus,  whether  due 
to  dropsy  of  the  amnios  or  to  the  presence  of  several  children ;  2,  of  a  first  preg- 
nancy, in  which  the  uterus  is  strongly  applied  to  the  posterior  walls  of  the  abdo- 
men, in  consequence  of  the  resistance  of  the  abdominal  parietes ;'  3,  why, 
according  to  the  observations  of  M.  P.  Dubois,  rachitis  is  often  connected  with 
eclampsia,  since,  in  women  affected  with  this  disease,  the  small  stature  and 
limited  space  within  the  abdominal  enclosure,  obstruct  the  development  of  the 
uterus,  which,  by  reacting  in  its  turn  upon  the  surrounding  parts,  forms  a 
greater  mechanical  obstacle  to  the  regular  fulfilment  of  all  the  functions,  and  to 
the  venous  circulation  in  particular. 

Whatever  the  cause  may  be,  long-continued  albuminuria  necessarily  occasions 
a  notable  diminution  of  the  amount  of  albumen  which  enters  into  the  normal 
composition  of  the  blood.  Hence,  it  is  extremely  probable  that  this  fluid,  when 
thus  altered,  gives  rise  to  a  peculiar  excitement  of  the  cerebro-spinal  centre, 
which  becomes  itself  the  direct  cause  of  the  convulsions,  or  at  least,  which  is 
more  frequently  the  case,  renders  it  more  susceptible  of  the  excitements  which 
reach  it  either  from  without,  or  from  previously  irritated  internal  organs.  These 
excitements,  which,  under  any  other  circumstances,  would  have  no  effect,  become 
here  so  many  determining  causes  of  an  attack  of  eclampsia. 

'  Seven-eighths  of  the  cases  of  eclampsia  have  occurred  in  primiparous  women  (Lacha- 
pelle)  ;  in  thirty-eight  of  those  reported  by  Merriman,  twenty-eight  were  of  this  class ;  and 
more  than  two-thirds  of  the  instances  given  by  Ramsbotham,  and  twenty-nine  in  thirty  of 
those  by  Collins,  refer  to  women  who  were  delivered  for  the  first  time. 


718  DYSTOCIA. 

An  alteration  in  the  quantity  or  quality  of  tlie  blood,  often  gives  ri.se  to  con- 
vulsions under  other  circumstances  than  the  puerperal  condition.  M.  Rayer,  and 
several  other  observers,  have  called  attention  to  symptoms  resembling  epilepsy, 
as  one  of  the  modes  of  termination  of  albuminuria  caused  by  albuminous  ne- 
phritis, and  it  is  well  known  that  convulsions  often  occur  in  the  last  moments  of 
the  unfortunate  victims  of  profuse  hemorrhage.  It  is,  therefore,  no  cause  for 
astonishment,  that  the  alteration  of  the  blood  produced  by  albuminuria,  may  have 
the  same  consequences  during  pregnancy.  The  reason  why  these  nervoixs  dis- 
orders are  more  frequent  in  pregnant  women  with  albuminous  urine  than  in  the 
other  diseases  attended  with  albuminuria  is,  that  to  the  only  producing  cause  of 
epilepsy,  in  ordinary  cases  of  albuminuria,  are  added  the  congestions  to  which 
the  nervous  centres  are  so  liable  during  pregnancy  and  labor. 

Although  the  convulsions  are  generally  spontaneous,  and  may  be  attributed 
simply  to  the  condition  just  mentioned,  there  are  some  whose  appearance  seems 
to  be  connected  with  a  more  readily  appreciable  cause,  and  which,  therefore,  may 
be  justly  regarded  as  a  determining  cause. 

In  the  list  of  occasional  causes,  certain  writers  have  included  the  most  com- 
mon and  indifferent  circumstances,  the  mere  recital  of  which  we  shall  spare  the 
reader;  but  will  simply  mention  strong  moral  emotions,  whose  influence,  though 
incontestable,  is,  in  some  cases,  hard  to  be  explained.  There  are  some,  however, 
which,  in  reference  to  treatment,  deserve  a  careful  mention,  for  it  is  especially 
by  removing  the  cause  that  the  attack  may  be  arrested,  or  at  least  rendered  less 
dangerous. 

The  influence  of  the  circumstances  to  which  we  allude  is  at  first  limited  to 
organs  at  a  greater  or  less  distance  from  the  nervous  centres,  and  it  is  only 
secondarily  that  the  irritation  transmitted  to  the  latter  excites  them,  and  gives 
rise  to  the  convulsion.  Thus  it  is,  that  an  irritation  of  the  nerves  of  the  uterus, 
vagina,  bladder,  rectum,  or  stomach,  may  become  the  determining  cause  of 
general  convulsions. 

A.  Uterus. — All  the  causes  of  essential  dystocia,  which  require  longer  con- 
tinued and  more  powerful  eff"orts  on  the  part  of  the  womb,  may  occasion  an 
excitement  of  the  sensitive  nerves  of  this  organ,  which,  when  transmitted  to  the 
spinal  marrow,  is  calculated  to  awaken  the  reflex  action  of  the  motor  nerves. 
Under  this  head,  we  would  indicate  a  malformation  or  obstruction  of  the  pelvis, 
a  partial  or  complete  obliteration  of  the  vagina  or  vulva,  organic  alterations,  and 
spasm  of  the  body  or  neck  of  the  womb,  foetal  deformities,  or  monstrosity,  &c. 
Unfavorable  positions  of  the  child  have  not,  certainly,  so  great  an  influence  as 
might  at  fir.st  be  supposed.  Churchill  says  that  ''  the  eff"ect  of  unfavorable  posi- 
tions has  been  greatly  exaggerated,  for  Drs.  Clark,  Sabatt,  and  myself,  have 
witnessed  but  a  single  case  of  convulsions  coinciding  with  a  bad  position  in 
48,397  labors."  Eclampsia  almost  always  occurs  in  head  presentations;  but,  as 
Tyler  Smith  remarks,  the  first  attack  does  not  come  on  at  the  moment  the  head 
presses  upon  the  neck  or  clears  its  orifice,  but  rather  when  it  distends  the  peri- 
neum, and  partially  dilates  the  vulva.     It  is  then,  especially,  that  a  prompt 


PUERPERAL    CONVULSIONS.  719 

/ 

termination  of  tlie  labor  puts  an  end  to  the  convulsive  attack  by  removing  the 

pressure  from  the  soft  parts. 

All  the  unfortunate  circumstances  that  may  complicate  the  labor  and  require 
the  introduction  of  the  hand,  whether  before  or  after  delivery,  should  be  men- 
tioned as  capable  of  producine-  the  same  excitation ;  such  are  encysted  placenta, 
its  abnormal  adhesions,  its  partial  or  complete  retention,  the  presence  of  large 
clots,  retroversion  of  the  iiterus,  &c. 

B.  Intestinal  Canal. — The  irritation  produced  by  distension  of  the  intestinal 
canal,  and  especially  by  the  accumulation  of  large  quantities  of  fecal  matters,  and 
the  presence  of  worms  or  foreign  bodies  in  the  large  intestine,  is  sometimes  also 
the  detei'mining  cause  of  eclampsia. 

Both  Merriman  and  Chaussier  have  insisted  upon  the  influence  of  a  saburral 
condition  of  the  primte  vise,  which  influence  is,  they  say,  sufficiently  shown  by 
the  state  of  the  tongue,  and  epigastric  pain  which  the  patient  nearly  always  com- 
plained of  at  the  onset  of  an  attack. 

The  presence  of  indigestible  food  in  the  stomach  appears,  in  some  cases,  to 
have  been  the  cause  of  convulsions.  John  Clarke  relates  the  history  of  several 
women  who  were  so  afi"ected  after  delivery,  in  consequence  of  having  eaten  largely 
of  oysters. 

C.  Bladder. — Lastly,  the  same  may  be  said  of  irritation  of  the  walls  of  the 
bladder  produced  by  its  extreme  distension  with  urine.  The  curious  observation 
of  Mauriceau  is  well  known,  and  Dr.  Vines  mentions  an  exactly  similar  case. 
In  the  latter,  the  convulsions  which  had  for  two  days  resisted  the  delivery  and 
all  the  generally-recommended  means,  ceased  immediately  upon  withdrawing 
from  the  bladder,  by  means  of  the  catheter,  five  pints  and  a  half  of  a  turbid  and 
highly  ammoniaeal  urine. 

Numerous  other  predisposing  causes  have  likewise  been  described,  the  influence 
of  which,  however,  it  must  be  acknowledged,  is  far  more  difficult  to  appreciate ; 
thus,  for  instance,  M.  Baudelocque  enumerates  in  his  thesis,  a  residence  in  large 
cities,  the  use  of  small  or  tight  garments,  an  over-succulent  diet,  the  abuse  of 
spirituous  liquors,  constipation,  retention  of  the  urine  (pointed  out  by  Delaraotte), 
sexual  intercourse,  the  suppression  of  an  habitual  discharge,  too  much  sleep,  want 
of  exercise,  the  frequentation  of  balls  or  plays,  anger,  jealousy,  bickerings,  dis- 
appointments, &:c.  There  can  be  no  doubt  that  all  these  causes,  by  modifying  or 
disordering  the  circulation,  may  render  it  more  active,  and  thus  facilitate  a  san- 
guineous determination  towards  the  brain;  but  they  should  evidently  be  consi- 
dered in  the  light  of  a  secondary  predisposition,  which  may  be  added  to  some 
one  of  those  mentioned  above. 

Epilepsy  has  also  been  considered,  though  improperly,  as  constituting  a  pre- 
disposition to  eclampsia;  for,  though  the  two  diseases  have  a  close  analogy,  yet 
those  pregnant  women  who  were  epileptic  before  their  gestation  commenced,  are 
less  subject  to  attacks  then  than  at  any  other  time.  Indeed,  some  authors  have 
supposed  that  pregnancy  suspends  the  epileptic  fits  altogether ;  but  this  is  not 
absolutely  the  case,  for  they  only  occur  then  more  seldom  than  usual. 

Dr.  Tj'ler  Smith  relates  a  curious  case  of  an  epileptic  woman  who  had  an 


720  DYSTOCIA. 

attack  immediately  after  what  she  regarded  as  the  fecundating  intercourse,  and 
who  experienced  an  entire  suspension  of  the  disease  during  the  remainder  of  her 
pregnancy. 

We  would  repeat,  in  terminating  this  etiological  study  of  eclampsia,  that  the 
various  determining  causes  exist  very  frequently  without  giving  rise  to  convul- 
sions. The  reason  of  this  is,  that  they  are  of  themselves  incapable  of  producing 
them,  and  have  no  real  influence  except  in  cases  presenting  in  a  greater  or  less 
degree  the  general  or  local  lesion  which  occasions  albuminuria. 

A  review  of  all  the  causes  will  enable  us  to  explain  their  mode  of  action.  It 
is  evident  that  all  of  them  have  a  tendency  to  produce  an  irritation  of  the  nerv- 
ous centres.  This  irritation  is  direct,  when  due  to  the  immediate  contact  of 
vitiated  blood,  and  indirect,  or  by  reflex  action,  when  it  follows  the  excitement  of 
a  distant  organ,  as  the  bladder,  uterus,  &c.  I  am  happy  to  find  in  the  work  of 
Scanzoni  a  confirmation  of  these  views,  long  since  proposed  by  me.  Setting  out 
with  these  ideas,  Scanzoni  divides  eclampsia  into,  1.  Reflex  convulsion,  proceed- 
ing from  the  peripheral  extremities  of  the  irritated  sensitive  nerves;  2.  Spinal 
convulsion,  produced  by  direct  irritation  of  the  spinal  marrow,  which  irritation  is 
transmitted  to  the  peripheral  extremities  of  the  nerves;  3.  Cerebral  convulsion, 
when  the  irritation  resides  in  the  brain,  and  is  transmitted  to  the  spinal  marrow. 
The  existence  of  this  latter  form  is  doubtful,  and,  for  our  own  part,  we  are  much 
disposed  to  believe  that  eclampsia  always  has  its  origin  in  spinal  irritation.  It  is 
a  fact,  proved  experimentally  by  physiologists,  that  irritation  of  the  spinal  mar- 
row, of  the  medulla  oblongata,  or  of  the  tuberculae  quadrigemin^e,  gives  rise  to 
convulsions  only,  whilst  irritation  of  any  other  part  of  the  brain  produces  nothing 
of  the  kind.  It  is  true  that  cerebral  lesions  may  destroy  voluntary  motion,  but 
involuntary  contractions,  the  excess  and  disorder  of  which  constitute  eclampsia, 
are  not  affected  by  them  in  the  least.  The  latter  may  be  produced  by  irritation 
of  the  spinal  marrow  or  of  its  nerves,  even  when  the  cerebrum  and  cerebellum 
have  been  completely  destroyed. 

§  2.  Symptoms. 

Like  Madame  Lachapelle,  we  shall  describe  three  orders  of  phenomena  in  the 
attack  of  eclampsia,  which,  under  the  triple  aspect  of  diagnosis,  prognosis,  and 
treatment,  are  of  great  importance,  namely,  the  precursory  symptoms,  those 
which  are  manifested  during  the  fits,  and  those  which  are  sometimes  developed 
in  their  intervals. 

A.  Precursory  Phenomena. — An  attack  of  eclampsia  scarcely  ever  appears 
unexpectedly,  as  it  is  almost  always  preceded  by  certain  phenomena,  which  enable 
us  to  foretell  its  speedy  invasion.  Chaussier  even  supposed  these  to  be  so  con- 
stantly present,  that,  in  the  few  exceptional  cases  where  the  observers  have  not 
mentioned  them,  it  was  because  they  were  of  short  duration,  and,  therefore, 
either  passed  away  unperceived,  or  else  were  misunderstood. 

These  precursory  phenomena  are  variable  in  duration ;  thus,  for  some  days, 
though  occasionally  only  for  a  few  hours,  before  the  invasion  of  the  puerperal 
epilepsy,  the  patients  complain  of  agitation  or  malai.se ;  they  are  easily  excited, 


PUERPERAL     CONVULSIONS.  7-1 

are  iiiipationt  and  irritable;  they  experience  a  marked  difficulty  in  respiratii/ii ; 
and  they  suffer  from  an  exceedingly  poignant  and  acute  pain  in  the  head,  which, 
like  the  megrim,  occupies  but  one-half  of  the  cranium,  and  sometimes  is  even 
still  more  concentrated,  and  appears  fixed  upon  one  coronal  boss,  or  some  other 
equally  circumscribed  point.  This  pain  in  the  head,  Avhich  is  one  of  the  most 
important  diagnostic  signs,  nearly  always  resists  all  the  curative  measures  usually 
employed ;  it  is  accompanied  with  nausea,  or  even  vomiting,  by  vertigo,  dimness 
of  vision,  tinnitus  aurium,  and  sometimes  by  an  acute  pain  in  the  epigastrium, 
(Chaussier,  Denman.) 

When  these  primary  symptoms  have  lasted  for  some  time,  they  acquire  a 
greater  degree  of  intensity,  and  are  often  complicated  with  a  more  or  less  marked 
disorder  in  the  sensorial  and  intellectual  faculties.  The  vision  becomes  affected, 
the  sight  seeming  to  be  obscured  by  a  thick  mist,  and  the  patient  distingviishes 
objects  less  clearly;  sometimes  even,  as  in  a  case  observed  by  Dr.  Meigs, ^  of 
Philadelphia,  she  sees  only  one-half  of  an  object  held  before  her.  The  hearing 
is  likewise  less  distinct ;  the  touch  not  so  fine  and  less  delicate;  the  woman's 
countenance  exhibits  an  unusual  hebetude ;  the  expression  is  fixed,  the  linea- 
ments immovable,  and  slie  appears  sunk  in  a  deep  abstraction,  from  which  she 
can  only  be  aroused  with  some  difficulty ;  she  scarcely  comprehends  the  ques- 
tions addressed  to  her,  and  very  frequently  replies  incoherently.  In  a  plethoric 
female,  the  pulse  is  full,  slow,  and  hard,  and  the  face  is  occasionally  flushed  and 
animated;  on  the  contrary,  where  the  patient  is  affected  with  anasarca,  particu- 
larly if  she  happens  to  be  of  an  irritable,  nervous  constitution,  the  pulse  is  small, 
hard,  and  contracted,  the  face  is  pale  and  the  skin  cold,  especially  on  the  extre- 
mities ;  and  sometimes  there  is  a  slight  chill,  or  an  imperfect  horripilation.  In 
addition  to  these,  some  women  experience  pricking  sensations  and  formications  in 
the  limbs. 

When  the  eclampsia  appears  during  labor,  it  is  often  preceded  by  extreme  in- 
docility  and  agitation;  the  uterine  contractions  also  present  for  a  time  that  pecu- 
liar character  of  continuity  and  irregularity  which  has  gained  for  them  the  name 
of  uterine  tetanus. 

The  patient  laughs  and  weeps  alternately,  and  speaks  with  volubility.  A  state 
of  hebetude  and  stupor  sometimes  succeeds  to  this  extreme  agitation. 

According  to  M.  Wieger,  the  comparative  frequency  of  the  prodromes  differs 
according  to  the  period  at  which  the  convulsions  occur.  Those  which  come  on 
before  labor,  are,  he  says,  preceded  by  symptoms  in  about  40  cases  out  of  a  hun- 
dred;  those  which  appear  during  labor  or  the  delivery  of  the  after-birth,  have 
initiatory  symptoms  in  30  out  of  a  hundred  cases ;  and  those  which  are  first 
manifested  during  the  lying-in,  have  prodromes  in  about  twenty  per  cent,  of  the 
cases. 

B.  Phenomena  of  the  Attack. — After  a  variable  duration  and  intensity  of  the 
symptoms  just  indicated,  the  first  fit  comes  on;  a  most  accurate  outline  of  which 
is  furnished  by  M.  Prestat,  in  his  inaugural  dissertation,  as  follows :  The  cx- 

»  Meigs'  Philadelphia  Practice  of  Midwifery,  1842,  page  200. 
46 


722  DYSTOCIA. 

pression  becomes  at  once  completely  fixed,  and  there  is  a  moment  of  general 
immobility.  Then,  if  the  patient  be  attentively  examined,  the  muscles  of  her 
iace  will  be  found  agitated  by  slight,  limited,  and  ver}'  rapid  movements,  which, 
however,  are  perceptible  through  the  skin;  these  movements  become  more  and 
more  marked,  the  features  are  wholly  altered,  the  muscles  of  the  face  contract  in 
a  thousand  waj^s,  and  she  grimaces  horribly ;  the  eyelids  are  agitated  by  an  in- 
cessant winking,  though  they  are  wide  enough  apart  to  bring  the  ball  of  the  eye 
into  view;  the  latter  rolls  in  the  orbit  in  every  direction,  and  then  becomes 
fixed  on  one  side,  where  it  remains  stationary;  the  pupil  is  dilated  and  immov- 
able ;  the  muscles  of  the  alee  of  the  nose,  being  forcibly  contracted,  draw  the  base 
of  the  nostrils  outwards,  and  thus  render  its  extremity  sharper;  the  lips  are  in 
continual  motion,  and  one  of  the  angles  of  the  mouth  is  drawn  towards  the  same 
side  as  the  eyelids,  that  is,  to  the  one  towards  which  the  head  is  inclined ;  the 
mouth,  being  at  first  partly  open,  permits  the  tongue  to  hang  out,  which  latter 
is  excited  by  irregular  movements,  and  is  thrust  forward  between  the  dental 
arches ;  and,  unless  the  precaution  be  taken  to  return  it,  or  to  prevent  the 
closing  of  the  teeth,  the  masseters  force  the  jaws  together,  and  the  tongue  is 
severely  bitten  or  bruised.  The  small  muscles  of  the  chin,  by  contracting,  like- 
wise render  its  extremity  more  pointed ;  so  that,  according  to  the  comparison  of 
M.  Dubois,  the  woman's  countenance  then  looks  like  a  satyr's. 

The  convulsions  never  appear  to  this  extent  in  the  muscles  of  the  face,  with- 
out soon  invading  those  of  the  extremities  and  trunk;  affecting  the  extensor 
muscles  particularly,  the  contractions  of  which  overcome  those  of  the  flexors. 
The  arms,  being  forcibly  extended  along  the  sides,  and  sometimes  held  a  little 
in  front  of  the  trunk,  though  often  turned  in  a  forced  pronation,  are  excited  by 
small  convulsive  jerks  ;  the  fists  are  usually  clenched,  and  the  thumb  is  either 
flexed  into  the  palm,  or  else  extended  between  the  index  and  the  medius;  the 
lower  extremities  exhibit  a  similar  extension,  and  the  same  spasmodic  jerks,  as 
the  arms  ;  the  body,  also,  is  in  a  state  of  almost  permanent  extension.  Whence 
it  follows  that  the  continual  tendency  to  throw  herself  about,  and  to  change  her 
position  every  instant  is  not  met  with  in  this  aff'ection,  as  it  is  in  many  other 
convulsive  diseases  ;  for  when  the  woman  is  placed  on  her  back,  she  retains  that 
position  throughout  the  whole  duration  of  the  fit ;  and  there  is  no  necessity  for 
taking  any  precautions  to  prevent  her  from  falling  out  of  bed,  or  from  striking 
herself  violently  on  the  face  or  other  part  of  the  body. 

The  muscles  of  the  hollow  organs  do  not  remain  altogether  indiff"erent  to  the 
disorder  in  the  external  muscular  apparatus ;  for  the  fecal  matters,  the  urine, 
and  the  contents  of  the  stomach,  are  often  expelled  by  the  convulsive  contraction 
of  the  reservoirs  in  which  they  had  accumulated. 

The  respiration  is  interrupted,  noisy,  and  efl'octed  by  continual  jerkings  with- 
out any  regular  order ;  sometimes,  indeed,  as  Madame  Lachapelle  has  observed, 
it  is  wholly  arrested  by  the  spasmodic  contraction  of  the  diaphragm  and  other 
muscles  of  the  thorax. 

According  to  Dr.  Tyler  Smith,  the  muscles  of  the  larynx  are  contracted  con- 
vulsively, so  as  to  obliterate  the  glottis  almost  completely;  hence  the  respiration 


PUERPERAL  CONVULSIONS.  723 

is  either  suspended  or  noisy,  and  the  inspiration  short  and  quick ;  consequently, 
hematosis  is  either  suspended  or  diminished.  This  momentary  asphyxia  ex- 
phiins  satisfactorily  the  bluish,  or  even  blackish  color  of  the  face  and  extremities, 
the  swelling  of  the  head  and  neck,  which  are  gorged  with'black  blood,  as  also 
the  frightful  turgescence  of  the  skin,  eyes,  and  tongue.  The  carotids  beat 
violently,  and  the  jugulars  stand  out  prominently.  The  secretion  of  the  salivary 
glands  is  increased  by  their  congestion.  The  jaws  are  closed  forcibly,  and  in 
consequence  of  the  approximation  of  the  teeth,  and  the  quantity  of  saliva  in  the 
mouth,  the  air  escapes  with  a  hissing  noise,  and  by  agitating  the  saliva,  forms  a 
thick  foam,  which  is  expelled  continually  from  the  mouth.  This  foam  is  not 
unfrequently  stained  with  blood  from  wounds  produced  in  the  tongue  by  the 
teeth. 

The  spasm  of  the  pharynx  renders  swallowing  impossible,  so  that  substances 
placed  upon  the  base  of  the  tongue,  remain  there  to  the  risk  of  producing  as- 
phyxia. In  a  case  of  this  kind.  Dr.  Simpson  (of  Stamford),  excited  deglutition 
by  placing  the  substance  to  be  swallowed  in  the  upper  part  of  the  pharynx,  and 
sprinkling  the  face  with  cold  water. 

According  to  Dr.  Smith,  the  muscular  fibres  of  the  heart  may  also  participate 
in  the  general  convulsion.  The  extreme  lividity  and  turgescence  of  the  entire 
surface  of  the  body  are  sometimes  greater  in  eclampsia  than  in  ordinary  asphyxia, 
the  entire  body  being  in  the  condition  in  which  the  head  is  found  in  persons 
who  have  been  hung.  Dr.  Smith  thinks  that  this  state  is  attributable  to  the 
venous  circulation;  may  it  not  be  asked,  he  says,  whether  there  is  not  a  spas- 
modic contraction  of  the  right  auricle,  giving  rise  to  a  congestion  of  the  entire 
venous  system  from  the  vena  cava  to  the  capillaries  ?  And  is  not  this  supposi- 
tion confirmed  by  the  autopsy,  exhibiting  as  it  does,  the  ventricles  and  auricles 
completely  emptied  of  blood  ? 

A  very  remarkable  circumstance,  and  one  which  seems  to  me  to  prove  the 
uroemic  nature  of  eclampsia,  is  the  suspension  for  a  longer  or  shorter  time  of  the 
urinary  secretion.  I  have  had  occasion  several  times,  to  introduce  the  catheter 
during  the  attack,  and  have  found  the  bladder  quite  strongly  contracted,  and 
entirely  empty.  In  the  majority  of  cases,  I  have  not  been  able  to  obtain  more 
than  half  a  spoonful  of  urine,  whilst  in  others,  it  was  impossible  to  extract  a 
drop.  It  is  well  known  that  ischuria  is  one  of  the  symptoms  of  poisoning  by 
urasmia. 

At  the  commencement  of  the  fit,  the  pulse  is  full  and  hard,  subsequently  be- 
coming smaller  and  almost  imperceptible ;  the  skin  is  hot  and  dry,  and  is  soon 
covered  by  a  profuse  perspiration.  This  transpiration  usually  coincides  with  a 
diminution  in  the  frequency  and  intensity  of  the  spasm,  and  announces  its 
speedy  termination.  While  it  lasts,  the  sensorial  and  intellectual  functions  are 
wholly  abolished;  the  patient  is  conscious  of  neither  sound  nor  light;  the  sensi- 
bility is  entirely  lost,  and  we  may  pinch,  incise,  or  burn  the  skin  with  impunity, 
and  without  her  knowledge,  and  even  without  her  recollecting  it  after  the  fit. 

The  eflFect  of  the  convulsions  upon  the  contractility  of  the  uterus  is  extremely 
variable.     During  the  attack,  the  uterus  sometimes  remains  passive,  astonished, 


724  DYSTOCIA. 

as  it  were,  at  the  universal  disorder;  whilst,  on  the  other  hand,  there  are  cases 
in  which,  whether  the  eclampsia  comes  on  dviving  labor  or  precedes  it,  the  con- 
tractions continue  with  their  normal  regularity.  Occasionally,  also,  it  seems  to 
participate  in  the  general  irritation,  and  expels  the  foetus  very  rapidly,  even 
when  the  slight  dilatation  of  the  neck  would  appear  to  indicate  that  delivery  was 
yet  distant.  This  rapid  expulsion,  of  which  the  patient  is  entirely  vinconscious, 
may  escape  the  attention  of  the  accoucheur,  and  in  some  instances  the  child  has 
died  asphyxiated  between  the  mother's  thighs,  for  want  of  the  proper  attentions. 

I  think,  however,  that  these  rapid  deliveries  are  far  less  frequent  than  some 
accoucheurs  imagine.  The  idea  of  an  earlier  delivery  than  usual,  may  have  had 
its  origin  in  a  neglect  to  ascertain  the  condition  of  the  cervix,  which  may  have 
become  dilated  without  the  consciousness  of  the  female.  Whenever  I  have 
been  able  to  follow  up  the  labor,  the  cervix  has  always  appeared  to  nie  to  dilate 
very  slowly,  and  has  often  seemed  to  be  contracted  spasmodically,  as  though  it 
participated  in  the  general  convulsions.  The  expulsive  stage,  is,  I  think, 
shorter  than  usual,  a  fact  readily  accounted  for  by  the  energy  of  the  uterine  con- 
tractions and  the  slight  resistance  of  the  perineum,  the  muscles  of  which  are  in 
a  state  of  resolution  during  the  coma. 

Although  the  fits  do  not  accompany  each  pain,  they  nearly  always  come  on 
just  at  the  commencement  of  one.  "This  appears  to  me  to  be  so  manifest  and 
decided,"  says  Dewees,  "that  I  think  I  could  tell  what  is  going  on  at  the  mouth 
of  the  uterus,  without  an  examination  per  vaginam."  This,  however,  is  not 
always  the  case  j  for,  under  some  unusual  circumstances,  the  contraction  appears 
only  when  the  convulsion  has  reached  the  lower  extremities.  Therefore,  al- 
though in  the  first  case  the  uterine  action  appears  to  determine  the  convulsive 
attack,  in  the  second  it  seems  to  be  the  consequence  of  it.  It  is  possible  that 
this  difference  may  furnish  an  explanation  of  the  variable  eflPect  of  eclampsia  upon 
the  termination  of  labor. 

The  cessation  of  the  convulsive  attack  is  never  abrupt;  the  movements  and 
spasms  gradually  become  less  violent ;  the  respiration  is  less  hurried  and  more 
full ;  the  face  loses  part  of  its  lividity ;  the  muscles  are  only  agitated  at  intervals, 
and  their  action  resembles  that  which  is  excited  by  passing  a  brisk  electric  shock 
through  them. 

In  general,  the  first  fit  is  of  short  duration,  and  not  very  violent;  but,  in  most 
cases,  the  fits  are  repeated  frequently,  and  the  symptoms  become  more  and  more 
frightful  in  proportion  as  they  are  renewed ;  the  succeeding  one,  say  Merriman 
and  Velpeau,  being  often  heralded  by  an  uncommon  slowness  in  the  pulse.  In 
the  latter  paroxysms,  Madame  Lachapelle  has  remarked  that  the  convulsive 
shocks  are  less  considerable,  and  sooner  over  than  the  earlier  ones,  but  that  the 
comatose  symptoms  are  more  grave  and  persistent.  I  do  not  regard  this  as  cor- 
rect, but  it  is  true  that  the  comatose  symptoms  are  more  serious  and  persistent. 

The  duration  of  an  attack  is  very  variable.  The  first  fits  are  commonly  the 
shortest,  becoming  more  prolonged  as  they  are  renewed.  At  first,  they  last  from 
one  to  two  minutes,  and  afterwards  from  three  to  four;  but  they  rarely  exceed 
six  to  eight  minutes.     It  is  said  that  they  have  lasted  for  a  quarter  or  luilf  an 


rUEltPERAL     CONVJLSIONS.  725 

hour,  and  even  for  a  Avliole  hour;  but  tliose  authors  who  pretend  to  have  known 
them  to  continue  for  several  hours,  have  evidently  regarded  both  the  convulsive 
and  the  comatose  periods  as  parts  of  the  paroxysm.  The  number  and  rapidity 
of  the  convulsions  are  equally  variable  :  in  nearly  all  cases,  there  are  two  or 
more,  and  sometimes  they  have  reached  as  high  as  sixty.  In  some  instances, 
there  is  an  interval  of  several  hours,  or  half  a  day  between  them ;  while  in  others, 
on  the  contrary,  only  a  few  minutes  elapse  before  the  return  of  the  next. 

c.  Inf.erval. — The  patient  remains  in  a  state  of  complete  prostration  during 
the  intervals  of  the  first  three  or  four  paroxysms ;  but  she  soon  comes  to  herself, 
opens  her  eyes,  and  looks  at  everything  around  with  astonishment;  she  scarcely 
recognizes  the  persons  and  objects  about  her,  and  cannot  be  made  to  comprehend 
the  distress  and  anxiety  of  her  friends  and  family,  for  she  has  no  knowledge  of 
what  took  place  while  the  fit  lasted ;  but  in  a  short  time  her  ideas  become  clearer, 
and  at  length  she  entirely  recovers  the  use  of  her  faculties.  These  lucid  inter- 
vals are  quite  prolonged  after  the  early  attacks;  but,  as  they  are  renewed,  the 
moments  of  intelligence  become  shorter  and  shorter  during  their  intervals,  and 
the  woman  ultimately  sinks  into  a  state  of  profound  coma  or  apparent  death ; 
from  which  she  is  only  aroused  by  the  return  of  fresh  convulsive  movements. 

This  comatose  state  presents  all  the  characteristics  of  an  intense  cerebral  con- 
gestion, of  which  indeed  it  certainly  is  a  consequence.  Even,  if  it  be  supposed 
that  during  the  convulsion  the  muscular  fibres  of  the  auricles  present  no  obstruc- 
tion to  the  return  of  the  venous  blood,  the  viojent  contraction  of  the  muscles  of 
the  neck  certainly  compresses  the  veins  there  situated,  and  by  preventing  the 
return  of  the  blood,  gives  rise  to  a  cerebral  congestion,  which  produces  the  insen- 
sibility during  the  attack,  and  the  sleep  which  follows  it.  The  stupor  is  pro- 
found, the  face  injected,  the  respiration  stertorous,  and  the  limbs  are  in  a  state 
of  perfect  flexibility ;  but  the  sensibility,  though  greatly  blunted,  is  rarely  lost 
altogether,  for  when  we  pinch  the  patient,  or  rub  her  roughly,  she  shows  signs 
of  uneasiness,  and  groans  very  much  like  individuals  who  are  laboring  under  a 
severe  concussion  of  the  brain.  However,  the  torpor  may  be  such  that  the  sensi- 
bility is  entirely  lost ;  but  even  then  the  female  appears  to  be  conscious  of  the 
pain  caused  by  the  uterine  contraction,  for,  when  the  latter  comes  on,  she  evinces, 
by  her  countenance  and  groans,  the  sufferings  she  experiences.  The  intellectual 
faculties  seem  to  be  wholly  abolished,  the  pupils  are  dilated  and  insensible.  In 
general  the  pulse  is  strong  and  developed. 

When  this  comatose  state  is  about  passing  off,  it  changes  into  a  somnolency, 
from  which  the  woman  may  be  aroused  by  speaking  to  her ;  and  the  sensorial 
faculties  gradually  return.  When  the  torpor  is  dissipated,  she  complains  of 
great  fatigue,  and  of  a  feeling  of  painful  weariness ;  then,  at  the  end  of  a  vari- 
able period,  this  prostration  gives  way  to  great  anxiety,  the  prelude  of  a  fresh 
attack. 

§  3.  Termination  of  Eclampsia. 

An  attack  of  eclampsia  may  terminate  either  by  recovery,  by  death,  or  by 
giving  rise  to  some  other  disease.     Where  the  patient  is  likely  to  get  well,  the 


726  DYSTOCIA. 

paroxysms  arc  usually  few  in  number,  of  short  duration,  and  occurring  after  long 
intervals.  During  this  latter  period,  the  female  recovers  more  or  less  completely 
the  use  of  her  limbs,  as  also  of  her  sensorial  and  intellectual  faculties. 

When  there  is  to  be  no  return  of  the  fit,  the  intellectual  Acuities  are  the 
longer  in  regaining  their  normal  condition  as  they  have  been  the  more  disor- 
dered, or  as  they  have  been  suspended  for  a  greater  period.  The  memory  parti- 
cularly is  much  weakened,  sometimes  even  is  altogether  destroyed,  for  the  patient 
not  only  cannot  recall  what  took  place  during  the  fit,  but  she  has  likewise  for- 
gotten the  common  occurrences  of  the  few  days  preceding  the  invasion  of  the 
symptoms ;  and  it  is  only  restored  by  degrees,  each  hour  adding  some  facts  to 
those  of  which  she  had  previously  recovered  the  recollection.  It  is  singular  that 
this  defect  of  memory  is  often  limited  ta  isolated  words;  thus  some  have  been 
known  to  forget  entirely  the  names  of  their  nearest  relatives ',  others  could  no 
longer  recall  the  name  of  the  street,  or  the  number  of  the  house  they  occupied ; 
and  certain  others  again  had  entirely  lost  the  memory  of  dates. 

Alphonse  Leroy  reports  one  instance  in  which  a  very  singular  aberration  of 
vision  followed  some  convulsive  phenomena,  that  held  the  patient's  life  in  jeo- 
pardy for  several  days;  all  the  objects  that  wore  brought  before  her,  and  all  the 
surrounding  persons,  looked  black. 

The  sight  and  hearing  likewise  require  a  certain  time  for  the  recovery  of  their 
perfect  integrity;  the  woman's  general  condition  is  thus  gradually  ameliorated, 
and  ultimately  she  regains  her  usual  health. 

On  the  contrary,  when  the  disease  is  about  to  terminate  by  death,  the  convul- 
sive attacks  are  observed  to  last  for  four,  five,  or  six  minutes  with  great  inten- 
sity;  they  occur  in  rapid  succession,  and,  during  the  interval  that  separates  them, 
the  female  is  sunk  in  a  torpor,  from  which  she  cannot  be  aroused  by  any  exter- 
nal irritants.  The  period  at  which  death  takes  place  under  such  circumstances 
is  very  variable,  though  in  general  it  is  between  twelve  and  forty  houre  after  the 
invasion  of  the  first  symptoms.  Sometimes,  however,  the  patient  dies  at  the  out- 
set of  the  disease.  The  head,  says  M.  Depaul,  began  to  distend  the  perineum 
and  appear  at  the  vulva,  and  there  was  nothing  to  excite  alarm,  when  I  sud- 
denly observed  a  change  in  the  patient's  countenance,  characterized  by  convul- 
sive movements,  and  grimaces,  heralding  eclampsia,  and  death  followed  imme- 
diately. 

The  child  was  extracted  alive  by  the  forceps,  but  it  died  a  few  moments  after 
with  eclamptic  convulsions. 

Death  may  occur  in  the  convulsive  stage,  or  in  that  of  the  coma.  In  the  former 
case  it  is  evidently  due  to  asphyxia,  which  is  itself  produced  by  the  paralysis, 
or  rather  by  the  permanent  contraction  of  the  muscles  of  the  chest  and  of  the 
glottis;*  in  the  latter,  it  is  a  result  of  the  cerebral  congestion,  and  sometimes 
even  of  a  true  apoplexy. 

'  This  asphyxia  might  also  result,  according  to  Boiir,  as  a  consequence  of  the  obstruction 
of  the  bronchial  ramifications,  in  which  a  considerable  quantity  of  frothy  mucus  sometimes 
accumulates. 


PUERPERAL     CONVULSIONS.  727 

Finally,  there  is  no  reason  why  we  should  not  admit  with  M.  Aran,  that  death 
may,  in  some  cases  of  eclampsia,  result  from  a  sudden  arrest  of  the  movements 
of  the  heart.' 

Airain,  an  attack  may  not  be  grave  enough  to  end  in  death,  and  yet  may  give 
rise  to  several  very  serious  disorders.  For  instance,  when  the  eclampsia  occurs 
in  the  commencement  of  the  labor,  the  violent  contractions  of  the  womb  may 
cause  a  rupture  of  the  organ,  if  the  os  uteri  is  not  sufSciently  dilated.  Again, 
it  is  possible  that  the  disordei's  in  the  circulation  may  occasion  a  cerebral  conges- 
tion ;  and  the  consequent  engorgement  of  the  vessels  of  the  brain  may  be  such 
as  to  produce  their  rupture,  which  is  followed  by  an  apoplectic  effusion,  and,  as  a 
consequence,  by  hemiplegia.  In  plethoric  women,  this  anatomical  lesion  might 
even  be  produced  by  the  early  paroxysms;  and  it  is  probably  in  this  way  that 
the  cases  observed  and  described  by  M.  Meniere,  under  the  name  of  puerperal 
apoplexy,  must  be  interpreted. 

A  sanguineous  determination  may  also  take  place  towards  the  lung,  and  thus 
produce  congestion  of  that  organ. 

As  a  possible  consequence  of  the  congested  condition  of  the  brain  and  its  mem- 
branes, we  should  also  mention  a  state  of  irritation,  which  occasions  and  main- 
tains for  a  longer  or  shorter  time,  a  complete  or  partial  delirium,  and  sometimes, 
even,  the  symptoms  of  a  true  meningitis  or  meningo-encephalitis.  Of  the  seven 
eclamptic  women  treated  at  the  Obstetrical  Clinic,  whilst  I  was  on  duty,  four 
presented  evident  symptoms  of  meningitis  after  the  coma  had  entirely  passed  off; 
two  of  them  died,  and  exhibited  the  anatomical  characters  of  meningitis  at  the 
autop.sy. 

But  independently  of  these  unfiivorable  complications,  which  constitute  so 
many  new  diseases  for  the  physician  to  combat,  there  is  another  one  which  is 
less  immediate,  but  not  less  rare,  says  Madame  Lachapelle ;  that  is,  puerperal 
peritonitis. 

In  conclusion,  certain  cutaneous  or  intestinal  inflammations  may  result  in  con- 
sequence of  the  energetic  measures  employed  against  the  eclampsia.  Thus,  the 
life  of  the  patient  has  sometimes  been  endangered  by  an  attack  of  entero-colitis. 
The  sinapisms,  also,  which  are  then  crowded  on  the  lower  extremities  are  not  felt 
by  the  patient,  and  may  be  forgotten  in  the  general  agitation  ;  consequently,  they 
remain  applied  too  long,  and  thus  produce  erysipelas  and  severe  vesications.  A 
lady,  reported  by  M.  Yelpeau,  was  attacked,  on  the  second  day  of  her  convales- 

'  The  heart,  says  M.  Aran,  is  a  muscular  organ,  and  as  such  is  certainly  liable  to  have  its 
innervation  affected,  as  also  the  properties  with  which  it  is  endowed  as  a  contractile  agent, 
that  is  to  say,  its  irritability,  motor  power,  and  tenacity. 

To  whom,  for  example,  is  it  not  evident,  that  if  the  heart,  which  is  sometimes  known  to 
be  lacerated  by  its  own  contractions,  should  be  paralyzed  by  an  interruption  of  nervous 
action  or  by  the  loss  of  some  of  its  muscular  properties,  death  would  be  instantaneous? 
Would  it  not  be  equally  so,  if,  instead  of  ceasing  to  contract,  it  should  be  affected  with  spasm, 
as  happens  to  some  of  the  external  muscles?  May  it  not  be  supposed  that  several  convul- 
sive neuroses,  in  which  death  sometimes  takes  place  suddenly,  as  epilepsy,  eclampsia,  spasm 
of  the  glottis,  &c.,  prove  fatal  less  from  deficient  hcematosis  than  from  a  complete  and  instan- 
taneous cessation  of  the  pulsations  of  the  heart? 


iZb  DYSTOCIA. 

cence,  by  a  violent  eiysipelas  over  the  wliole  leg,  because  the  sinapisms  applied 
there  produced  no  efl'ect  at  first,  and  therefore  were  allowed  to  remain  on  too  long. 

§  4    Diagnosis. 

The  minute  detail  into  which  we  have  entered  in  describing  the  symptoms  of 
eclampsia  might  possibly  dispense  with  a  return  to  its  principal  characters ;  but 
as  there  are  some  affections  that  have  a  strong  analogy  to  puerperal  convulsions, 
we  shall  again  bring  forward  the  signs  by  which  they  can  be  distinguished. 

When  considered  as  a  whole,  eclampsia  is  so  easy  to  diagnosticate,  and  its 
symptoms  are  so  well  marked,  that  it  really  seems  useless  to  recapitulate  them  ; 
but  it  is  composed  of  two  widely  different  stages,  the  paroxysmal  and  the  coma- 
tose, during  either  of  which  the  physician  may  be  called  upon  to  decide  what  is 
the  nature  of  the  affection.  Thus,  during  the  paroxysm,  it  may  be  confounded 
with  h3'steria,  epilepsy,  catalepsy,  or  tetanus;  while  apoplexy,  concussion  of  the 
brain,  and  the  coma  of  drunkenness,  may  be  mistaken  for  it  in  the  comatose  stage. 

However,  in  hysteria  there  is  sometimes  an  alteration,  but  never  a  total  aboli- 
tion, of  the  intellectual  powers ;  indeed,  the  sensorial  faculties  have  an  unusual 
degree  of  delicacy  and  perfection  ;  there  is  no  coma  after  the  fit,  and  the  convul- 
sive movements  are  altogether  different  from  eclampsia ;  thus,  the  limbs  become 
forcibly  flexed  (instead  of  being  extended),  and  subsequently  writhe  with  vio- 
lence, there  is  a  continual  tendency  to  change  the  position,  and  the  patient  would 
certainly  throw  herself  out  of  the  bed  if  she  were  not  held  down  by  vigorous 
arms.  Again,  an  hysterical  paroxysm  is  nearly  always  preceded  or  accompanied 
by  the  sensation  of  a  ball  rising  from  the  hypogastrium  towards  the  throat,  which 
gives  rise  to  a  feeling  of  suffocation  similar  to  that  produced  by  strangulation. 

Deglutition  is  very  difficult  or  impossible,  but  the  muscles  are  much  less 
strongly  contracted,  and  instead  of  that  whistling  respiration  which  indicates 
constriction  of  the  throat,  there  are  loud  cries,  proving  a  free  opening  of  the 
larynx.  There  is  almost  never  frothing  at  the  mouth  as  in  eclampsia.  The 
thumb,  instead  of  being  flexed  in  the  palm  of  the  hand,  is  extended  outside  of 
the  other  fingers,  which  are  flexed.  Finally,  hysteria  generally  appears  in  the 
early  months,  whilst  eclampsia  appertains  more  particularly  to  the  termination  of 
pregnancy. 

But  of  all  the  convulsive  affection.s,  epilepsy  is  the  most  likely  to  be  confounded 
with  eclampsia ;  however,  after  the  epileptic  fit  is  over,  there  is  but  little  or  no 
coma,  whereas  more  or  less  of  it  always  exists  after  the  puerperal  convulsion. 
Still,  as  epilepsy  is  sometimes  followed  by  profound  coma,  it  will  be  necessary  to 
examine  the  urine,  which  will  not  usually  be  found  to  contain  albumen  as  it  would 
in  a  case  of  eclampsia. 

The  persistence  of  the  convulsive  rigidity  of  the  limbs  distinguishes  tetanus 
from  every  other  disease.  Finally,  catalepsy  presents  as  an  essential  character 
the  singular  peculiarity, — that  the  extremities  often  preserve  throughout  the  whole 
fit  the  position  which  they  happened  to  have  at  its  commencement,  or  any  one 
we  can  succeed  in  making  them  assume  during  this  convulsive  state. 

The  comatose  stage  of  eclampsia  will  be  distinguished  from  apoplexy  by  the 


PUERPERAL     CONVULSIONS.  729 

following  signs  :  it  has  been  preceded  by  convulsive  phenomena,  which  is  not  the 
case  in  the  latter  disease ;  all  the  exti-emities  are  in  a  state  of  complete  resolu- 
tion, and  they  have  entirely  lost  their  sensibility  and  motility;  and,  most  gene- 
rally, only  hemiplegia  results  as  a  consequence  of  the  cerebral  effusion.  It  must, 
liowever,  be  observed  that,  when  the  eclamptic  paroxysms  are  frequently  re- 
newed, and  the  patient's  intelligence  has  beea  lost  for  some  time,  the  cerebral 
congestion,  which  keeps  up  the  coma,  may  determine  an  effusion  into  the  sub- 
stance of  the  brain.  Hemiplegic  phenomena  then  appear  at  once,  and  it  will  be 
possible  to  detect,  on  the  side  opposite  to  the  one  where  the  effusion  took  place, 
a  more  complete  loss  of  sensibility  and  motility,  though  the  limbs  on  the  other 
side  may  be  in  a  state  of  resolution.  The  reader  will  understand  that,  if  the 
previous  history  were  unknown,  the  diagnosis  would  then  be  very  obscure.  The 
lo.ss  of  intelligence  is  always  constant  and  total  in  eclampsia,  -whilst  this  pheno- 
menon may  be  wanting  in  apoplexy,  or  be  limited  to  a  simple  obtuseness. 

In  cases  of  concussion  of  the  brain,  the  absence  of  all  pievious  convulsions, 
together  with  the  presence  of  the  marks  of  a  fall,  or  of  a  violent  blow  on  the 
head,  will  serve  to  make  out  the  diagnosis. 

Lastly,  the  previous  history  of  the  patient,  the  ejection  of  the  contents  of  the 
stomach  mixed  with  a  large  quantity  of  alcoholic  liquors,  and  the  vinous  odor  of 
the  breath  of  intoxicated  individuals,  will  enable  us  to  distinguish  the  coma  of 
drunkenness  from  that  of  eclampsia. 

§  5.  Prognosis. 

Eclampsia  is  a  very  dangerous  affection,  but  we  cannot  agree  witii  Madame 
Lachapelle,  who  states  that  one-half  of  the  women  affected  with  it  are  lost.  In 
order  to  appreciate  this  conclusion  from  the  practice  of  the  illustrious  midwife, 
it  is  necessary  to  bear  in  mind  the  peculiar  conditions  in  which  the  patients  at 
la  Maternite  are  placed.  After  consulting  the  numerous  cases  which  I  have  had 
occasion  to  observe,  I  think  I  might  safely  say,  that  when  the  patients  receive 
proper  care  in  due  time,  the  mortality  is  hardly  greater  than  one  out  of  three  and 
perhaps  four. 

The  prognosis  varies,  however,  according  to  the  cause  that  gave  rise  to  the 
convulsions,  to  the  stage  of  the  puerperal  condition  at  which  they  are  manifested, 
and  to  the  particular  progress  of  the  symptoms. 

Of  all  the  various  predisposing  causes,  a  serous  plethora,  or  a  partial  or  general 
infiltration,  says  Madame  Lachapelle,  must  give  rise  to  the  most  unfavorable 
prognosis.  This  proposition  now  appears  to  us  a  great  deal  too  absolute.  Gene- 
ral infiltration  should  doubtless  be  considered  as  predisposing  to  eclampsia  much 
more  than  partial  redema ;  but  when  the  disease  has  once  appeared,  the  general 
or  partial  infiltration  adds  nothing  to  the  gravity  of  the  prognosis.  This  results 
evidently  from  the  observations  of  MM,  Blot,  Regnault,  and  Devilliers.  Thus, 
of  four  patients  with  eclampsia,  observed  by  M.  Blot,  three  died,  whilst  all  of 
three  others  affected  in  the  same  way,  but  free  from  oedema,  recovered.  So,  also, 
MM.  Regnault  and  Devilliers,  who  had  two  deaths  for  two  non-infiltrated  cases 
of  eclampsia,  observed  but  five  deaths  for  nine  oedematous  cases,  and  three  others 


730 


DYSTOCIA. 


fell  victims  to  Inter  complications  succeeding  the  eclampsia.  In  short,  the  pa- 
tients with  eclampsia  and  albuminuria,  without  oedema,  give  a  mortality  of  7  out 
of  15;  and  those  with  oedema,  a  mortality  of  11  out  of  51. 

As  albuminuria  is  ahuost  always  pre  existent  to  eclampsia,  it  can  have  no 
other  effect  than  is  referable  to  its  longer  or  shorter  duration  and  its  quantity. 
Albuminuria  of  very  recent  date,  or  of  the  kind  styled  transitory,  and  which 
gives  only  a  slight  cloud  by  the  use  of  reagents,  will  lead  to  a  much  less  unfavor- 
able prognosis  than  if  it  had  existed  for  several  months  and  had  afforded  a 
copious  deposit  of  albumen.  An  old  case  of  albuminuria  always  supposes  an 
advanced  disease  of  the  kidney,  or  else  an  altered  state  of  the  fluid.  The  cases 
observed  by  MM.  Devilliers  and  llegnault,  prove  that  death  then  occurs  most 
frequently  either  during  the  coma,  or  as  a  consequence  of  ulterior  complications. 
The  fullowing  table  of  36  cases,  by  Braun,  leads  to  the  same  conclusion. 


Albuminuria. 

No.  of  cases. 

Mothers  cured. 

Died. 

In  the 
convulsions. 

Of  complica- 
tions. 

Very  severe, 

Very  considerable,  .     .     . 
Considerable,       .... 

Moderate,  .     .     .     ...     . 

Slight, 

3 

7 

14 

8 

4 

1 
3 
9 
7 
4 

2 
3 
4 
0 
0 

0 
1 
1 
1 
0 

The  convulsions  that  are  developed  in  hysterical  and  epileptic  patients,  or  in 
women  of  great  nervous  susceptibility,  and  those  which  succeed  any  acute  moral 
emotion,  are  less  formidable  than  those  which  have  no  relation  with  the  former 
nervous  state  of  the  female.  Finally,  the  eclampsia  that  can  only  be  explained 
by  the  general  alteration  of  the  blood  produced  by  albuminuria,  is  much  more 
dangerous  than  that  whose  appearance  seems  connected  with  the  irritation  of 
some  organ,  as  the  uterus,  bladder,  intestine,  &c. ;  for  in  the  latter  case,  suhlata 
causa,  tolUtur  effectus. 

As  the  depletion  of  the  uterus  is  one  of  the  most  favorable  conditions  for  the 
cure  of  the  paroxysms,  it  is  evident  that,  other  things  being  equal,  eclampsia  is 
far  more  serious  when  it  comes  on  at  the  commencement  of  the  labor,  than 
where  it  is  not  manifested  until  the  dilatation  of  the  parts  is  so  advanced  as  to 
render  a  spontaneous  or  an  artificial  delivery  both  possible  and  easy.  The  convul- 
sions are  likewise  more  dangerous  when  manifested  at  an  early  period  of  the 
gestation  ;  not  only  because  the  patient,  in  case  of  recovery,  is  exposed  to  fresh 
attacks  during  the  remainder  of  this  state,  but  also  because  the  complete  oblite- 
ration of  the  orifice,  and  the  hardness  and  length  of  the  cervix,  will  render  the 
depletion  of  the  womb  impossible.  It  is  unnecessary  to  add  that,  in  this  respect, 
priniiparae  will  be  much  more  exposed  than  women  who  have  previously  borne 
children.  The  truth  of  this  assertion  has  been  questioned  of  latter  time,  but  I 
am  happy  to  find  a  resume  in  the  memoir  of  31.  Wieger,  which  confirms  it  fully. 
Of  sixty-five  women  at  different  stages  of  pregnancy,  who  were  attacked  with 
eclampsia,  twenty-five  died,  either  during  the  attack,  or  in  consequence  of  sub- 


PUERPERAL     COxWULSIONS.  731 

sequent  complications.  That  which  takes  place  after  the  deliyery  is  the  least 
unfavorable  of  all,  or  rather  such  is  the  opinion  of  Duges;  but  I  believe  with 
Eamsbotham,  that  the  prognosis  would  then  be  much  more  serious.  I  have 
remarked,  says  the  latter,  and  here  again  I  agree  with  him,  that  when  the  convul- 
sions come  on  in  the  last  stages  of  labor,  and  continue  after  the  delivery,  the 
woman  generally  dies ;  but  if  they  are  arrested  by  the  delivery,  they  seldom 
return,  and  a  gentle  slumber  which  then  succeeds,  is  the  signal  of  a  prompt  cou- 
valescence. 

The  course  and  intensity  of  the  symptoms  of  a  convulsive  attack  greatly 
influence  its  termination  :  thus,  when  the  paroxysms  are  numerous  and  violent, 
and  follow  each  other  in  quick  succession,  more  particularly  if  the  comatose  state 
is  prolonged  during  the  whole  interval  that  separates  them,  and  when  the  patient 
does  not  recover  the  use  of  her  sensorial  and  intellectual  faculties  in  this  interval, 
the  prognosis  is  exceedingly  unfavorable;  for  death  most  usually  results  as  a 
necessary  consequence. 

Again,  it  must  not  be  supposed  that  all  danger  is  over  when  the  labor  is  termi- 
nated and  the  convulsions  have  altogether  disappeared  ;  for,  according  to  Denman, 
Collins,  and  others,  the  patients  are  then  much  exposed  to  consecutive  abdominal 
inflammations,  which,  as  is  well  known,  often  compromise  their  existence. 

After  the  complete  cessation  of  the  accidents,  the  albuminuria  is  generally 
found  to  disappear  rapidly,  so  that  sometimes  no  traces  of  it  remain  at  the  expira- 
tion of  four  or  five  days  subsequent  to  delivery. 

This  circumstance  is  a  happy  one,  since  it  justifies  the  expectation  of  a  happy 
convalescence.  But  if  the  urine  remains  charged  with  albumen  for  ten  or  fifteen 
days  after  the  termination  of  the  eclampsia,  a  return  of  the  accidents  is  to  be 
feared,  as  I  once  observed  on  the  fifteenth  day ;  or  else  it  may  be  dreaded  lest 
the  alteration  of  the  secretion  might  be  due  to  a  more  advanced  degeneration 
of  the  kidney,  which  of  itself  would  be  likely  to  endanger  the  woman's  life. 

If  the  prognosis  is  grave  as  regards  the  mother,  it  is  at  least  equally  so  for  the 
child,  since  it  very  frequently  dies  during  the  convulsions  that  take  place  in  the 
course  of  the  gestation  or  at  the  commencement  of  parturition  ;  for  the  disorder 
created  in  the  maternal  circulation  must  necessarily  affect  that  of  the  foetus. 
The  latter  may  be  afl'ected  with  fatal  eclampsia  in  the  womb.  I  have  sometimes 
seen  it  present  a  contracted  state  of  all  the  muscles  of  the  limbs,  immediately  after 
its  expulsion;  nor  is  it  necessary  to  the  production  of  the  latter  condition,  that 
the  mother's  convulsions  should  have  lasted  for  a  long  time.  I  saw  (October, 
1846),  a  highly  infiltrated  primiparous  female,  in  whose  case  the  complete  dila- 
tation of  the  cervix  and  powerful  expulsive  pains,  gave  promise  of  f  speedy 
delivery  notwithstanding  a  slight  contraction  of  the  pelvis,  suddenly  seized  with 
an  attack  of  convulsions.  I  applied  the  forceps  immediately,  and  the  child, 
whose  heart  was  beating  a  few  moments  before,  was  extracted  without  difficulty. 
It  was  dead,  and  the  upper  and  lower  extremities,  those  of  the  right  side  espe- 
cially, were  strongly  contracted.  The  biceps  muscles  were  extremely  hard.  M. 
Prestat  mentions  a  nearly  similar  case. 

Although  the  foetus  may  escape  the  danger  to  which  the  convulsions  expose 
it  whilst  still  within  the  womb,  it  is  not  yet  entirely  safe,  for  it  is  subject  to  a 


732  DYSTOCIA. 

sort  of  hereditary  influence,  during  the  early  part  of  its  existence,  ^-hich  renders 
it  liable  to  convulsions  similar  to  those  with  which  the  mother  was  affected. 
Schniitt  (of  Paderborn),  relates,  that  a  woman  in  whose  case  an  attack  of 
eclampsia  assumed  for  more  than  three  hours  the  appearance  of  decided  cata- 
lepsy, was  delivei'ed  by  the  forceps  of  a  living;  child.  At  five  o'clock  of  the  next 
day,  the  latter  presented  symptoms  of  catalepsy  resembling  precisely  those  of  the 
mother,  and  died  in  spite  of  all  that  could  be  done. 

But  these  are  not  the  only  dangers  to  which  eclampsia  exposes  the  child,  for 
it  is  evident  that  version  or  the  application  of  the  forceps,  which  is  then  so  often 
necessary,  always  endangers  its  existence  more  or  less.  Thus,  of  fifty-one 
children  reported  by  Merriman,  thirty-four  were  stillborn,  and  seventeen  were 
born  alive ;  which  statement,  unfavorable  as  it  is,  proves  at  least  that,  contrary 
to  the  opinion  of  many  accoucheurs,  the  child  is  not  always  lost ;  and  that  we 
should  not  regard  its  life  as  worthless  in  those  cases  in  which  the  intervention 
of  art  becomes  requisite. 

Notwithstanding  the  gravity  of  the  general  symptoms  of  eclampsia,  its  effect 
upon  the  progress  of  gestation  is  not  always  so  disastrous,  for  it  has  been  known 
to  continue  in  spite  of  long  and  frequent  attacks.  Generally,  however,  abortion 
or  premature  labor  are  the  result,  and  that,  whether  the  child  be  living,  or 
■whether  it  has  perished  in  consequence  of  the  violent  shocks  experienced  by  the 
mother. 

However  severe  the  attack  may  be,  it  is  very  unusual  for  the  woman  to  die 
undelivered,  unless  the  expulsion  of  the  foetus  be  prevented  by  a  mechanical 
obstruction.  Still,  sudden  death  has  several  times  been  known  to  take  place, 
four  cases  of  the  kind  being  mentioned  by  M.  Wieger  as  having  occurred  in  the 
practice  of  German  accoucheurs.  The  Caesarean  operation  was  performed  upon 
the  bodies. 

§  6.  Pathological  Anatomy. 

Thus  far  post-mortem,  examinations  have  thrown  no  light  on  the  nature  of 
eclampsia,  for  most  usually  this  disease  leaves  no  appreciable  anatomical  lesion 
behind.  Often,  indeed,  there  is  a  little  serosity  found  in  the  ventricles  or  arach- 
noid cavity,  and  possibly  a  more  or  less  evident  congestion  of  the  encephalic 
vessels  5  and  when  the  affection  has  terminated  in  apoplexy,  the  dissection  has 
exhibited  either  an  apoplectic  extravasation  into  the  cerebral  substance,  or  else  a 
free  effusion  on  its  surface.  But  these  are  evidently  nothing  more  than  secon- 
dary lesions,  the  effects,  and  not  the  cause,  of  the  convulsions. 

In  a  woman  who  died  from  puerperal  epilepsy,  M.  Prestat  found  a  little  body, 
of  a  stony  consistence,  and  about  as  large  as  an  ordinary  pea,  in  the  corpus 
striatum  of  the  right  side;  and,  in  another  case,  M.  Baudelocque  detected  an 
ossification  of  the  dura  mater.  But  IM.  Prestat  was  certainly  correct  in  regard- 
ing such  anatomical  lesions  as  mere  coincidences,  for  nothing  would  warrant  the 
conclusion  that  a  relation  of  cause  and  effect  exists  between  them  and  the  con- 
vulsions. 

What  we  have  stated  in  regard  to  the  almost  uniform  coincidence  of  albumi- 
nuria with  eclampsia,  and  to  its  common  connection  with  lesions  of  the  kidneys, 


PUERPERAL     CONVULSIONS.  733 

sufficiently  indicate  that  the  anatomical  lesions  are  hereafter  to  be  sought  for  ia 
those  organs.  For  our  own  part,  we  have  never  failed  to  do  so  for  the  past  ten 
years,  nor  do  we  hesitate  at  the  present  time  to  consider  albuminous  nephritis 
as  one  of  the  most  common  lesions  after  puerperal  convulsions.  As  already 
stated,  the  kidneys  have  almost  universally  presented  the  anatomical  characters 
of  nephritis,  the  more  or  less  advanced  degrees  of  which  appeared  to  coincide 
with  the  chronicity  and  abundance  of  the  albuminuria. 

Other  observers,  amongst  whom  I  might  mention  ]MM.  Blot  and  Depaul,  state 
that  usually  they  have  met  with  no  disease  of  the  kidney,  and  regarding  the 
above-mentioned  facts  as  altogether  exceptional,  insist  that  in  the  majority  of 
cases  Bright's  disease  has  no  connection  with  eclampsia. 

In  the  first  place,  I  would  call  attention  to  the  fact,  that  I  do  not  regard 
Bright's  disease  as  residing  in  the  lesion  of  the  kidney  exclusively  (page  294) ; 
and  that  although  the  kidneys  should  present  nothing  abnormal,  the  alteration  of 
the  urine  is  sufficient  to  prove  its  existence.  I  might,  therefore,  strictly,  pay  no 
regard  to  the  facts  mentioned  by  my  opponents ;  but  let  us  examine  whether, 
independently  of  the  opinion  which  I  support,  the  observations  of  M3I.  Blot  and 
Depaul  are  of  much  value.  They  have  found  nothing,  say  they ;  but  perhaps 
their  not  having  done  so  is  their  own  fault  in  not  having  examined  sufficiently, 
and  I  have  to  acknowledge  that  hitherto  I  had  committed  the  same  error. 
"Works  recently  published  in  Grermany  show,  in  fact,  that  the  naked  eye  is  en- 
tirely incompetent  to  detect  anatomically  the  commencement  of  albuminous 
nephritis,  and  that  the  first  degrees  of  renal  alteration  can  be  discovered  onl}^  by 
the  microscope. 

The  nature  of  this  book  docs  not  permit  me  to  enter  into  the  anatomical  and 
microscopic  details  found  in  Frerichs'  work ;  but  the  researches  of  which  I  speak 
evidently  show  the  small  value  of  observations  in  which  the  microscope  has  not 
been  employed.  All  negative  facts  should,  therefore,  be  regarded  for  the  mo- 
ment as  having  no  existence,  and  more  accurate  observations  are  necessary  to 
determine  whether  or  not  there  are  cases  in  which  the  lesions  of  the  kidneys  are 
altogether  wanting. 

Henceforth,  therefore,  attention  should  be  especially  directed  to  the  kidneys. 

§  7.  Nature  of  Eclampsia. 

As  a  consequence  of  the  labors  of  those  modern  pathologists  who  have  fol- 
lowed the  impulse  given  by  M.  Bayer,  eclampsia,  which  had  been  so  long  classed 
with  the  neuroses,  that  is  to  say,  with  diseases  whose  nature  is  entirely  unknown, 
begins  to  be  better  understood.  Whoever  shall  have  read  attentively  what  we 
have  said  of  puerperal  albuminuria  (page  288),  and  of  its  relations  with  eclamp- 
sia (page  715),  will  perceive  that  we  can  no  longer  withhold  our  opinion  as 
respects  the  nature  of  puerperal  convulsions. 

In  the  first  place,  let  us  return  to  what  we  regard  as  the  fundamental  fact, 
which  must  decide  the  whole  question,  namely,  that  eclamptic  females  are 
almost  always  affected  with  albuminuria.  Now,  although  it  is  true  that  albumi- 
nuria may  be  present  in  a  great  number  of  general  or  local  diseases  of  easy 
diagnosis  (Bayer),  and  although  it  may  be  produced  artificially  by  wounding  cer- 


734  DYSTOCIA. 

tain  parts  of  the  nervous  system  of  living  animals  (Claude  Bernard),  it  is  very 
certain  that,  aside  from  these  conditions,  which  are  rare  and  exceptional  in  preg- 
nant women,  the  presence  of  albumen  in  the  urine  during  the  puerperal  state, 
always  denotes  a  general  alteration  of  the  urinary  secretion.  This  alteration,  as 
stated  (page  288),  first  consists  in  a  modification  of  the  elements  of  the  blood, 
which  is  soon  complicated  with  a  lesion  of  the  kidneys,  constituting  its  anato- 
mical expression,  as  albuminuria  and  still  later  eclampsia,  are  its  symptomatic 
expression.  Eclampsia  is,  therefore,  the  ultimate  phenomenon  of  Bright's  dis- 
ease, whether  it  be  merely  a  general  affection  or  more  especially  localized  in  the 
kidneys. 

This  alteration  of  the  blood,  or  species  of  poisoning,  has  received  the  appella- 
tion of  itnemid  from  the  Clerman  authors.  It  is  characterized  anatomically  by 
the  loss  of  albumen  from  the  blood,  and  by  its  admixture  with  a  greater  or  less 
amount  of  urea. 

It  is  impossible  for  mo  to  exhibit  and  discuss  the  value  of  the  theories  of 
Frerichs,  Schotin,  and  others,  in  regard  to  uraemia.  I  must  content  myself  with 
observing,  that  although  differing  as  regards  the  explanation,  all  of  these  authors 
agree  in  considering  the  alteration  of  the  blood  as  the  cause  of  most  of  the  symp- 
toms of  Bright's  disease. 

We  have  already  said  that  this  alteration  of  the  blood  had  been  detected 
during  pregnancy;  let  us  now  examine  whether  the  symptoms  to  which  it  gives 
rise  are  also  met  with  in  the  pregnant  female  with  albuminuria. 

In  the  excellent  memoir  of  M.  ImbertGoubeyre,  which  was  crowned  by  the 
Academy,  the  author,  who  defends  with  much  brilliancy  and  talent  the  opinion 
which  I  hold,  has  proved  that  the  history  of  the  symptoms  of  Bright's  disease  is 
also  the  history  of  puerperal  albuminuria.  In  both  cases,  he  has  observed  amau- 
rosis, cephalalgia,  lumbar  pains,  partial  paralysis  or  hemiplegia,  various  neural- 
gias, blindness,  contractions,  hemorrhages,  gastric  disorders,  convulsions,  and 
lastly,  what  it  is  almost  unnecessary  to  mention,  the  analysis  and  microscopic 
examination  of  the  urine  furnish  in  both  cases  the  same  results. 

But,  it  may  be  said,  these  symptoms  are  rarely  observed  in  puerperal  albu- 
minuria. We  might  reply,  that  they  are  also  rare  in  albuminous  nephritis. 
Still,  they  are  probably  much  more  common  during  gestation  than  is  generally 
supposed.  They  have,  in  fact,  always  been  noted  in  connection  with  pregnancy, 
but  the  examination  of  the  urine  was  neglected.  However,  since  attention  has 
been  turned  to  the  subject,  several  authors  have  pointed  out  their  coincidence 
with  albuminuria.  Besides,  in  Bright's  disease  these  symptoms  are  rarely  met 
with,  except  at  an  advanced  stage,  whereas  during  pregnancy  it  is  unusual  for 
the  renal  affection  or  the  alteration  of  the  fluids  to  be  carried  so  far.  Therefore, 
they  are  witnessed  more  rarely.  Considering  the  slight  progress  made  by  the  so- 
called  puerperal  Bright's  disease,  it  would  seem  as  though  the  symptoms  ought 
to  be  met  with  still  less  frequently,  and  in  most  cases  their  appearance  might 
be  regarded  as  premature ;  but  this  early  appearance  is  readily  explained  by  the 
reflex  irritations  resulting  from  the  pregnancy  and  labor. 

The  similarity  of  the  symptoms  and  anatomical  alterations  induce  me,  there- 


PUERPERAL  COXVULSIOXS.  735 

fore,  to  attribute  the  eclampsia  and  the  albuminuria  which  always  accompanies 
it,  to  Bright's  disease. 

MM.  Blot,  Depaul,  and  some  others,  having  raised  several  objections  to  this 
opinion,  we  shall  next  endeavor  to  appreciate  their  value. 

"  1.  As  albumen  is  not  discovered  in  the  urine  of  all  pregnant  women,  there- 
fore, eclampsia  is  not  necessarily  connected  with  albuminuria  and  Bright's  dis- 
ease." 

Supposing  the  observations  upon  which  this  first  objection  is  based  to  have 
been  well  made,  and  some  of  them,  at  least,  seem  to  me  deserving  of  all  confi- 
dence, they  still  do  not  prove  incontestably  what  is  desired.  Albumen,  indeed, 
is  not  found  invariably  in  all  individuals  who,  not  being  in  the  puerperal  state, 
are  certainly  affected  with  albuminous  nephritis;  although  very  abundant  at  cer- 
tain periods  it  diminishes  greatly  at  others,  and  sometimes  even  disappears  en- 
tirely for  a  longer  or  shorter  time  but  only  to  return  again  rather  later.  These 
same  intermissions  may  also  be  met  with  during  pregnancy,  and  we  may  readily 
imagine  that  unless  the  urine  of  the  same  woman,  who  afterward  was  attacked 
with  eclampsia,  had  been  examined  frequently  and  through  a  long  period,  it 
could  not  be  concluded  that  she  was  not  albuminuric,  especially  if  the  albumen 
should  appear  during  the  convulsive  attack. 

Furthermore,  facts  have  been  observed  by  Mazoun,  a  Russian  physician,  and 
referred  to  by  M.  Imbert-Goubeyre,  which  appear  to  me  to  answer  the  objection 
still  more  completely.  Mazoun  mentions  three  cases  in  which  the  autopsy  dis- 
closed,— once,  the  anatomical  type  of  the  second  degree  of  Bright's  disease ; 
once,  a  lard-like  condition  of  the  kidney;  and  once,  the  characters  of  the  first 
degree  of  Bright's  disease :  yet,  although  the  patients  were  observed  daily  for 
several  weeks,  albumen  was  never  detected  in  their  urine.  Unless  we  admit  that 
the  fatty  kidneys  did  not  mark  a  case  of  Bright's  disease,  it  must  be  allowed  that 
this  disease  may  exist  exceptionally  without  albuminuria.  Now  if  this  is  so, 
what  can  be  concluded  from  those  rare  cases  in  which  the  eclampsia  was  neither 
preceded  nor  accompanied  by  albuminuria  ? 

"  2.  When  the  kidneys  present  no  alteration  at  the  autopsy,  can  it  still  be  said 
that  the  eclampsia  was  the  consequence  of  Bright's  disease  V 
■  I  have  already  replied  to  this  objection;  affirmatively,  if  we  regard,  as  always 
should  be  done,  the  general  alteration  of  the  fluids,  and  also  if  the  microscope 
has  not  been  employed,  for  it  alone  can  now  enable  us  to  say  that  no  renal  altera- 
tion exists. 

"3.  The  difficulty  and  rarity  of  the  cures  of  Bright's  disease  are  well  known; 
how,  then,  if  puerperal  albuminuria  is  due  to  the  same  cause,  explain  the  prompt 
disappearance  of  the  albumen  after  delivery,  and  the  rapid  recovery  of  the  pa- 
tients?" 

It  is  true  that  the  albuminuria  disappears  quickly  in  a  certain  proportion  of 
cases ;  but  generally  in  these  cases  no  eclampsia  had  taken  place,  or,  at  least,  the 
patients  recovered.  Here,  as  was  stated  (page  294),  it  is  probable  that  the  blood 
was  but  slightly  altered,  and  that  the  active  or  passive  congestion  of  the  kidneys 
produced  by  the  obstruction  to  the  venous  circulation,  contributed  to  a  certain 
extent  to  the  production  of  the  albuminuria.    "We  can  then  readily  imagine  that, 


736  DYSTOCIA. 

one  of  the  causes  being  removed  by  the  delivery,  the  other  might  be  incapable 
of  maintaining  the  functional  disorder;  but  it  is  not  true  to  say  that  in  other 
than  these  favorable  conditions,  the  albuminuria  ceases  in  a  few  hours.  I  have 
already  quoted  the  statistics  of  M.  Imbert-Goubeyre  (page  294),  from  which  it 
evidently  follows  that  when  the  disease  proves  fatal,  the  albumen  continues  to  the 
end;  and  that  in  a  certain  number  of  cases,  which  will  probably  be  found  to 
increase  when  the  patients  shall  be  followed  more  carefully,  it  passes  into  the 
chronic  condition.  I  might  add  with  M.  Wieger,  that  the  medium  duration  of 
the  albuminuria  in  the  non-fatal  cases,  is  from  eight  to  ten  days  after  delivery. 

We  see,  therefore,  that  these  objections  have  no  great  force,  and  are  not  of  a 
character  to  invalidate  the  many  good  reasons  which  go  to  support  our  opinion. 

We  do  not  wish  to  deny  absolutely  the  possible  occurrence  of  apparently 
eclamj/tic  convulsions,  in  the  case  of  a  woman  in  labor,  who  presents  neither  albu- 
minuria nor  any  of  the  symptoms  of  Bright's  disease.  On  the  contrary,  we  be- 
lieve that  in  some  very  rare  cases,  the  reflex  irritation  produced  by  an  extremely 
painful  labor,  or  the  violent  congestion  of  the  veins  of  the  spinal  column,  occa- 
sioned by  the  extreme  efforts  of  the  woman,  may  over-excite  the  spinal  marruw 
and  give  rise  to  partial,  or  even  general  convulsions.  But  we  regard  such  cases 
as  altogether  exceptional,  and  would  even  be  disposed  to  debar  them  from  the 
title  of  eclampsia,  and  consider  them  as  simple  convulsions,  hysterical  or  other- 
wise, in  their  nature.  Such,  at  least,  is  the  impression  left  upon  us  by  the  two 
cases  of  the  kind  which  have  come  under  our  own  observation;  and  the  reading 
of  the  published  cases  inclines  me  to  believe  that  most  of  them  were  not  instances 
of  real  eclampsia. 

§  8.  Treatment. 

The  management  of  eclampsia  must  necessarily  be  divided  into  the  preventive 
and  the  curative  treatment. 

We  have  dwelt  sufficiently  upon  the  etiology  of  eclampsia  to  show  the  impor- 
tance which  we  attach  to  albuminuria,  or,  rather,  to  the  disease  of  which  it  is  the 
symptom.  The  presence  of  albumen  in  the  blood  of  a  pregnant  woman,  is  the 
indication  of  a  marked  predisposition  on  her  part  to  puerperal  convulsions,  and 
the  best  preventive  treatment  would  be  that  which  would  result  in  the  most 
favorable  alteration  in  the  condition  of  the  blood,  or  in  the  amelioration  of  the 
renal  affection  which  is  the  apparent  cause  of  the  albuminuria.  Unfortunately, 
all  the  therapeutic  measures  employed  hitherto  in  other  conditions  than  the  puer- 
peral, have  been  very  unsatisfactory.  The  tonic  treatment,  however,  has  seemed 
in  some  cases  to  be  sufficiently  useful  to  encourage  new  trials,  especially  during 
pregnancy,  in  which,  as  we  have  seen,  the  diminution  of  the  albumen  is  attended 
by  a  lessening  in  the  amount  of  all  the  solid  principles  of  the  blood.  I  would, 
therefore,  have  no  hesitation  in  recommending  an  animal  diet  and  the  adminis- 
tration of  iron,  in  cases  of  albuminuria  complicating  pregnancy. 

The  recent  investigations  of  M.  Mialhc,  which  prove  that  an  excess  of  water 
in  the  blood  is  one  of  the  most  active  causes  of  albuminuria,  are  evidentlj'  calcu- 
lated to  confirm  us  in  the  therapeutic  course  which  we  have  recommended  for  a 
lon<i;  time. 


PUERPERAL    CONVULSIONS.  737 

But,  as  we  have  already  observed,  convulsions  almost  never  appear  in  a  preg- 
nant woman  with  albuminuria,  unless  some  accidental  circumstance,  so  to  speak, 
should  happen  to  excite  them.  They  are  usually  connected  with  cerebro-spinal 
congestions,  themselves  occasioned  by  fortuitous  circumstances,  with  serous  ple- 
thora, or  the  mechanical  obstruction  to  which  the  venous  circulation  is  subjected 
during  gestation  and  labor;  therefore,  the  first  object  should  be  to  prevent  this 
congestion.  On  this  account  it  is,  that  bleeding  should  have  the  precedence  of 
all  others  as  a  preventive  measure.  It  should  be  practised  several  times  during 
the  latter  months  of  pregnancy  in  such  women  as  may  present  some  of  the  symp- 
toms of  cerebral  congestion;'  it  might  also  be  practised  with  the  happiest  suc- 
cess in  oedematous  females,  more  particularly  when  the  precursory  phenomena  of 
eclampsia  shall  be  manifested.  In  the  latter,  we  should  also  resort  to  the  mea- 
sures calculated  to  diminish  the  volume  of  the  parts  distended  by  infiltration ; 
such  as  derivatives  to  the  intestinal  canal  and  urinary  passages,  the  application  of 
compresses  steeped  in  cold  water,  or  some  aromatic  decoction,  and  to  punctures 
with  the  lancet.  Nervous  and  irritable  women,  of  a  dry  habit,  will  also  be  bene- 
fited by  a  moderate  bleeding  from  the  arm,  and  by  lukewarm  baths,  repeated 
frequently  during  the  latter  months  of  pregnancy;  and  they  should  avoid  all 
acute  moral  emotions.  Sic,  with  the  greatest  possible  care. 

Eeserve  is  called  for  in  the  use  of  diuretics,  for  although  they  are  useful  in 
certain  cases,  they  may,  in  others,  affect  the  progress  of  the  disease  unfavorably. 
Generally  speaking,  when  there  is  no  diminution  in  the  amount  of  urine  ex- 
creted, they  should  not  be  employed,  for  the  increased  urination  would  augment 
the  waste  of  albumen,  and  consequently  the  impoverishment  of  the  blood. 
When,  however,  the  patient  passes  but  little  urine,  it  is  important  to  increase  the 
secretion,  in  order  to  prevent  an  admixture  of  the  principles  of  the  urine  with 
the  blood,  and  thus  lessen  the  chances  of  uraemic  intoxication.  The  prepara- 
tions of  squill,  digitalis,  juniper,  &c.,  may  then  be  used  with  advantage. 

After  the  venesection  and  purgatives  have  been  tried,  Drs.  Collins  and  John- 
son highly  extol  the  use  of  tartar  emetic,  administered  in  such  a  way  as  to 
nauseate  without  producing  vomiting.  For  this  purpose,  a  tablespoonful  of  the 
following  mixture  is  given  by  the  mouth  every  half  hour : 

IJ. — Tartar  emetic,  .  .  .  .  .  gr.  vj. 

Laudanmn,  .....  gtt.  xxx. 

Simple  syrup,  .....  f^ijss. 

Iiifu--ion  of  pennyroyal,     ....  fo''J- 
F.  M. 

'  By  way  of  showing  the  importance  of  venesection,  as  a  preventive  measure.  Dr.  Dewees 
relates  tlie  following  case:  Mrs. ,  pregnant  with  her  first  child,  was  seized  with  fre- 
quent headaches  towards  the  end  of  her  gestation ;  she  neglected  to  be  bled,  and  was  at- 
tacked with  severe  epileptic  convulsions  at  the  onset  of  labor,  from  which,  however,  she 
recovered.  During  her  second  pregnancy  she  was  bled  freely,  and  delivered  without  acci- 
dent. In  the  third  and  fifth,  venesection  was  not  resorted  to,  and  they  were  attended  with 
convulsions;  whilst,  in  the  other  gestations,  she  had  recourse  to  this  remedy,  and  was  safely 
confined. 

4r 


73S  DYSTOCIA. 

The  quantity  of  tartar  emetic  is  increased  or  diminished  according  to  the  in- 
tensity of  the  symptoms,  and  the  imminence  of  the  disease.  The  same  potion 
is  also  strongly  recommended  as  a  curative  measure,  after  the  invasion  of  tlie 
convulsive  attack.  For  our  own  part,  we  should  regard  it  as  much  less  useful  at 
that  period. 

During  parturition,  the  accoucheur  should  endeavor  to  modify  or  prevent  the 
influence  of  the  various  causes  of  dystocia ;  thus,  if  the  contractions  assume  the 
character  of  irregular,  tetanic  pains,  he  must  attempt  to  restore  them  to  their 
normal  and  regular  type,  by  a  resort  to  bathing,  to  the  opiates,  or  belladonna, 
and  to  venesection;  for  it  is  an  ascertained  fact  that  the  excessive  agitation  pro- 
duced by  these  pains  is  often  the  forerunner  of  eclampsia  in  a  nervous  and  irri- 
table woman. 

It  were  hardly  necessary  to  call  attention  to  the  favorable  effect  that  inhala- 
tions of  chloroform  might  have  under  these  circumstances,  both  by  changing 
the  character  of  the  contractions,  and  diminishing  the  irritability  of  the  nervous 
centres. 

At  the  very  commencement  of  the  labor,  the  precaution  should  be  taken  to 
empty  the  bladder  and  large  intestine,  and  to  relieve  the  stomach  of  indigestible 
food,  which  might  have  an  unfavorable  effect,  by  vomiting. 

All  these  measures  are  particularly  indicated  when  the  patient,  under  care,  had 
previously  suffered  from  convulsions  in  her  former  labors,  for  she  is,  by  that  very 
fact,  predisposed  to  a  return  of  them. 

After  the  delivery,  the  accoucheur  might  often  prevent  this  accident,  by 
carefully  exploring  the  state  of  the  womb  subsequent  to  the  expulsion  of  the 
child  and  placenta;  and  by  assuring  himself  that  it  is  well  retracted,  and  that  it 
contains  no  foreign  bodies,  such  as  coagula,  or  portions  of  the  membranes  or 
placenta. 

The  curative  treatment  consists  of  the  general  measures  that  are  applicable  in 
all  cases,  and  of  the  special  means,  which  necessarily  vary  according  to  the  period 
at  which  the  puerperal  convulsions  are  manifested. 

A.  General  Measures. — At  the  head  of  the  list  of  curative  means  we  must 
place  sanguineous  emissions,  which  have  been  resorted  to  under  every  form.  To 
these,  therefore,  we  must  first  have  recourse;  but,  in  the  employment  of  this 
remedy,  several  questions,  that  are  important  in  a  practical  point  of  view,  are 
presented  for  solution.  Ought  we  to  employ  general  or  local  bleeding?  And, 
if  general,  which  vein  is  to  be  opened?  And  what  quantity  of  blood  should  be 
drawn  ? 

In  a  large  majority  of  cases,  general  venesection  will  first  be  preferred;  and 
the  revulsive  application  of  leeches  or  cupping  will  only  be  resorted  to  in  those 
instances  where  the  convulsions  shall  have  followed  a  profuse  hemorrhage. 
Where  free  bleeding  has  been  practised,  and  the  coma  continues,  notwithstand- 
ing, throughout  the  whole  interval  between  the  fits,  thus  announcing  an  intense 
congestion  about  the  encephalon,  we  might  apply  leeches  with  advantage  to  the 
mastoid  processes,  or  to  the  neck,  and  also,  perhaps,  around  the  malleoli. 

Writers  have  sharply  discussed  the  question  as  to  what  vessels  should  be 


PUERPERAL  CONVULSIONS.  739 

opened;  and  avteriotomy  in  the  temporal,  bleeding  in  the  arm  or  foot,  and  open- 
ing the  jugular  vein,  have  been  extolled  in  turn.  The  advantages  of  blood- 
letting are  very  nearly  the  same,  whichever  vessel  be  opened;  and,  consequently, 
as  venesection  in  the  arm  is  by  far  the  most  easy,  and  as  we  can  always  obtain 
there  as  much  blood  as  may  be  deemed  advisable,  this  is  usually  practised,  and, 
as  a  general  rule,  should  be  preferred. 

It  is  very  important  that  the  vein  should  be  opened  largely,  and  that  the  blood 
should  flow  in  a  full  stream.  Should  it  dribble  away,  or  the  jet  be  very  small, 
the  bleeding,  Eamsbotham  says,  is  almost  useless,  and  another  vein  had  better  be 
opened  at  once. 

The  quantity  of  blood  to  be  drawn  varies  according  to  the  patient's  constitu- 
tion, the  violence  of  the  paroxysms,  &c.  &c. :  thus,  in  lymphatic  individuals,  we 
should,  as  a  general  rule,  be  satisfied  with  the  extraction  of  fourteen  to  eighteen 
ounces;  and  if  the  symptoms  still  continue  after  this,  and  it  be  deemed  necessary 
to  keep  up  the  sanguineous  emission,  it  ought  to  be  confined  to  the  application 
of  fifteen,  twenty,  or  thirty  leeches  behind  each  ear.' 

In  plethoric  women,  after  a  copious  bleeding  of  sixteen  ounces,  a  second,  of 
ten  to  fourteen  ounces,  might  be  resorted  to,  tvro  or  three  hours  afterwards,  and 
perhaps  even  a  third ;  but  a  fourth  is  rarely  admissible,  and  we  would  preferably 
apply,  instead,  either  leeches  to  the  mastoid  processes  or  cups  to  the  back  of  the 
neck. 

Bleeding  has  the  double  advantage  of  removing  the  congestion  or  irritation  of 
the  spinal  marrow,  and  of  preventing  at  the  same  time  the  cerebro-splnal  con- 
gestion, which  takes  place  during  the  fit,  and  which  may  produce  fiital  disorders, 
or  at  least  become  indirectly  the  cause  of  a  fresh  attack. 

General  bleeding,  even  when  carried  so  far  as  to  weaken  the  patient  greatly, 
does  not  surely  prevent  congestion  of  the  brain  or  even  effusion ;  for  all  these 
anatomical  lesions  have  been  observed  in  women  who  died  after  profuse  bleeding 
by  the  lancet.  On  the  other  hand,  when  carried  beyond  certain  limits,  it  may 
become  itself  the  -occasion  of  a  fresh  excitement  of  the  spinal  marrow,  as  is  ob- 
served after  all  great  hemorrhages,  which  almost  always  end  in  convulsions. 
The  particular  object,  in  applying  leeches  or  cups  to  the  nucha  or  behind  the 
ears,  is  to  supply  the  insufficiency  of  venesection,  or  to  avoid  any  unfavorable 
effect  which  the  latter  might  possibly  have. 

Though  the  gravity  of  the  symptoms,  and  the  fear  of  congestions  and  effusions 
in  the  brain  and  spinal  marrow,  may  often  call  for  bleeding,  it  should  not  be  for- 
gotten that  the  impoverishment  of  the  blood  of  most  eclamptic  patients  contra- 
indicates  a  too  abundant  loss  of  blood.  It  is  proper,  therefore,  to  bleed  sufficiently 
to  remove  the  congestion  of  the  nervous  centres  or  lungs,  and  to  prevent  apo- 
plectic effusions,  but  going  too  far  in  this  direction  would  involve  the  most 
deplorable  consequences. 

Simultaneously  with  the  venesection,  it  is  advisable  to  produce  a  salutary 
derivation  to  the  intestinal  canal  and  skin.  The  emetics  have  been  recom- 
mended for  this  purpose;  but,  in  most  cases,  they  ought  to  be  proscribed,  as 

'  The  reader  will  bear  in  mind  that  the  leeches  directed  in  the  text  are  of  the  European 
variety,  which  extract  a  much  larger  quantity  of  blood  than  our  own. — Translator. 


740  DYSTOCIA. 

being  calculated  to  augment  the  convulsive  movements  and  cerebral  congestion 
by  the  retchings  they  determine;  still,  if  there  was  good  reason  for  supposing 
that  the  accidents  were  partly  caused  by  the  presence  of  badly-digested  food  in 
the  stomach,  vomiting  should  be  encouraged  either  mechanically,  by  tickling  the 
throat,  or  by  the  administration  of  an  emetic. 

Purgatives  are  much  to  be  preferred,  especially  when  the  large  intestine  is 
filled  with  hardened  fecal  matters. 

The  fact  that  extreme  distension  of  the  bladder  has  occasionally  appeared  to 
be  the  determining  cause  of  the  attack  should  always  lead  us  to  ascertain  the 
condition  of  that  viscus  by  percussion,  and  to  use  the  catheter  if  it  should  chance 
to  be  found  distended. 

If  the  patient  recovers  her  intelligence  during  the  intervals,  and  she  can  be 
induced  to  swallow,  we  might  exhibit  castor  oil  by  the  mouth  in  the  dose  of  one 
or  two  ounces;  or,  still  better,  two  grains  of  calomel  every  quarter  of  an  hour, 
until  it  produces  a  purgative  effect.  If,  on  the  contrary,  she  cannot  swallow,  a 
plan  advised  by  Merriman  might  be  adopted ;  that  is,  to  put  the  calomel  mixed 
with  moist  sugar  in  equal  proportions  between  the  lips  and  alveolar  arches,  or, 
if  possible,  into  the  mouth,  and  renew  it  until  several  stools  are  procured.  If 
this  latter  measure  be  ineffectual,  it  will  be  requisite  to  act  on  the  lower  part  of 
the  intestinal  canal  by  administering  injections,  rendered  purgative  by  the  addi- 
tion of  an  ounce  and  a  half  or  two  ounces  of  castor  oil,  or  of  the  miel  mercurial, 
and,  if  necessary,  by  incorporating  with  it  a  few  drops  of  croton  oil. 

There  are  yet  some  other  measures  that  cannot  be  relied  on  when  employed 
alone;  but  which,  nevertheless,  are  too  important  to  be  neglected.  We  allude 
to  sinapisms  applied  successively  on  the  thighs,  calves  of  the  legs,  and  feet,  to 
vesicatories,  and  to  dry  cups  placed  on  the  back  of  the  neck,  and  on  the  lower 
extremities.  I  apply  them,  says  M.  Yelpeau,  to  both  thighs  and  the  nape  of  the 
neck,  so  that  they  may  act  whilst  we  are  engaged  with  the  bloodletting,  blisters, 
or  leeches. 

They  have  appeared  to  me,  remarks  M.  Prestat,  particularly  useful  in  a?de- 
matous  women  ;  only  it  is  necessary  to  watch  their  effects  for  a  few  days  aftei'wards, 
lest  their  surface  become  gangrenous. 

I  place  an  application  of  the  large  cups  of  Dr.  Junod'  to  the  lower  extremities 
in  the  first  class  of  revulsives,  as  being  the  most  powerful  and  prompt  in  their 
action  of  any.  In  a  case  of  eclampsia,  that  occurred  five  hours  after  delivery, 
the  symptoms  lasted  for  thirteen  hours ;  and  the  patient's  condition  became  more 
and  more  dangerous,  notwithstanding  the  employment  of  all  the  measures  just 
spoken  of.  At  the  first  application  of  these  cups,  the  convulsive  paroxysms  dis- 
appeared;  at  the  second,  the  coma  became  less  profound;  and  at  the  third,  the 
patient  regained  her  intelligence.  In  three  other  cases,  the  effect  was  not  so 
rapid,  although  they  appeared  to  have  a  favorable  influence. 

'  The  apparatus  of  Dr.  Junod  consists  of  a  large  metallic  boot,  capable  of  receiving  the 
greater  portion  of  a  lower  extremity.  The  upper  part  of  the  boot  is  so  adapted  to  the  limb 
as  to  prevent  the  ingress  of  air,  and  a  partial  or  complete  vacuum  is  obtained  by  the  use  of 
an  air-pump. — Translator. 


PUERPERAL    CONVULSIONS.  741 

These  cups  are  especially  applicable  when,  notwithstanding  large  general  bleed- 
ings, the  application  of  leeches  or  scarified  cups  has  failed  to  remove  the  symp- 
toms. Under  these  circumstances,  they  have  the  immense  advantage  of  opposing 
the  cause  which  seems  to  drive  the  fluids  toward  the  brain,  by  keeping  a  large 
amount  of  blood  in  the  lower  extremities. 

Cold  aspersions  upon  the  face  and  chest,  and  tickling  the  nostrils,  have  some- 
times had  the  effect  to  render  the  inspirations  more  easy  and  perfect,  and  thus 
defer  the  attack  of  convulsions.  Harvey  relates  the  case  of  a  woman  in  labor, 
who  was  awakened  from  a  deep  coma  by  tickling  the  interior  of  the  nostrils. 
Denman  gives  the  history  of  a  lady  whose  every  pain  was  attended  by  a  convul- 
sion, until  he  put  an  end  to  the  latter  for  the  rest  of  the  labor,  by  sprinkling  the 
face  at  the  beginning  of  each  contraction  by  means  of  a  feather  dipped  in  cold 
water.  Even  if  useless,  the  measure  is  too  innocent  a  one  not  to  be  had  re- 
course to. 

Such  are  the  measures  that  ought  to  be  primarily  employed;  but  there  are 
certain  others  which,  without  having  the  same  efficacy,  may  however  prove  very 
useful.  For  instance,  when  the  intervals  between  the  attacks  last  for  an  hour  at 
least,  and  during  all  this  time,  the  patient  has  recovered  her  senses,  it  is  ad- 
visable to  place  her  in  a  lukewarm  bath,  and  whilst  she  is  there,  to  keep  com- 
presses, steeped  in  some  iced  liquid,  constantly  applied  on  her  head.  This  appli- 
cation of  cold  should  be  kept  up  throughout  the  whole  duration  of  the  attack ; 
this  measure  has  often  seemed,  in  our  hands,  says  Madame  Lachapelle,  to  second 
the  venesection  beneficially.  It  is  particularly  useful  when  a  febrile  coma  suc- 
ceeds the  eclamptic  paros3-sm  ;  as  also  when  the  occurrence  of  delirium  announces 
the  commencement  of  a  cerebral  fever. 

The  antispasmodics,  recommended  by  M.  Yelpeau  in  the  hysteric  form  of 
eclampsia,  that  is  to  say,  in  the  hysteria  of  pregnant  women,  appear  to  me  use- 
less in  most  cases  of  puerperal  convulsions ;  and  it  would  only  be  as  a  preventive 
measure,  or  else  in  a  very  slight  attack,  that  they  could  be  resorted  to  with 
benefit ;  besides  which,  we  should  lose  precious  time  by  depending  on  them  in 
these  grave  cases. 

The  compression  of  the  two  primitive  carotids,  which  has  recently  been  pro- 
posed as  a  remedy  for  most  convulsive  affections,  has  been  successfully  practised 
in  some  cases  of  eclampsia ;  and  hence  it  constitutes  another  measure  to  which 
we  might  recur,  without,  however,  attaching  too  much  importance  to  its  action, 
for  it  has  failed  in  several  instances.   (Journal  de  Trousseau,  Nov.,  1840,  p.  186.) 

In  my  estimation,  the  opiates  ought  to  be  wholly  banished  from  the  treatment 
of  a  disease  which  so  often  terminates  in  cerebral  congestions,  at  least  whenever 
the  condition  of  the  patient  is  such  as  to  allow  of  the  abstraction  of  blood ;  but 
in  the  ca.se  of  an  ana3mic  female,  or  of  one  who  has  already  been  bled  very  freely, 
opium,  by  acting  as  a  sedative  to  the  nervous  centres,  might  perhaps  be  produc- 
tive of  some  advantage. 

During  the  paroxysm,  the  necessary  precautions  must  be  taken  to  restrain  the 
patient's  dangerous  movements ;  but  it  is  not  requisite  to  employ  violence  for 
that  purpose,  as  some  persons  advise ;  for  we  have  elsewhere  stated  that  there  is 


742  DYSTOCIA. 

scarcely  any  tendency  to  change  the  position;  and  it  will  be  quite  sufficient  to 
merely  watch  over  her,  without  endeavoring  to  prevent  the  convulsive  move- 
ments, the  intensity  of  which  might  thereby  be  augmented. 

Particular  care  is  requisite  to  prevent  the  tongue  from  being  bitten,  since  it  is 
very  liable  to  be  pushed  beyond  the  alveolar  arches,  and  often  becomes  wounded 
by  the  conviilsive  contraction  of  the  masseter  muscles.  To  prevent  such  an 
accident,  it  has  been  advised  to  place  some  hard  body,  the  handle  of  a  spoon,  for 
instance,  between  the  teeth,  so  as  to  hold  them  apart ;  but  Madame  Lachapelle 
says  this  is  an  almost  inflillible  way  of  breaking  the  incisors.  Gardien  directs  a 
piece  of  cork  to  be  put  between  the  molars  instead,  as  it  would  not  be  attended 
with  this  inconvenience ;  but  this  might  escape  from  the  fingers,  and  be  drawn 
down,  by  an  inspiratory  movement,  into  the  opening  of  the  glottis,  and  thus  suf- 
focate the  patient.  A.  much  more  simple  plan  is  to  push  back  the  tongue  behind 
the  alveolar  arches  with  the  fingers  themselves,  at  the  commencement  of  each  fit; 
when,  the  jaws  being  once  closed,  the  tongue  can  no  longer  protrude ;  it  may  be 
contused  between  the  teeth,  but  that  is  all.  Besides,  this  little  operation  may 
easily  be  explained  to  the  assistants,  who  perform  it  without  difficulty,  as  soon  as 
they  have  overcome  the  chimerical  fear  of  being  bitten. 

B.  Special  Measures. — The  course  pointed  out  thus  far,  might  be  considered 
as  the  medical  part  of  the  treatment  of  eclampsia. 

But  when,  notwithstanding  the  employment  of  these  means,  the  convulsions 
continue  and  increase  in  violence,  what  is  to  be  done  ?  The  pregnant  condition 
being  the  first  cause  of  eclampsia,  it  was  natural  to  expect  to  find  the  most  efi'ec- 
tual  remedy  in  the  evacuation  of  the  uterus.  Such,  indeed,  is  the  opinion  of 
almost  all  practitioners,  and  it  was  also  our  own,  until  within  a  few  years  past. 
Since,  however,  we  have  so  often  seen  the  convulsions  continue  for  several  days 
after  the  spontaneous  expulsion  or  the  extraction  of  the  foetus,  we  have  far  less 
confidence  in  the  immediate  results  of  the  cessation  of  pregnancy.  As  we  have 
already  said,  the  principal  cause  of  eclampsia  is  to  be  sought  for  in  a  general 
alteration  of  the  economy;  now,  although  this  modification  is  due  to  the  course 
of  gestation  and  sustained  thereby,  it  is  impossible  that  it  should  disappear  im- 
mediately upon  delivery.  It  remains  for  a  longer  or  shorter  time,  and  the  woman 
returns  but  slowly  to  the  normal  state  of  the  unimpregnated  condition.  Although 
lessened,  it  may  still  exert  its  influence,  as  is  proved  by  the  occasional  occurrence 
of  attacks  several  hours,  and  sometimes  even  several  days,  after  delivery.  To 
empty  the  uterus  is,  therefore,  to  attack  but  one  of  the  remote  causes  of  eclamp- 
sia, by  no  means  the  immediate  one,  and  the  results  to  be  expected  from  it  appear 
to  me  too  uncertain  to  compensate  for  the  serious  dangers  inseparable  from  the 
operations  required  to  eff'ect  it. 

In  order  to  explain  our  view  thoroughly,  we  shall  examine  successively  the 
indications  afforded  by  severe  eclampsia,  according  to  whether  the  convulsions 
are  manifested  in  the  course  of  pregnancy  or  during  parturition,  or  subsequent 
to  the  delivery. 

1.  DariiKj  the  Gestation. — Prior  to  the  seventh  month,  that  is  to  say,  before 
the  period  at  which  the  foetus  is  viable,  the  treatment  must  be  restricted  to  the 


PUERPEKAL  CONVULSIONS.  743 

employment  of  the  means  above  indicated ;  even  though  there  be  an  absolute 
certainty  that  the  fcetus  is  dead,  nothing  should  be  done  to  induce  an  abortion, 
for  the  time  required  for  the  abortive  measures  to  act,  and  for  the  expulsion  of 
the  product  of  conception  to  take  place,  exceeds  by  far  the  ordinary  duration  of 
eclampsia,  and  the  woman  would  be  either  dead  or  cured,  before  their  influence 
could  be  felt. 

At  a  more  advanced  period  two  very  different  cases  may  present;  that  is,  either 
the  uterine  contractions  are  prematurely  and  spontaneously  developed  under  the 
influence  of  the  general  convulsions,  or  the  womb  remains  entirely  apart  from  the 
general  disorders  produced  by  the  eclampsia.  In  the  former  case  the  labor  has 
commenced,  and  we  shall  treat  below  of  the  means  to  be  then  employed,  upon 
which  most  accoucheurs  are  agreed  5  but,  in  the  latter,  the  proper  course  to  follow 
is  far  from  being  so  clearly  marked  out.  The  question  naturally  arises,  what  then 
is  to  be  done,  supposing  the  eclampsia  has  resisted  venesection,  the  intestinal  and 
cutaneous  revulsives,  &c. ;  and  supposing  that  the  patient  has  arrived  at  the 
eighth  or  ninth  month,  and  the  labor  has  not  commenced,  but  still  the  convul- 
sions continue  and  threaten  the  mother's  life. 

The  induction  of  labor,  and  forcible  delivery,  have  been  recommended  under 
these  dangerous  circumstances.  In  regard  to  the  first,  we  would  repeat  what  we 
have  already  said  of  abortion  :  the  means  usually  employed  to  provoke  the  uterine 
contractions,  act  too  slowly  in  a  case  in  which  we  suppose  the  mother's  life  to  be 
threatened,  by  convulsions  which  have  already  lasted  for  a  long  time,  and  against 
which  all  the  resources  of  therapeutics  have  been  expended  in  vain.  A  prompt 
depletion  of  the  uterus  is  the  only  thing  likely  to  afford  a  favorable  chance,  and 
forced  delivery  is  the  only  means  of  effecting  it.  But  at  a  period  still  quite  dis- 
tant from  terra,  the  length  of  the  neck,  and  the  resistance  of  its  unsoftcned  in- 
ternal orifice,  would  render  the  forcible  introduction  of  the  hand  very  difficult, 
and  the  efforts  required  to  penetrate  within  the  womb  are  very  likely  to  excite, 
to  irritate  the  organ,  and  consequently,  to  increase  the  general  convulsions. 

These  resistances,  and  the  general  irritation  which  they  produce,  are  so  great 
in  most  cases,  that  efforts  have  been  made  to  overcome  them  by  making  nume- 
rous incisions  around  the  circumference  of  the  cervix.  Doubtless,  when  the 
neck  is  effaced  either  by  the  progress  of  gestation  or  by  premature  contractions, 
these  incisions  may  be  useful  and  harmless,  since  they  are  practised  upon  the 
intra-vaginal  portion  of  the  neck  only ;  but  in  the  eighth  month,  whilst  the  neck 
retains  its  entire  length,  the  greatest  difficulties  are  presented  at  the  internal 
orifice  and  upper  part  of  the  cervix.  To  incise  the  external  orifice,  would  re- 
move only  the  least  resistance,  and  I  think  that  no  surgeon  would  have  the 
temerity  to  apply  a  cutting  instrument  to  the  internal  orifice.  I  have  yet  no 
experience  of  such  cases,  but  am  convinced  that  when  the  incisions  have  been 
successful,  it  has  been  in  cases  of  far  advanced  pregnancy,  or  when  unobserved 
contractions  had  dilated  the  upper  part  of  the  cervix.  This,  happily,  is  what 
takes  place  in  most  cases  of  long-continued  convulsions,  but  which  we  exclude 
from  the  supposed  conditions. 

Admitting,  however,  that  a  forcible  introduction  of  the  hand,  whether  prepa- 


744  DYSTOCIA. 

ration  liavc  been  made  or  not  by  incisions,  can  be  effected  without  mucli 
difficulty,  it  must  not  be  supposed  that  the  extraction  of  the  fcjctus  is  unaccompa- 
nied by  danger.  We  have  supposed  the  uterus  to  be  inert;  now,  although  the 
irritation  produced  by  the  hand  of  the  accoucheur  and  the  movements  impressed 
upon  the  foetus  during  its  extraction,  are  calculated  to  excite  contractions,  is 
there  not  cause  to  fear  lest  inertia  of  the  organ  might  result  from  this  too  rapid 
depletion,  and  become  the  source  of  fresh  accidents  ? 

If,  finally,  after  having  overcome  all  these  difficulties  we  were  sure  that  the 
eclampsia  would  cease,  I  could  understand  how  such  an  operation  might  be  under- 
taken ;  but  as  experience  proves  the  contrary,  I  think  that  during  pregnancy, 
however  severe  the  convulsive  attack  may  be,  we  should  restrict  ourselves  to  the 
employment  of  general  measures. 

There  are  certain  females  who  are  subject  during  pregnancy  to  repeated 
attacks  of  convulsions  at  variable  intervals,  and  in  whom  also,  each  fresh 
attack  is  more  serious  than  the  preceding.  The  recurrence  of  these  attacks  every 
eight  days  or  two  weeks,  compromises  increasingly  the  life  of  both  mother  and 
child,  and  we  might  reasonably  fear  lest  another  should  prove  fatal  to  both  in- 
dividuals. Now,  although  we  have  rejected  the  provocation  of  labor  during  the 
attack  itself,  we  think  it  proper  in  the  cases  just  mentioned.  But  it  should  be 
practised  only  in  the  intervals  of  the  convulsive  paroxysms. 

2.  During  Lahor. — The  prompt  termination  of  the  labor  so  generally  advised, 
should  not,  however,  be  practised  except  with  a  certain  degree  of  reserve;  and 
for  the  sake  of  clearness  in  this  recapitulation  of  the  indications,  we  shall 
endeavor  to  solve  the  following  questions  in  order: 

What  ought  to  be  done  when  the  cervix  is  dilated  or  dilatable  ?  And  what 
is  the  proper  course  to  pursue  when  it  is  neither  sufficiently  dilated  nor  dilatable, 
to  permit  a  prompt  artificial  termination  of  the  labor? 

a.  The  cervix  is  dilated  or  dilatable. — If  the  head  has  descended  into  the 
excavation  and  distends  the  perineum,  or  presses  strongly  upon  the  circumference 
of  the  uterine  orifice,  if  but  one  or  two  attacks  have  yet  occurred,  and  especially, 
if  there  is  reason  for  supposing  that  extreme  sensibility  of  the  cervix  or  of  the 
soft  parts,  may  have  had  any  agency  in  the  production  of  the  eclampsia,  the 
forceps  should  be  applied  immediately.  It  is  under  these  circumstances  more 
particularly,  that  the  immediate  termination  of  the  labor  prevents  a  recurrence 
of  the  accidents. 

If  the  eclampsia  is  slight,  though  it  has  lasted  for  a  certain  time,  that  is  to 
say,  if  the  convulsive  attacks  are  moderate  and  the  intervals  between  them  long; 
and  if  the  woman  regains  her  consciousness  entirely  during  the  interval ;  if, 
under  these  circumstances,  the  labor  is  advanced,  the  dilatation  complete,  and 
the  head  of  the  child  has  passed  through  the  orifice  and  descended  deeply  into 
the  excavation ;  if  the  uterus  contracts  powerfully,  and  if  the  perineum  is  not 
too  resisting,  we  think  it  right  to  wait  for  the  expulsion  to  take  place  naturally. 

But  if,  under  the  same  conditions,  the  pains  are  feeble,  distant,  and  ineffica- 
cious, or  if  the  contractions  are  energetic,  but  the  convulsions  are  frequent  and 
prolonged,  with  profound  coma  during  the  interval  of  the  paroxysms,  we  believe 


PUERPERAL  CONVULSIONS.  745 

that  tlie  mother  and  infant  should  be  immediately  relieved  from  the  dangers  that 
threaten  them,  by  the  application  of  the  forceps. 

When,  so  far  from  having  cleared  the  os  uteri,  the  head  is  still  retained  above 
the  superior  strait,  especially  if  the  membranes  are  still  intact,  the  pelvic  version 
would  in  general  appear  preferable  to  an  application  of  the  forceps.  (See  For- 
ceps.) We  say  that  the  version  would  appear  in  general,  not  always  preferable, 
for  we  know  this  is  at  times  impracticable,  even  where  the  head  is  still  above 
the  abdominal  strait.  The  almost  total  discharge  of  the  amniotic  liquid,  and 
the  violeiit  contractions  of  the  uterus,  which  often  participates  in  the  general  con- 
vulsions, and  the  violent  irritation  that  the  organ  has  to  support  during  the  in- 
troduction of  the  hand  and  the  evolution  of  the  foetus,  sufficiently  explain  our 
reserve,  as  well  as  the  preference  that  we  accord  to  the  forceps  in  this  particular 
case. 

Should  the  face  present,  and  be  well  down  in  the  excavation,  we  would  like- 
wise apply  the  forceps;  but,  on  the  contrary,  we  should  have  recourse  to  the 
pelvic  version  if  it  were  yet  above  the  superior  strait,  or  even  when  engaged  in 
this  strait,  if  it  happened  to  be  in  a  mento-posterior  position.  In  the  presenta- 
tions of  the  pelvic  extremity,  it  is  advisable  to  hasten  the  termination  of  the 
labor,  by  drawing  judiciously  and  carefully  on  this  extremity.  In  the  presenta- 
tions of  the  trunk,  the  feet  are  to  be  brought  down;  for  we  would  only  have 
recourse  to  the  cephalic  in  preference  to  the  pelvic  version,' when  the  pelvis  is 
greatly  contracted;  and  when  the  cephalic  version  is  resorted  to,  it  must  evidently 
be  followed  by  a  prompt  application  of  the  forceps,  and  if  these  should  fail,  of  the 
cephalotribe. 

h.  Wliat  is  to  he  done  tclien  the  cervix  is  neither  dihited  nor  dilatable  P — 
If  the  membranes  are  not  broken,  and  more  particularly  if  the  uterus  appears  to  be 
greatly  distended  by  a  large  quantity  of  water,  they  should  be  ruptured,  and  a 
discharge  of  the  liquid  and  a  partial  depletion  of  the  organ  be  facilitated,  by 
pushing  up  the  presenting  part  with  the  linger;  for  such  a  rupture  has  often 
proved  sufficient  to  diminish  the  frequency  and  intensity  of  the.  convulsive 
paroxysms,  and  has  justified  the  accoucheur  in  waiting  for  the  complete  dilata- 
tion of  the  cervix.  But  if  the  distension  of  the  womb  is  not  fiir  from  normal, 
we  think  that  the  interest  of  the  foetus  demands  that  the  membranes  .should  be 
respected,  and  spontaneous  dilatation  awaited  ;  when  this  dilatation  progresses 
too  slowly,  the  ointment,  or  still  better,  the  extract  of  belladonna  should  be  em- 
ployed, and  be  smeared  over  both  the  internal  and  external  portions  of  the 
orifice. 

But,  supposing  the  eclampsia  is  more  serious,  the  coma  still  continues,  and  the 
convulsions  have  not  been  alleviated  by  the  rupture  of  the  membranes;  and, 
moreover,  the  os  uteri  is  not  yet  dilated,  or  else  is  so  convulsively  contracted  as 
to  prevent  an  introduction  of  the  hand  or  instruments,  are  we,  under  such  favor- 
able circumstances,  to  abandon  the  delivery  to  nature,  as  some  accoucheurs 
advise  ?  Or,  on  the  contrary,  ought  we  to  penetrate  forcibly  into  the  uterine 
cavity,  by  opening  a  route  by  violence,  or  a  cutting  instrument. 

At  the  commencement,  or  even  during  the  first  four  or  five  hours  of  labor, 


746  DYSTOCIA. 

these  extreme  measures  doubtless  should  not  be  resorted  to;  but  when  the  con- 
vulsions persist,  notwithstanding  the  employment  of  the  most  rational  means ; 
when  ten,  twenty,  or  thirty  hours  have  elapsed  since  the  onset  of  the  symptoms; 
when  the  woman's  life  is  compromised  by  the  duration  and  the  constantly-in- 
creasing intensity  of  the  paroxysms,  our  only  hope  is  in  a  depletion  of  the  utenis; 
a  forced  delivery  then  appears  to  us  the  sole  resource,  and  authorized  by  the 
interest  of  the  child  even  more  than  by  that  of  the  mother. 

Two  plans  have  been  proposed  for  effecting  this  object,  namely,  a  forcible  in- 
troduction of  the  hand  into  the  womb,  and  the  division  of  the  cervix  Ijy  the  aid 
of  a  cutting  instrument.  We  shall  hereafter  revert  to  the  mode  of  operating  iu 
both  cases  when  describing  the  difficulties  that  may  be  met  with  in  making  the 
pelvic  version ;  and  will  therefore  only  remark  here  that,  by  the  length  of  time 
it  demands,  by  the  excitement  and  irritation  thereby  produced  (all  which  are 
assuredly  calculated  to  increase  the  convulsions),  and  by  the  lacerations  to  which 
it  gives  rise,  however  carefully  it  may  be  performed,  the  forcible  introduction  of 
the  hand  into  the  womb  is  very  dangerous,  and  ought  to  be  rejected;  and  that, 
unless  there  is  a  very  feeble  resistance  at  the  orifice  to  be  overcome,  repeated 
incisions,  made  at  divers  points  of  the  circumference  of  the  neck,  ought,  in  our 
opinion,  to  be  decidedly  preferred. 

But,  whatever  operative  process  be  employed,  the  resistance  from  the  os  uteri 
being  once  overcome,  the  labor  will  be  terminated  by  an  application  of  the 
forceps,  or  by  the  pelvic  evolution,  according  as  the  conditions  shall  be  found 
more  or  less  favorable  to  the  practice  of  the  one  or  the  other  operation ;  which 
conditions  will  be  carefully  detailed  when  we  shall  treat  of  version  and  the 
forceps. 

Inasmuch  as  the  expectation,  recommended  by  us  when  the  cervix  is  neither 
dilated  nor  dilatable,  except  in  cases  of  imminent  danger  to  the  mother,  is  op- 
posed to  the  generally-received  opinion,  it  becomes  necessary  to  defend  it. 
Although  regarding  in  a  general  way  the  termination  of  the  labor  as  a  favorable 
condition,  we  are  far  from  according  to  it  the  happy  effect  claimed  by  some  authors 
in  its  favor. 

In  no  case,  indeed,  in  which  the  eclampsia  had  existed  for  a  long  time  before 
we  were  called  to  the  patient,  have  we  ever  found  the  termination  of  the  labor  to 
put  an  end  to  the  symptoms,  and  very  rarely  did  it  ever  lessen  their  intensity. 
The  convulsions  continued  after  delivery  with  the  same  frequency  and  violence 
as  before.  In  three  cases  only  have  we  known  them  to  cease  after  the  applica- 
tion of  the  forceps ;  but  here  it  must  be  said,  that  having  witnessed  the  com- 
mencement of  the  eclampsia,  we  were  enabled  to  extract  the  foetus  immediately 
after  the  first  attack. 

If,  therefore,  we  regard  only  the  interest  of  the  mother,  we  think  that  the 
intervention  of  art  is  justifiable  only  when  the  dilatation  of  the  cervix  renders  it 
easy  and  but  moderately  irritating  to  the  maternal  organs;  but  if  the  foetus  is 
living,  its  life  is  seriously  endangered  by  a  too  long  continuance  in  the  cavity  of 
the  uterus,  especially  after  the  rupture  of  the  membranes;  and  since  the  termi- 
nation of  the  labor,  when  prudently  effected,  does  not  sensibly  increase  the 


EITPTURES    OF    THE     UTERUS.  747 

dangers  to  which  the  woman  is  exposed,  we  think  that  the  child  should  be 
extracted  as  early  as  possible. 

3.  After  the  Deliver)/. — The  only  special  indication,  presented  by  the  eclamp- 
sia after  the  child's  expulsion,  is  to  extract  the  after-birth  and  all  the  coagula, 
together  with  any  portions  of  the  membranes  that  may  have  been  retained  in  the 
uterus;  and  to  remove  the  sanious  matters  and  detritus  by  detergent  injections 
thrown  up  into  its  cavity. 

But  if  the  introduction  of  the  hand  should  prove  too  difficult  and  painful,  it 
should  be  withheld ;  for  the  retention  of  the  foreign  body  would  be  much  less 
irritating,  and  consequently  less  painful,  than  ill-timed  attempts  at  introduction. 

Within  a  few  years,  some  accoucheurs  have  thought  it  right  to  employ  anes- 
thetic inhalations  in  the  treatment  of  eclampsia.  Calculating  upon  the  power  of 
ether  and  chloroform  to  destroy  the  action  of  the  muscles  of  animal  life,  they 
hoped  that  they  might  act  in  the  same  way  upon  the  involuntary  and  spasmodic 
contractions  resulting  from  puerperal  convulsions.  The  observations  as  yet  pub- 
lished, though  not  numerous,  are  yet  sufficiently  so  to  enable  us  to  appreciate  the 
value  of  the  results.  This  appreciation  will  be  made  in  the  chapter  hereafter  to 
be  devoted  to  the  general  study  of  inhalations  of  ether  and  chloroform  in  obste- 
trical practice.  We  shall  be  content  with  saying  at  present,  that  an  attentive 
reading  of  almost  all  the  observations,  inclines  us  to  reject  inhalations  of  ether 
or  chloroform  in  eclampsia  as  generally  useless,  or,  perhaps,'  as  dangerous.  All 
proper  development  shall  be  given  to  this  proposition  further  on.  In  one  case 
only  they  might,  perhaps,  be  useful,  and  that  is,  when  the  eclampsia  appears  to 
have  had  its  origin  in  the  local  irritation  of  an  organ  (see  page  718),  the  extreme 
sensibility  of  which  had  awakened  the  reflex  action  of  the  spinal  nerves. 


CHAPTER  III. 

or   RUPTURES    OF   THE   UTERUS. 

A  RUPTURE  of  the  womb  is  one  of  the  most  dangerous  accidents  that  can 
happen  to  the  female  in  the  puerperal  state.  Exceedingly  rare  during  the  early 
months  of  gestation,  it  is  somewhat  more  frequent  in  the  latter  half  of  pregnancy; 
but  it  is  during  the  second  stage  of  the  labor,  especially,  that  it  most  frequently 
takes  place. 

Rupture  of  the  uterus  has  seldom  been  observed  in  women  bearing  their  first 
child.  Thus,  in  seventy-five  cases,  reported  by  Churchill,  nine  occurred  in 
primiparce,  fourteen  in  women  in  their  second  pregnancy,  thirteen  in  their  third, 
and  thirty-seven  in  their  fourth  or  succeeding  ones. 

The  woman's  age  does  not  seem  to  have  any  marked  influence  over  the  pro- 
duction of  this  accident.  Nevertheless,  the  organic  alterations  which  constitute 
a  predisposition  are  more  unusual  in  early  life  than  in  advanced  age. 


'748  DYSTOCIA. 

As  the  male  child  is  ordinarily  somewhat  larger  than  the  female,  this,  accord- 
ing to  Dr.  Clarke,  would  be  a  predisposing  circumstance;  thus,  in  twenty  cases 
of  rupture,  mentioned  by  Dr.  M.  Keever,  fifteen  were  male  children ;  and  of 
thirty -four  cases  by  Collins,  twenty-three  of  the  children  were  boys. 

The  rupture  may  be  seated  either  in  the  body  or  the  neck  of  the  organ.  When 
it  affects  the  cervix,  it  is  highly  important  to  ascertain  whether  it  only  involves 
the  sub-vaginal  portion,  or  whether  it  invades  that  part  situated  above  the  inser- 
tion of  the  vagina ;  because  the  former  is  attended  with  ver}'^  little  danger,  and 
occurs  very  frequently;  indeed,  it  takes  place  at  nearly  every  labor  just  at  the 
instant  when  the  head  is  clearing  the  orifice,  and  it  is  scai-cely  ever  followed  by 
any  unpleasant  symptoms.  The  last,  on  the  contrary,  presents  the  same  dangers, 
and  has  similar  consequences  with  the  ruptures  of  the  body.  Therefore,  we  need 
only  mention  here  the  lacerations  that  are  limited  to  the  orifice,  and  which  do 
not  extend  beyond  the  vaginal  insertion ;  and  all  that  we  are  about  to  say  con- 
cerning uterine  ruptures  refers  exclusively  to  those  in  the  body  of  the  womb  and 
in  the  supra-vaginal  portion  of  the  neck.  These  latter  are  the  more  frequent, 
and  they  are  located  somewhat  oftener  on  the  posterior  than  on  the  anterior 
face. 

§  1,  Causes. 

A  rupture  of  the  uterus  always  supposes  a  distension  of  the  organ,  and  this 
distension  is  most  frequently  dependent  on  pregnancy.  The  uterine  walls  become 
softened,  in  consequence  of  the  modifications  they  undergo;  their  thickness  is  a 
little  diminished  at  certain  points,  and  they  become  more  supple,  more  elastic, 
and  therefore  better  calculated  te  support  a  slow  and  gradual  pressure ;  for  owing 
to  this  suppleness,  they  can  yield  without  rupturing,  though  their  distension 
rendei-s  them  less  fitted  to  sustain  a  sudden  and  forcible  shock.  By  this  disten- 
sion, and  the  increase  in  volume  to  which  it  gives  rise,  the  uterus  is  forced  to 
ascend  above  the  superior  strait;  and  thenceforth  it  is  no  longer  protected  by  the 
osseous  walls  of  the  pelvis,  and,  consequently,  is  more  exposed  to  external  vio- 
lence, from  which  it  was  shielded  during  the  non-gravid  state.  Becoming  from 
its  situation,  in  immediate  contact  with  the  abdominal  parietes  without  the  inter- 
vention of  any  other  body,  it  is  subjected  to  the  unequal  pressure  which  the 
rapid  and  irregular  contraction  of  the  abdominal  muscles  during  any  violent 
efi'orts  may  make  upon  it. 

Pregnancy,  and  the  modifications  thereby  impressed  on  the  uterus,  are  there- 
fore the  essential  predispositions  to  rupture  of  the  uterus ;  but,  independently  of 
these  conditions,  which  exist  in  all  gravid  women,  there  is  a  number  of  other 
circumstances  which  have  a  more  immediate  influence  over  the  production  of  this 
accident ;  and  which  authors  have  designated  under  the  titles  of  the  predisposing 
and  the  determining  causes. 

1.  Prcdiqwsing  Causes. — Under  this  head  we  must  include  everything  that 
can  augment  the  distension  or  diminish  the  resistance  of  the  uterine  walls,  as, 
for  instance : 


RUPTUllES    OF    THE     UTERUS.  749 

A.  A  great  abundance  of  the  amniotic  liquid,  the  presence  of  several  children, 
&c. 

B.  The  extreme  thinness  of  the  uterine  walls,  which  is  met  with  in  certain 
women,  and  which  cannot  be  accounted  for. 

c.  An  enfeeblement  of  the  uterine  parietes,  dependent  on  causes  which  have 
operated  at  a  more  or  less  remote  period,  such  as  falls,  blows,  &c. ;  the  contused 
walls  inflame,  become  softened,  and  ulcerate ;  sometimes  the  rupture  comes  on 
during  the  same  pregnancy,  at  others,  several  gestations  may  succeed  it  without 
any  accident,  and  yet  a  rupture  take  place  at  a  subsequent  one. 

The  enfeeblement  may  likewise  result  from  divers  softenings;  such  as  those 
designated  by  M.  Dezeimeris  as  the  atrophied,  the  apoplectiform,  the  inflamma- 
tory, and  the  gangrenous  ramollissements,  and  those  produced  by  organic  altera- 
tions. We  must  add  another  circumstance,  which  is,  in  truth,  very  unusual,  but 
whose  influence  has  been  fully  demonstrated  by  several  Avell-attested  instances; 
namely,  those  women  who  have  undergone  the  Cajsarean  operation,  and  who 
have  had  the  rare  fortune  to  escape  the  grave  dangers  that  attend  it,  seem  more 
disposed  than  others  to  uterine  rupture  in  the  following  pregnancy ;  thus.  Dr. 
Kayser  has  brought  forward  six  cases  in  his  excellent  thesis,  in  which  the 
patients,  who  had  before  been  operated  upon  safely,  have  been  compelled  to  sub- 
mit to  gastrotomy,  in  consequence  of  a  rupture  of  the  womb ;  three  of  these 
women  died. 

D.  All  the  organic  alterations,  and  all  the  degenerations  of  tissue  of  which  the 
uterus  may  be  the  seat ;  such  as  the  scirrhous,  fibrous,  or  encephaloid  tumors. 
The  softening  and  ulceration  of  these  morbid  masses  may  render  that  portion  of 
the  walls  they  occupy  thinner  and  weaker;  oftener,  on  the  contrary,  they  aug- 
ment the  thickness  and  even  the  consistence  of  the  uterine  tissue,  but  still  act 
as  predisposing  causes  of  ruptures,  at  least  during  parturition,  in  the  following 
way :  the  point  thus  affected  not  contracting  whilst  all  the  others  are  in  action, 
the  resistance  made  by  it  would  be  wholly  passive ;  and  hence,  whatever  be  its 
strength,  it  cannot  hold  out  against  the  contractions  of  all  the  rest  of  the  organ, 
the  action  of  which,  being  aided  by  that  of  the  abdominal  walls,  weighs  with  all 
its  force,  as  it  were,  on  that  portion  which  does  not  participate  in  the  general 
action ;  and  if  we  suppose  that  any  obstacle  whatever  prevents  the  ready  engage- 
ment of  the  foetus,  the  uterine  effort,  which  is  incapable  of  overcoming  the  resist- 
ance it  encounters  in  clearing  the  superior  strait,  is  felt  at  the  point  which  does 
not  contract,  and  consequently  this  latter  becomes  ruptured.  And  it  is  by  a 
similar  mechanism  that  the  irregular  or  partial  contractions  may  produce  a  rup- 
ture, by  leaving  some  one  point  of  the  uterine  walls  in  a  state  of  inertia,  whilst 
all  the  others  are  contracting. 

During  the  labor,  we  must  add  everything  that  may  render  the  parturition 
difficult,  or  require  unusual  and  long-repeated  contractions  on  the  part  of  the 
organ.  In  this  respect,  all  narrowing  of  the  pelvis,  every  tumor  that  obstructs 
the  excavation,  all  resistances  offered  by  the  cervix  uteri,  whether  dependent  on 
an  agglutination  of  the  lips,  a  degeneration  of  its  tissue,  on  a  state  of  spasm,  or 
a  considerable  obliquity  of  the  body,  and  the  malpositions,  as  well  as  the  malfor- 
mations of  the  foetus,  may  become  causes  of  rupture  of  the  uterus. 


750  DYSTOCIA. 

The  ruptures  of  the  uterus  which  take  place  during  labor  almost  always  occur 
after  the  rupture  of  the  meiubranes.  Still,  James  Hamilton  reports  a  case  in 
■which  the  memhranes  were  found  entire  at  the  autopsy. 

2.  Deterniining  Causes. — A  number  of  causes  may  serve  to  produce  a  rupture 
under  the  influence  of  some  one  of  these  predispositions;  all  of  which,  however, 
can  be  classified  under  two  principal  heads,  namely,  the  external  or  traumatic, 
and  the  internal  causes. 

3.  External  or  Traximatic  Causes. — It  is  not  without  some  hesitation  that  I 
venture  to  say  a  few  words  here  about  the  traumatic  lesions  to  which  the  womb 
is  exposed  as  a  cause  of  rupture ;  for  it  is  well  known  that,  at  every  period  of 
life,  this  organ  is  liable  to  be  injured  by  a  projectile  thrown  by  gunpowder,  by 
any  murderous  instrument,  or  by  the  horn  of  an  infuriated  animal.  But  it  must 
be  remembered  that  the  increased  size  of  the  organ,  during  gestation,  exposes  it 
then  more  than  ever  to  this  variety  of  lesions ;  though  the  consequences  and  the 
indications  for  treatment  are,  in  other  respects,  nearly  the  same.  Again,  wo 
must  add  that  perforations  and  lacerations  of  the  uterus  often  result  from  ill- 
directed  obstetrical  manipulations. 

The  womb  is  also  greatly  exposed  to  compression  or  violent  contusion  of  its 
walls,  when  it  is  developed  by  the  product  of  conception.  This  compression  may 
be  mediate,  that  is  to  say,  dependent  on  exterior  causes,  such  as  fidls  or  blows  on 
the  abdomen,  the  pressure  of  this  region  by  the  backing  up  of  a  coach  against  a 
wall,  or  the  passage  of  its  wheels  over  the  belly;  or  it  may  be  immediate,  that  is, 
due  to  the  violent  contraction  of  the  abdominal  muscles.  The  effects  of  mediate 
compression  are  generally  of  little  consequence,  owing  to  the  mobility  of  the 
uterus,  the  suppleness  of  its  walls,  and  the  2^oint  d'appui  which  the  latter  find 
in  the  surrounding  parts.  Nevertheless,  they  sometimes  are  followed  by  disas- 
trous consequences:  thus,  it  is  stated,  in  the  old  Journal  de  Mcdccine,  that  a 
woman  had  a  rupture  of  the  womb  at  the  seventh  month  of  her  gestation,  in 
consequence  of  having  been  pressed  between  a  wall  and  a  carriage.  As  before 
stated,  the  contusion  of  the  ventral  parietes  seldom  produces  an  immediate  rup- 
ture ;  but  the  bruise  and  consecutive  inflammation  of  the  uterine  structure  may 
determine  an  ulceration,  and  then  a  perforation  at  some  future  period. 

The  ruptures  by  immediate  compression,  or  those  which  result  from  the  vio- 
lent contraction  of  the  abdominal  muscles,  seldom  occur  without  the  pre-exist- 
ence  of  some  one  of  the  alterations  of  the  uterine  walls,  considered  above  as 
predisposing  causes.  They  generally  follow  a  fit  of  coughing,  sneezing,  or 
vomiting,  or  take  place  during  a  paroxysm  of  anger;  but  they  may  likewise  be 
occasioned  by  the  patient's  attempts  to  raise  some  burden,  and  by  the  forcible 
bending  of  the  body  "backward,  which  latter  cannot  occur  without  the  recti 
muscles  of  the  abdomen  becoming  closely  approximated  to  the  vertebral  column 
during  the  forward  curvature  of  the  trunk ;  in  all  these  movements,  the  womb  is 
forcibly  compressed  between  the  abdominal  muscles,  which  contract  vigorously, 
and  the  posterior  plane  of  the  abdominal  cavity.  A  rupture  has  been  known  to 
occur  at  all  stages  of  gestation,  from  the  earliest  months  up  to  full  term,  under 
the  influence  of  some  one  of  these  causes. 


RUPTURES  OF  THE  UTERUS.  751 

4.  Infernal  Causes. — Authors  have  incorrectly  considered  the  enormous  dis- 
tension of  the  uterus  during  pregnancy  as  being  capable  of  producing  a  rupture  ; 
for,  although  this  distension  is  a  predisposing  cause,  yet,  however  great  it  may 
be,  it  cannot  of  itself  give  rise  to  such  an  accident  without  the  previous  existence 
of  an  organic  alteration.  The  same  is  true  of  the  violent  and  convulsive  move- 
ments of  the  fcjctus,  whose  impetus  is  too  inconsiderable  to  occasion  a  rupture  ] 
and  besides,  the  womb  is  fully  protected  against  its  influence  by  the  amniotic 
liquid  and  the  suppleness  of  the  walls. 

During  labor,  the  uterine  contraction  is  the  most  frequent  determining  cause; 
and  though  the  walls  of  the  organ  were  altogether  passive  in  the  course  of  gesta- 
tion, they  here  play  the  principal  part  in  the  production  of  the  rupture. 

After  the  membranes  are  ruptured  and  the  waters  entirely  discharged,  the 
walls  of  the  uterus  are  applied  directly  upon  the  foetal  ovoid.  Now,  in  the 
doubled  up  condition  of  the  various  parts  of  the  child,  numerous  projections  and 
irregularities  are  presented,  which  make  the  resistance  at  its  different  points  very 
unequal.  Consequently,  some  parts  of  the  uterus  are  more  or  less  stretched  over 
the  projecting  parts,  and,  to  use  jMadame  Lachapelle's  expression,  some  of  the 
muscular  fasciculi  act  in  a  wrong  direction,  whilst  others,  finding  a  firm  support, 
contract  with  greater  energy. 

The  equilibrium  of  the  forces  is  then,  says  M.  Taurin,  broken  at  several  points 
of  the  womb,  and  the  organ  contracts  irregularly.  The  non-compressed,  healthy, 
and  thicker  parts,  contract  with  greater  power,  and  draw  upon  the  parts  in  the 
vicinity;  the  latter,  already  distended  by  the  foetal  projections,  become  still 
thinner,  their  resistance  yields  more  and  more,  and  at  last  incapable  of  longer 
resistance,  they  give  way  under  the  more  powerful  contractions  of  the  neighbor- 
ing parts. 

Such  would  be  the  course  of  affairs,  more  especially,  in  an  unflivorablc  posi- 
tion of  the  foetus, — one  of  the  shoulder,  for  example. 

We  would  add  further,  that  when  the  labor  is  prolonged  greatly,  the  pressure 
of  the  foetal  projections  upon  the  walls  of  the  uterus  may  cause  their  inflamma- 
tion, ulceration,  or  even  gangrene,  all  of  them  circumstances  likely  to  facilitate 
rupture. 

Deformities  of  the  pelvis,  by  presenting  a  mechanical  obstacle  to  the  passage 
of  the  foetus,  also  constitute  a  predisposition  to  rupture ;  but  even  here,  the  con- 
traction is  the  determining  cause.  In  some  other  cases,  the  hard  and  unequal 
projections  presented  by  the  irregularly  contracted  circumference  of  the  pelvis 
may  produce  a  direct  rupture  of  the  lower  segment  of  the  uterus,  or  of  the  walls 
of  the  cervix.  Thus,  we  may  readily  conceive  that  a  too  great  anterior  projec- 
tion of  the  sacro-vertebral  angle,  as  also  the  prominent  ridge  sometimes  presented 
by  the  superior  and  posterior  face  of  the  symphysis  pubis,  might  bruise,  or  even 
tear,  the  part  of  the  uterus  which  is  strongly  compressed  between  it  and  the 
head  of  the  foetus.  M.  Taurin  mentions  a  case  in  his  thesis  in  which  M.  P.  Du- 
bois attributed  to  this  compression  a  rupture  comprising  a  part  of  the  vagina,  the 
whole  anterior  surface  of  the  neck,  and  which  extended  up  the  left  side  of  the 
body  of  the  uterus. 


752  DYSTOCIA. 

The  clilld's  active  movements  are  as  foreign  to  the  Ulceration  that  takes  place 
in  parturition  as  to  those  that  occur  during  pregnancy.  For,  according  to  the 
observation  of  M.  Duparcque,  if  this  movement  is  effected  during  the  relaxation 
of  the  walls,  their  suppleness  and  extensibility  enable  them  to  yield  to  this  force; 
but  if,  on  the  contrary,  it  takes  place  while  the  contraction  lasts,  the  resistance 
•which  they  then  present  would  require  a  far  greater  impetus  to  overcome  it  than 
any  that  can  result  from  even  a  convulsive  movement  of  the  foetus.  The  con- 
traction is  therefore  the  sole  determining  cause  ;  but,  for  it  to  produce  a  rupture, 
its  action  must  be  favored  by  one  of  the  predisposing  circumstances  before  indi- 
cated, the  influence  of  which  is  easily  understood. 

These  spontaneous  ruptures  hardly  ever  take  place  except  in  labors  at  term, 
and  appear  impossible  in  abortions  at  four  or  five  months.  A  case  which  re- 
moves the  smallest  doubt  as  to  the  possibility  of  such  an  accident  within  the  first 
six  months  of  gestation,  has,  however,  been  communicated  to  M.  Danyau  by  M. 
Castelneau.  A  woman  died  almost  suddenly  in  consequence  of  a  profuse  hemor- 
rhage, and  it  was  found  that  the  neck  of  the  uterus  and  the  vagina  were  ruptured, 
the  former  through  its  entire  length  and  the  latter  at  its  upper  part.  The  acci- 
dent occurred,  in  all  probability,  during  contractions  which  expelled  the  ovum 
very  rapidly;  for  although  no  portion  of  it  remained  in  the  uterus,  the  organ 
presented  every  appearance  of  one  which  had  attained  the  usual  development  at 
five  months  of  gestation. 

However,  it  must  not  be  forgotten  that  rupture  of  the  womb  has  often  occurred 
during  parturition,  from  the  imprudent  manipulations  made  with  a  view  of  ter- 
minating the  labor.  For  how  often  has  an  application  of  the  forceps,  a  resort  to 
version,  or  a  difficult  extraction  of  the  placenta  performed  by  inexperienced 
hands — how  often  have  all  of  them  been  followed  by  the  early  death  of  the 
patient,  and  a  laceration  of  the  organ  been  detected  at  the  autopsical  examina- 
tion !  In  fact,  cases  of  the  kind  are  mentioned  by  nearly  all  authors;  and 
Madame  Legrand,  the  midwife  in  chief  of  La  Maternite,  informed  me  that  several 
women  are  brought  to  the  hospital  every  year  to  die,  the  victims  of  such  attempts 
made  in  the  city.  I  have  seen  a  uterus  the  lower  two-thirds  of  whose  body  on 
the  right  side  had  been  torn  away  by  the  embryotomy  forceps;  and,  in  another 
case,  I  found  at  the  2X)st-7nortem  examination  a  perforation  in  the  right  superior 
part  of  the  body  of  the  womb,  produced  by  the  attempts  which  a  practitioner 
had  made  to  separate  a  firmly  adherent  placenta.  Facts  of  this  nature  cannot 
be  repeated  too  often,  for  they  are  calculated  to  render  young  physicians,  who 
intend  to  practise  midwifery,  more  cautious ;  and  to  convince  them  that,  to  have 
attended  two  or  three  women  in  labor  is  not  all  that  is  needed  to  render  them 
capable  of  performing  the  most  difficult  operations  of  our  art. 

§  2.  Symptoms. 

The  signs  of  rupture  of  the  uterus  are  easily  made  out ;  for  most  frequently 
the  laceration  takes  place  suddenly  after  some  violent  effort  that  has  necessitated 
a  forcible  contraction  of  the  abdominal  muscles.  It  is  manifested  by  an  exceed- 
ingly sharp  pain  just  at  the  point  where  the  accident  occurred,  which  makes  the 


RUPTURES  OF  THE  UTERUS.  753 

patient  scream  out  from  the  intensity  of  suffering.  This  acute,  or,  as  Desormcaus 
describes  it,  agonizing  and  cramp-like^  pain,  is  accompanied  by  a  sound  of 
tearing  or  cracking,  loud  enough,  in  some  cases,  to  be  heard  by  the  surrounding 
persons.  This  pain  soon  changes  to  a  sensation  of  numbness,  and  is  followed 
almost  immediately  by  swooning;  the  patient  becomes  pale,  her  pulse  sinks,  and 
she  falls  into  a  state  of  syncope.  These  primary  phenomena  are  the  only  ones 
that  are  manifested  when  the  pregnancy  is  not  f\ir  advanced,  and  when  the 
uterus  has  not  ascended  high  enough  to  be  easily  accessible ;  or,  else,  when  the 
ovum,  having  engaged  in  the  lips  of  the  wound,  plugs  it  up  in  such  a  way  as  to 
prevent  any  effusion  into  the  abdominal  cavity.  A  deceitful  calm  may  thus 
succeed  the  storm,  and  the  symptoms  be  only  renewed  after  several  hours,  or 
even  days,  when  the  uterus,  by  contracting,  shall  expel  the  parts  it  encloses  into 
the  abdominal  cavity.  In  the  opposite  case,  and  more  especially  in  the  advanced 
stages  of  gestation,  we  can  readily  detect  the  softening  and  depression  of  the 
hypogastric  walls  by  an  examination  of  the  patient;  for,  instead  of  feeling  the 
hard,  globular  tumor  formed  by  the  womb  in  this  region,  we  simply  find  the 
yielding,  depressible  walls  of  the  abdomen,  and  still  lower  the  more  or  less  re- 
duced and  distorted  neck  of  the  uterus.  The  patient  who,  at  the  instant  of  rup- 
ture, or  shortly  after,  experienced  a  gentle  heat  diffusing  itself  through  the 
abdomen,  now  feels  some  strange  movements,  or  an  unusual  weight  at  a  point 
where  she  never  had  them  before  ;  and  the  accoucheur  himself  detects  the  pre- 
sence of  the  child  in  a  spot  where  it  should  not  be,  and  he  can  now  distinguish 
its  movements  and  the  prominences  it  offers  much  more  clearly  than  usual. 
But  these  active  motions  of  the  fcetus  soon  cease  to  be  apparent,  though  their 
final  disappearance  is  ordinarily  preceded  by  an  unusual  and  almost  convulsive 
agitation ;  most  generally,  a  little  blood  escapes  from  the  vulva,  in  consequence 
of  the  detachment  of  the  placenta,  but  this  phenomenon  may  be  wanting,  espe- 
cially in  first  pregnancies.  Where  the  accident  occurs  during  labor,  the  pains, 
that  were  hitherto  strong  and  energetic,  disappear  at  once. 

The  most  conclusive  signs  are  furnished  by  the  touch  ;  thus,  during  gestation, 
the  finger  can  detect  a  change  in  the  position  of  the  womb,  and  the  want  of  the 
volume  which  it  generally  has  at  the  stage  of  pregnancy  the  woman  supposes 
herself  to  have  arrived  at.  Sometimes  it  can  even  feel  a  part  of  the  foetus 
situated  externally  to  the  womb,  and  depressing  the  upper  part  of  the  vagina. 
During  the  labor  it  finds  the  bag  of  waters  to  become  suddenly  collapsed,  or  no 
longer  projecting  through  the  os  uteri,  and  yet  without  the  escape  of  any  liquid 
by  the  vagina.     The  presenting  part  of  the  child,  which,  a  few  moments  before, 

'  According  to  Dr.  Roberton,  when  a  rupture  takes  place  in  consequence  of  a  contraction 
of  the  pelvis,  it  is  preceded  by  crampy  pains  and  a  sensibility  to  pressure  at  a  circumscribed 
point  of  the  hypogastrium.  This  crampy  pain  is  caused  by  a  compression  of  the  uterus  be- 
tween the  child's  head  and  the  promontory  of  the  sacrum,  or  some  other  prominent  osseous 
part.  A  pain  of  this  nature  existed  in  a  high  degree  in  a  woman,  in  whom  the  anterior  lip 
of  the  cervix  uteri  was  considerably  tumefied,  and  was  also  situated  much  lower  than  the 
liead  :  Dr.  Roberton  succeeded  in  relieving  it,  by  pushing  up  the  tumefied  lip  during  the 
interval  between  the  contractions. 

48 


754  DYSTOCIA. 

was  accessible  to  the  finger,  has  now  gone  up,  and  perhaps  disappeared  alto- 
gether ;  the  cervix  uteri  has  shrunk  up,  and  the  orifice  is  much  less  dilated  than 
it  was  previously. 

If  an  attempt  be  then  made  to  pass  the  hand  into  the  uterine  cavity,  perhaps 
it  will  find  this  cavity  wholly  obliterated  by  the  retraction  of  the  walls;  or  pos- 
sibly it  may  encounter  the  intestines  there,  or  else  only  a  part  of  the  foetus,  the 
rest  having  escaped  into  the  belly.  The  seat  and  extent  of  the  laceration  can 
thus  be  determined,  and,  in  some  instances,  the  hand  may  even  be  made  to 
penetrate  through  into  the  abdomen. 

When  all  these  phenomena  are  met  with,  there  can  be  no  doubt  in  regard  to 
the  nature  of  the  accident,  but  it  is  not  always  possible  to  recognize  them  so 
clearly;  for  if  the  child,  instead  of  being  displaced,  remains  in  the  cavity  of  the 
womb  after  the  rupture,  it  may  happen  that  the  signs  furnished  by  the  vaginal 
touch,  and  the  abdominal  palpation,  will  be  altogether  wanting.  In  this  case, 
the  diagnosis  is  very  difficult,  and  the  cause  of  death  is  disclosed  only  by  the 
autopsy. 

§  3.  Prognosis  and  Termination. 

The  prognosis  of  uterine  ruptures  is  exceedingly  unfavorable ;  for  they  nearly 
always  prove  fatal  to  the  child,  and  expose  the  mother  to  an  almost  certain  death. 
Nevertheless,  its  gravity  varies  according  to  the  extent  and  the  seat  of  the  lesion, 
and  the  consecutive  phenomena  to  which  this  gives  rise. 

Some  cases  have  been  reported  in  which  the  great  disorder  in  the  organism 
produced  by  the  rupture,  and  the  escape  of  the  blood,  waters,  and  foetus  into  the 
abdominal  cavity,  caused  instantaneous  death.  But,  most  genei'ally,  some  par- 
ticular phenomena,  or  symptoms,  occasioned  by  the  accidents  consecutive  to  the 
primary  lesion,  precede  the  fatal  termination ;  which  latter  may  result  either 
from  hemorrhage,  from  the  inflammations  and  suppurations  created  by  the  pro- 
longed sojourn  of  a  foreign  body  in  the  peritoneal  cavity,  cr  from  the  operations 
necessary  for  its  extraction. 

A.  Hcmorrliaje. — Flooding  is  the  most  frequent,  and  at  the  same  time  the 
most  speedily  fatal,  of  all  these  accidents.  Its  source  is  evidently  in  the  torn 
vessels  of  the  womb,  especially  when  the  rupture  takes  place  at  the  point  of  the 
insertion  of  the  placenta  ;  but  when  this  point  remains  intact,  it  principally  comes 
from  the  utero-placental  vessels  which  have  been  torn  by  the  detachment  of  the 
after-birth ;  since  the  margins  of  the  rupture,  when  this  occurs  at  some  distance 
from  the  placenta,  usually  furnish  but  little  blood.  As  a  general  rule,  only  a 
small  quantity  of  it  reaches  the  exterior;  while,  on  the  contrary,  it  is  effused 
abundantly  into  the  belly  along  with  the  amniotic  waters  and  the  body  of  the 
child  (which  has  passed  in  a  great  measure  into  the  peritoneal  cavity),  and  the 
whole  distends  the  abdomen  enormously.  Again,  this  effusion  is  equally  profuse 
in  those  cases  in  which  the  waters  have  escaped,  and  the  infant  lies  in  the  womb 
in  such  a  way  as  to  prevent  its  issue.  The  ruptured  margins  being  hindered 
from  coming  together,  the  lacerated  vessels  continue  to  pour  out  their  blood,  until 
the  hypogastric  walls  oppose  a  resistance  to  the  effusion,  which  is  always  too  late 
to  prevent  death ;  and  the  latter  may  thus  take  place  without  being  preceded  by 


RUPTURES     OF    THE     UTERUS.  755 

any  sign  that  would  lead  us  to  suspect  the  rupture.  Again,  it  may  happen,  even 
•when  the  delivery  is  effected  immediately,  that  the  contraction  is  not  sufficiently 
energetic  to  obliterate  the  calibre  of  the  vessels  entirely,  and  the  hemorrhage 
continues  long  enough  to  destroy  the  patient. 

The  effusion  ordinarily  takes  place  into  the  sac  of  the  peritoneum ;  but  when 
this  serous  tunic  is  not  implicated  in  the  solution  of  continuity,  the  blood  infil- 
trates between  it  and  the  uterus,  gains  the  duplicature  of  the  broad  ligaments, 
and  may  thus  get  into  the  cellular  tissue  of  the  pelvis  and  loins.  In  such  cases, 
a  layer  of  black  blood  is  found  interposed  between  the  peritoneum  and  the  womb, 
where,  by  becoming  exactly  modelled  on  the  external  surface  of  the  organ,  as- 
sumes its  form,  and  may  thus  by  its  livid  color  be  mistaken  for  a  gangrenous  state 
of  this  viscus.   (Duparcque.) 

Nevertheless,  the  uterus  may  be  ruptured,  without  being  necessarily  followed 
by  a  profuse  hemorrhage ;  as  where  the  laceration  takes  place  at  a  point  which 
is  moderately  provided  with  vessels,  in  the  vicinity  of  the  neck,  for  example. 
On  the  other  hand,  it  may  happen  that,  the  ovum  remaining  intact  after  the 
accident,  the  fissure  becomes  filled  up  in  a  measure,  either  by  a  portion  of  the 
membranes  or  placenta,  or  a  part  of  the  child;  or,  the  body  of  the  infant  may  be 
partly  driven  into  the  abdomen,  whilst  the  borders  of  the  laceration  become  so 
retracted  around  it  that  the  salutary  compression  thereby  produced  prevents  a 
continuation  of  the  hemorrhage.  Again,  when  the  entire  ovum  passes  rapidly 
through  the  fissure  into  the  peritoneal  cavity,  the  uterus  prevents  or  at  least 
diminishes  the  bleeding  by  contracting  at  once,  whereby  a  powerful  obstacle  to 
the  further  discharge  of  blood  is  created. 

B.  Injlavimation. — When  the  patient  does  not  die  from  the  loss  of  blood  that 
immediately  follows  the  rupture,  a  momentary  calm  succeeds,  but  the  presence 
of  foreign  bodies  in  the  cavity  of  the  peritoneum  gives  rise  to  an  inflammation 
of  this  membrane,  which  is  the  more  serious  as  they  are  the  larger ;  and  even 
where  the  accoucheur  has  succeeded,  by  any  mode  whatever,  in  removing  the 
foetus  and  after-birth,  inflammation,  though  less  to  be  dreaded,  may  still  result 
from  the  operation  or  measures  necessary  for  this  extraction,  and  may  speedily 
terminate  in  death. 

0.  Escape  of  an  Intestine  tliroufjh,  and  its  Strangulation  in,  the  Fissure. — 
A  considerable  portion  of  intestine  has  been  known  to  pass  through  the  lacera- 
tion in  the  uterus,  and  to  become  strangulated  by  the  retraction  of  the  organ. 
This  accident,  which  would  not  be  suspected,  if  the  foetus  were  still  enclosed  in 
the  womb,  or  if  the  latter  had  completely  retracted,  might,  however,  be  detected 
immediately  after  the  delivery;  but  should  it  escape  detection,  it  would  infallibly 
terminate  in  death,  as  occurred  in  the  case  reported  by  Percy,  and  reproduced  by 
M.  Deneux.  Consequently,  whenever  there  is  reason  to  suspect  a  rupture  of  the 
womb,  it  is  necessary  to  carry  the  hand  up  into  the  interior  of  the  organ  as  soon 
as  the  delivery  is  effected,  and  (following  the  plan  of  Kungius)  to  press  back  the 
intestines  into  the  abdomen,  and  then  keep  the  hand  in  the  uterine  cavity  until 
the  organ  is  sufficiently  retracted,  and  the  fissure  diminished,  to  prevent  a  return 
of  the  hernia. 


756  DYSTOCIA. 

D.  Recovery. — Some  women  have  recovered  from  all  these  dangers;  a  few 
have  even  undergone  gastrotomy,  and  survived  the  consecutive  accidents ;  while 
in  others,  the  fetus  and  its  appendages  have  escaped  bodily  into  the  peritoneal 
cavity,  and  have  there  given  rise  to  inflammatory  symptoms  which  gradually 
passed  off.  Salutary  adhesions  were  formed,  as  a  consequence  of  the  inflamma- 
tion, whereby  the  foetus  and  its  appendages  were  enclosed  in  a  pseudo-membra- 
nous cyst  that  isolated  them  from  the  surrounding  parts;  the  latter  became  habi- 
tuated to  this  new  vicinage,  which  has  continued  for  a  variable  period,  and 
sometimes  even  throughout  life.  But  this  cyst,  like  those  which  surround  other 
extra-uterine  products,  may  become  the  seat  of  a  fresh  inflammatory  action ;  its 
walls  contract  new  adhesions  with  neighboring  organs,  and  we  sometinies  find 
ulcerations  and  perforations  occurring,  after  the  lapse  of  many  years,  by  which 
the  cavity  of  the  cyst  is  made  to  communicate  with  that  of  the  intestine  or  blad- 
der, and  the  last  pieces  of  the  skeleton  are  finally  expelled  through  the  urethra, 
the  rectum,  or  the  oesophagus.' 

Where  the  child  remains  in  the  uterine  cavity,  notwithstanding  the  rupture, 
and  the  contractions  do  not  immediately  expel  it  by  the  natural  passages,  the 
same  phenomena  may  be  subsequently  manifested ;  that  is,  the  inflamed  and 
ulcerated  uterine  tissue  contracts  adhesions  either  with  the  abdominal  parietes  or 
with  those  of  some  adjacent  organ,  and  the  foetal  debris  then  escape  through  the 
ulcerated  and  perforated  wall,  or  else  by  the  natural  openings  of  the  excretory 
organs.   (Duparcque.) 

§  4.  Patholooical  Anatomy. 

Every  portion  of  the  uterus  may  become  the  seat  of  rupture,  though  there  are 
some  parts  which  are  more  liable  to  be  aff"ected  than  others ;  such  are  the  inferior 
regions,  the  fundus,  and  the  lateral  portions  of  the  body,  and  the  superior  or 
supra-vaginal  parts  of  the  neck.  Moreover,  the  seat  of  laceration  varies  accord- 
ing to  the  cause  that  has  given  rise  to  it,  as  also  to  the  period  at  which  it  takes 
place ;  thus,  during  gestation,  the  body  is  always  ruptured,  but  during  labor,  on 
the  contrary,  these  solutions  of  continuity  are  met  with  about  the  neck  or  in- 
ferior portion  of  the  body,  which  is  in  general  thinner,  and  not  so  well  supported 
as  the  rest  of  the  organ.  Where  the  accident  has  resulted  from  some  external 
compression,  the  walls  usually  become  lacerated  towards  the  lateral  parts ;  when 
it  has  resulted  in  consequence  of  a  contusion,  the  bruised  point  is  ordinarily  the 
one  that  afterwards  gives  way :  and  if  the  rupture  has  been  preceded  by  any 

>  For  instances  of  recovery,  see:  Pen.  Pratique  dcs  Accoitchemcnts,  341  ;  Hamilton's  Out- 
lines of  Midwifery ;  James  Hamilton,  Select  Cases  in  Midivifery,  138;  Jos.  Clarke,  Trans,  of 
Association,  vol.  i ;  Douglas,  Essays  on  Ruptures  of  the  Uterus,  p.  7  ;  Labatt,  Dublin  Med.  Essays, 
p.  343  ;  Frizell,  Trans,  of  Association,  vol.  ii,  p.  15 ;  Roo?,  Annals  of  Med.,  vol.  iii,  p.  377  ;  Kite, 
3fem.  of  Med.  Society,  vol.  iv,  p.  253;  Powel,  3{ed.  Cliir.  Transact.,  vol.  xii,  p.  .^37  ;  Bird),  Ibid., 
xiii,  p.  537  ;  Smith,  Ibid.,  p.  373 ;  Mac-Intyre  et  Brook,  Med.  Gazette,  vol.  vii,  et  Janvier,  1  S->9  ; 
Hendrie,  Amer.  Journ.  of  Med.  Science,  vol.  vi,  p.  351;  Davi?-,  Obst.  Med.,  vol.  ii,  p.  1070. 

MM.  Keevar  and  Collins  have  each  reported  two  cases;  M.  Duparcque  quotes  four  from 
French  authors.  Osiander  states  that  he  has  met  with  several  cases  of  the  kind,  and  M.  Vel- 
peau  mentions  several  others. 


RUPTURES    OF    THE    UTERUS.  757 

organic  alteration,  tlie  laceration  takes  place  at  the  diseased  point.  It  may 
happen,  says  M.  Dubois,  that  the  part  of  the  uterus  affected  with  chronic  dis- 
ease, instead  of  being  weaker,  is  really  stronger  and  more  resisting  than  the 
healthy  parts  alongside,  which  are  the  ones  to  give  way.  (Taurin,  Tlilse.)  The 
front  and  back  walls  being  protected  by  the  anterior  and  posterior  planes  of  the 
abdomen,  would  seem  to  be  perfectly  sheltered  from  such  accidents ;  this,  how- 
ever, is  not  always  the  case,  for  instances  have  been  reported  which  prove  the 
possibility  of  ruptures  of  this  kind.  According  to  Dr.  Piobcrton,  when  the 
laceration  is  caused  by  a  narrowness  of  the  pelvis,  it  may  occupy  any  portion  of 
the  womb,  though  more  frequently,  perhaps,  it  involves  its  posterior  inferior 
part;  which  is  explained,  in  his  opinion,  by  the  pressure  tTiat  the  sacro-lumbar 
prominence  makes  on  this  region.  Sometimes,  also,  it  takes  place  in  the 
anterior  inferior  part,  and  is  then  due  to  the  osseous  projections  located  on  the 
internal  face  of  the  pubic  symph3-sis.  The  anterior  superior  wall  is  oftener  in- 
jured by  foreign  bodies ;  indeed,  it  is  the  almost  exclusive  seat  of  ruptures  pro- 
duced by  wounds. 

Nothing  can  be  more  uncertain  than  the  extent,  form,  and  direction  of  the 
uterine  ruptures ;  since  they  vary  in  size,  from  a  little  hole  that  is  scarcely  capa- 
ble of  admitting  the  end  of  the  finger,  up  to  a  large  fissure  extending  over  two- 
thirds  of  the  fundus,  or  periphery  of  the  neck,  or,  indeed,  occupying  nearly  the 
whole  organ.  It  may  have  a  longitudinal,  a  transverse,  or  an  oblique  direction, 
or  it  may  affect  a  circular  form,  as  often  happens  about  the  neck;  or  it  may  run 
in  a  straight  line,  or  in  a  zigzag  course.  The  divided  margins  are  rarely  observed 
to  present  a  clear  and  regular  section ;  but,  instead,  they  are  most  usually  found 
unequal,  haggled  as  it  were,  contused,  and  ccchymosed  to  a  more  or  less  con- 
siderable extent.  If  the  rupture  has  resulted  from  some  organic  alteration,  the 
anatomical  traces  of  the  previous  disease  are  found  at  the  affected  point.  Lastly, 
if  the  patient  has  not  died  till  several  days  after  the  accident,  the  autopsical 
examination  will  verify  the  presence  of  the  matters  effused  into  the  peritoneum, 
and  the  unequivocal  marks  of  a  violent  inflammation  of  this  serous  membrane ; 
besides  which,  the  borders  of  the  uterine  fissure  will  sometimes  be  red,  livid, 
and  inflamed,  and  occasionally  even  gangrenous. 

The  lacerations  of  the  womb  do  net  always  implicate  the  whole  thickness  of 
the  organ,  for  the  tunics,  that  enter  into  the  composition  of  its  walls,  do  not  all 
possess  the  same  degree  of  elasticity ;  and  hence  it  is  possible  for  them  to  be 
ruptured  separately.  Madame  Lachapelle  says,  a  fissure  of  the  orifice  propagated 
to  the  neck,  and  even  to  the  body  of  the  organ,  has  very  often  divided  the  whole 
muscular  layer,  leaving  the  serous  membrane  intact.  I  have  particularly  ob- 
served, she  continues,  fissures  of  this  kind  on  the  sides  of  the  womb  which  were 
covered  by  the  duplicature  of  the  broad  ligament,  whereby  the  wound  was  pre- 
vented from  extending  into  the  abdomen.  M.  Duparcquc  furnishes  a  very  simi- 
lar case ;  and  Dr.  Collins  reports  nine  others  in  which  the  peritoneum  was  not 
injured,  though  the  muscular  layer  of  the  neck  was  lacerated  to  a  considerable 
extent.  I  have  likewise  had  an  opportunity  of  observing  an  identical  instance 
in  the  practice  of  Professor  Velpeau,  in  which  I  was  enabled  to  verify  the  truth 
of  the  remark  made  by  M.  Cruveilhier;  namely,  that  the  laxity  in  the  adhesion 


758  DYSTOCIA. 

of  the  peritoneum  to  the  cervix,  and  to  the  sides  of  the  uterus,  fully  explains 
why  this  membrane  is  so  rarely  involved  in  those  cases  in  which  a  considerable 
rent  has  occurred  in  the  neck,  and  why  the  effusion  of  blood  then  takes  place 
between  the  uterine  tissue  and  the  peritoneal  serous  membrane.  Cases  have 
occurred  in  which  the  blood  collected  in  very  large  amount,  and  even  the  foetus 
itself,  completely  expelled  from  the  uterine  cavity,  has  been  found  in  the  species 
of  sac  formed  by  the  detached  serous  membrane. 

In  some  more  rare  cases,  the  muscular  structure  resists,  and  the  peritoneal 
layer  alone  gives  way.  Where  this  occurs,  the  disease  can  scarcely  be  recognized 
during  life,  for  the  phenomena  that  precede  death  are  cither  those  of  a  hemor- 
rhage, or  of  a  violent  peritonitis ;  but  a  large  quantity  of  blood  is  ordinarily 
detected  at  the  post-7no7-tem  examination,  and,  by  searching  for  its  source,  one 
or  more  fissures  of  a  variable  extent  are  found  in  the  uterine  serous  membrajie. 
To  the  case  of  this  kind  reported  by  Ramsbotham,  we  can  now  add  several  others 
that  have  recently  been  published ;  one  of  the  most  curious  of  which  is  that 
furnished  by  H.  Partridge  (ArcJi.  de  Med.  t.  19),  where  a  great  number  of 
lacerations  running  transversely,  were  found  at  i\\e  j)ost-mor(em  examination; 
these  were  more  or  less  cvirved,  and  were  variable  in  depth,  and  they  extended 
from  half  an  inch  to  two  inches  in  length.  A  shred  of  peritoneum  had  been 
completely  detached  and  hung  within  the  abdomen,  thus  laying  bare  the  naked 
fleshy  tissue  from  which  it  had  been  torn. 

§  5.  Treatment. 

The  measures  that  have  been  proposed  for  the  treatment  of  ruptures  of  the 
womb,  may  be  designated  as  the  prophylactic  and  the  curative.  The  object  of 
the  former  is  to  avert  the  influence  of  the  causes  that  have  been  described  as 
predisposing  to  this  accident ;  and  we  refer  for  an  account  of  those  whose  ex- 
istence it  is  possible  to  foresee,  such  as  the  divers  obstacles  to  delivery,  to  what 
has  ah'cady  been  said  on  this  subject;  and  with  regard  to  the  others,  as  it  is 
usually  impossible  even  to  suspect  their  presence,  we  shall  pass  them  over  alto- 
gether. 

A  rupture  of  the  uterus  is  only  serious  from  the  disastrous  consequences  which 
follow  it;  therefore,  the  prophylactic  measures  must  be  directed,  not  against  the 
rupture  itself,  but  rather  against  the  consecutive  accidents  to  which  it  gives 
rise.  The  best  mode  of  preventing  them  is  to  facilitate  the  retraction  of  the 
organ  by  immediately  extracting  the  foetus  and  its  appendages;  for  it  has  been 
shown  that  it  is  the  hemorrhage,  and  the  inflammatory  symptoms  which  follow 
the  child's  displacement  and  subsequent  sojourn  in  the  cavity  of  the  abdomen, 
that  are  to  be  particularly  dreaded. 

Perhaps  the  indications  for  treatment  presented  under  such  circumstances  will 
be  best  illustrated  by  supposing  the  rupture  to  take  place  at  three  different 
periods  of  the  puerperal  state,  namely  :  during  the  parturition  ;  during  the  latter 
months  of  gestation  ;  and  during  the  early  stages  of  pregnancy. 

1.  During  the  Labor. — In  this  ca.se  the  infant  may  either  remain  within  the 
womb,  or  it  ma}'  have  been  driven  out  of  the  uterine  cavity. 

A.  If  the  child  remains  in  situ,  its  extraction,  either  by  the  pelvic  version  or 


RUPTURES  OF  THE  UTERUS.  759 

by  the  forceps,  is  of  course  the  only  admissible  operation.  When  the  forceps 
are  used,  it  is  very  important,  as  M.  Dubois  remarks,  that  the  child  should  be 
fixed  in  its  position  by  the  hand  of  an  assistant  applied  to  the  walls  of  the 
abdomen,  in  order  to  prevent  its  ascending  into  the  peritoneal  cavity  through 
the  fissure.  The  introduction  of  the  blades,  also  demands  especial  care  when 
the  neck  is  ruptured  transversely,  in  order  to  avoid  passing  them  into  the  abdo- 
men through  the  rupture.  But  where  any  obstacle  appertaining  to  the  pelvis  or 
the  soft  parts  opposes  its  delivery  by  the  natural  passages,  gastrotomy  ought 
certainly  to  be  performed  if  the  infant  is  living  and  viable,  and  craniotomy  when 
it  is  dead,  or  when  it  has  sufiPered  severely  from  the  slowness  of  the  labor. 

B.  If  one  part  of  the  child  has  passed  into  the  abdominal  cavity  through  the 
fissure,  while  the  other  portion  of  it  is  still  enclosed  within  the  uterus,  we  must 
endeavor  to  deliver  it  through  the  natural  passages,  by  acting  on  the  portion 
retained  in  the  womb,  or  which  has  already  engaged  in  the  os  uteri  or  vagina- 
But  if  the  presenting  part  is  high  up,  and  the  hand  or  instruments  cannot  get  a 
sufficient  hold  upon  it,  it  will  be  necessary  to  search  through  the  fissure  after  the 
feet,  and  bring  them  down  into  the  vagina.  But  here  another  difficulty  arises, 
for  the  escape  of  the  waters  and  a  part  of  the  foetus  may  have  determined  a  con- 
traction of  the  womb,  and  the  lacerated  margins,  participating  in  this  retraction, 
may  be  found  so  closely  applied  to  the  child's  body  as  to  render  a  passage  of  the 
hand  impossible ;  under  such  circumstances,  we  might  follow  the  example  of  cer- 
tain accoucheurs,  and  open  a  passage  by  enlarging  the  wound  in  the  uterus  with 
a  cutting  instrument,  which  would  be  far  preferable  to  the  performance  of  the 
CfBsarean  operation. 

c.  Supposing  the  child  has  passed  into  the  abdominal  cavity,  and  that  the 
organ  has  not  as  yet  retracted,  that  the  os  uteri  is  sufficiently  dilated  or  dilatable, 
and  the  uterine  fissure  is  still  large  enough  to  permit  the  hand  and  foetus  to  pa,ss 
through,  which  conditions  are  scarcely  ever  met  with  when  the  rupture  occurs  at 
the  cervix,  we  ought,  as  in  the  preceding  case,  to  go  after  the  feet  even  into  the 
cavity  of  the  abdomen,  and  bring  them  back  through  the  lips  of  the  wound,  the 
neck  of  the  uterus,  and  the  vagina,  and  thus  extract  the  foetus  by  the  natural 
passages.  After  this  delivery,  the  hand  should  again  be  introduced  into  the 
uterine  cavity,  with  the  threefold  object  of  extracting  the  after-birth,  of  deter- 
mining the  contraction  of  the  organ,  and  of  preventing  the  strangulation  of  a 
loop  of  intestine,  if  any  portion  of  the  bowel  had  engaged  in  the  fissure. 

Should  the  placenta  have  happened  to  fall  into  the  peritoneal  cavity,  an  effl3rt 
should  be  made  to  extract  it  without  delay,  by  a  fresh  introduction  of  the  hand 
through  the  rupture.  An  attempt  should  be  made  at  the  same  time  to  remove 
the  clots  which  had  formed  in  the  abdomen. 

When  such  a  manoeuvre  is  impossible,  the  only  resource  is  in  the  Cesarean 
operation ;  unless,  being  fearful  of  the  disastrous  consequences  of  this  operation, 
the  accoucheur  should  conclude  to  abandon  the  foetus  in  the  peritoneal  cavity,  and 
allow  the  mother  to  ran  all  the  dangers  to  which  this  determination  must  neces- 
sarily expose  her.  If  the  child's  death  were  positively  ascertained,  the  arrest 
of  the  hemorrhage  might  perhaps  authorize  this  latter  procedure,  more  especially 


760  DYSTOCIA. 

if  lie  should  not  see  the  patient  until  several  hours  after  the  accident;  but  it 
would  never  be  excusable  if  the  infant  were  living,  and  if  he  were  not  satisfied 
that  the  uterus,  by  being  completely  retracted,  had  obliterated  the  vessels  which 
furnished  the  blood ;  for,  otherwise,  gastrotomy  should  be  resorted  to  at  once. 

2.  Durhuj  the  latter  months  of  Gestation. — Here,  likewise,  the  extraction  of 
the  ovum  is  the  wisest  course  to  pursue ;  indeed,  it  is  imperiously  indicated  when 
the  child  is  living,  and  the  pregnancy  has  advanced  beyond  the  seventh  month ; 
and  it  may  be  accomplished  by  resorting  either  to  gastrotomy,  to  a  forced  dilata- 
tion of  the  OS  uteri,  or  to  incisions  made  directly  on  the  neck  of  the  womb.  The 
Cassarean  operation  will  be  preferred  whenever  the  fcetus  is  displaced  ;  but  if  it 
is  still  resident  in  the  uterine  cavity,  we  must  endeavor  to  dilate  the  os  uteri 
artificially,  which  will  generally  be  feasible  when  the  patient  is  near  term,  more 
especially  if  she  has  previously  borne  several  children  ;  and  the  introduction  of 
the  hand  might  likewise  be  facilitated  by  incising  the  periphery  of  the  cervix. 
But  these  attempts  ought  to  be  made  with  the  greatest  care,  and,  should  they 
offer  any  serious  difficulties,  and  require  too  much  time,  we  must  renounce  them 
at  once,  and  open  a  passage  through  the  abdominal  wall. 

3.  During  the  early  Months  of  Gestation. — Most  of  our  leading  teachers  ad- 
vise us  to  abandon  the  patient  in  these  cases  to  the  resources  of  nature,  to  abstain 
from  all  operations,  and  to  be  content  with  combating  the  consecutive  symptoms 
as  they  arise.  Three  new  indications  are  now  presented,  says  M.  Duparcque, 
namely:  1.  To  prevent  or  arrest  the  disorders  of  innervation,  by  raising  the 
morale  of  the  woman,  who  is  instinctively  struck  with  fears  and  inquietudes, 
and  by  administering  the  diffusible  antispasmodics  by  the  mouth,  the  skin,  or  the 
respiratory  passages;  2.  To  combat  or  prevent  the  hemorrhage  by  abdominal 
compression,  by  refrigerants,  compression  of  the  aorta,  &c. ;  and,  3.  To  prevent 
or  combat  the  inflammation,  which  ordinarily  follows  the  displacements  of  the 
ovum,  by  the  employment  of  local  and  general  antiplogistics. 

Of  Ruptures  of  the  Vagina. — The  walls  of  the  vagina  may  also  be  lacerated 
during  the  labor.  But,  owing  to  the  differences  that  exist,  according  to  the 
portion  of  the  canal  these  ruptures  may  occupy,  it  has  been  customary  to  study 
separately  the  lacerations  at  its  upper  and  lower  extremities,  and  at  its  middle  part. 
In  general,  the  two  latter  are  of  little  consequence,  or  at  least,  the  dangers  and 
indications  they  present  belong  rather  to  the  province  of  the  surgeon  than  to  that 
of  the  accoucheur ;  for,  with  the  exception  of  thrombus  of  the  vulva,  which  may, 
as  has  been  stated,  require  the  intervention  of  art  during  labor,  all  the  other 
lacerations  are  only  unfavorable  to  the  woman,  inasmuch  as  they  expose  her  to 
vesical  or  recto-vaginal  fistulas,  which  do  not  claim  our  attention  here.  On  the 
contrary,  the  lacerations  that  occupy  the  superior  extremity  of  the  vulvo-uterine 
canal,  require  a  cursory  notice,  because  they,  like  the  ruptures  of  the  lower  part 
of  the  uterus,  may  become  causes  of  dystocia.  The  lacerations  of  the  upper  part 
of  the  vagina  may  result  either  from  traction  or  from  direct  pressure.  The  former 
may  be  owing  to  the  uterine  contraction,  to  the  artificial  pressing  back  of  the 
uterus  or  presenting  part  of  the  child,  and  to  every  act  of  the  abdominal  walls, 
and  every  movement  of  the  trunk,  calculated  to  elevate  the  womb.     According 


RUPTUr.  ES     OF     THE     UTERUS.  761 

to  M.  Dnpareque,  the  uterine  contraction  alone  may  produce  a  transverse  lacera- 
tion of  the  vagina  in  the  following  manner:  the  child's  head  being  wedgod  in 
at  the  superior  strait,  or  more  or  less  engaged  in  the  excavation,  and  unable  to 
advance  any  further  in  consequence  of  the  resistances  it  encounters,  and  the 
womb  still  continuing  to  contract,  the  latter  withdraws  itself,  as  it  were,  from  the 
child.  The  margins  of  the  orifice  are  gradually  drawn  up  towards  the  fundus  of 
the  organ,  whereby  they  get  clear  of  the  head  in  a  great  measure,  and  sometimes 
altogether.  Whence  it  happens  that  the  vagina  becomes  subjected  to  an  active 
traction,  proportioned  to  the  energy  of  the  uterine  pains ;  and  consequently,  as  it 
offers  only  a  passive  resistance  to  the  distension  and  compression  it  undergoes,  it 
is  gradually  enfeebled,  and  ultimately  gives  way. 

The  mode  in  which  the  efforts  sometimes  made  during  version  for  the  purpose 
of  pressing  up  the  presenting  part,  or  for  penetrating  through  the  os  uteri  by 
main  force,  so  as  to  carry  the  hand  towards  the  fundus  of  the  organ,  act  in  the 
production  of  these  lacerations,  is  easily  understood.  And  this  transverse  rup- 
ture, having  once  commenced,  may  extend  far  enough  to  separate  the  uterus 
almost  entirely  from  the  vagina.  Those  fissures  and  vaginal  perforations  which 
result  from  direct  pressure,  are  ordinarily  produced  by  an  improper  application 
of  the  forceps,  or  by  the  prolonged  sojourn  of  the  head  at  the  superior  part  of  the 
excavation. 

The  signs  of  this  rupture,  and  the  accidents  to  which  it  "gives  rise,  are  very 
similar  to  those  of  rupture  of  the  uterus,  excepting  that  they  are  less  intense  and 
not  so  dangerous.  The  pain  is  less  acute  at  the  time  of  its  occurrence,  being 
sometimes  even  confounded  with  the  labor  pain  ;  and  the  existence  of  a  laceration 
is  only  suspected,  some  time  after,  when  searching  for  the  cause  of  the  arrest  of 
the  labor.  Here,  likewise,  the  child  may  either  preserve  the  place  it  occupied, 
or  may  pass  partially  or  wholly  into  the  abdomen.  Most  generally  there  is  no 
displacement  when  the  head  had  previously  engaged  in  the  excavation,  and  the 
rupture  has  taken  place  either  at  the  junction  of  the  vagina  with  the  cervix  or 
else  at  some  point  above  the  head.  Nevertheless,  should  the  laceration  be  very 
extensive,  the  head  may  remain  fixed  in  the  excavation,  while  the  trunk  is  car- 
ried back  into  the  abdominal  cavity  by  the  subsequent  retreat  of  the  womb,  the 
orifice  of  which,  being  no  longer  retained  by  the  vaginal  connections,  mounts  up 
and  retracts  towards  the  fundus  of  the  organ,  thus  abandoning  the  foetus  which 
it  cannot  expel.  It  seldom  happens  that  the  whole  child  escapes  into  the  abdo- 
men, and,  when  this  does  occur,  it  always  results  from  pushing  up  the  head 
during  the  ill-directed  efforts  to  effect  the  delivery.  But,  whether  this  passage 
is  partial  or  complete,  it  ordinarily  takes  place  in  such  a  way  that  the  pelvic  ex- 
tremity engages  first  in  the  lacerated  orifice. 

A  considerable  portion  of  intestine  has  sometimes  been  known  to  escape 
through  a  rupture  of  the  vagina :  it  is  evident  that  in  such  cases  reduction 
should  be  effected  as  soon  as  possible.  Although  it  would  seem  that  this  opera- 
tion ought  not  to  be  attended  with  diflScuIty,  it  has  occasionally  proved  impos- 
sible. Burns  quotes  from  Dr.  Kerver  a  case  of  rupture  of  the  vagina  complicated 
with  the  escape  of  a  portion  of  intestine  an  ell  long.     It  was  impossible  to 


7G2  DYSTOCIA. 

reduce  it,  and  gangrene  ensued.  The  feces  passed  by  the  vagina;  but,  after 
some  time,  were  discharged  by  the  anus,  and  the  patient  recovered. 

The  procnosis  is  much  less  unfiivorable  than  that  of  uterine  ruptures;  because 
there  is  far  less  danger  from  the  hemorrhage  and  consecutive  infl^immations,  and, 
besides,  it  is  always  possible  to  extract  the  foetus  by  the  natural  passages. 

This  extraction  through  the  vagina  is,  therefore,  the  only  indication  which 
presents.  If  the  het^d  remains  in  its  place,  the  forceps  must  be  applied ;  but 
where  any  other  part  presents,  we  must  search  after  the  feet  through  the  rent  in 
the  vagina,  which  is  to  be  enlarged  with  an  instrument,  if  it  be  not  free  enough 
or  should  offer  any  resistance.  The  Cesarean  operation  ought  not  to  be  resorted 
to,  even  when  the  foetus  has  passed  wholly  into  the  peritoneal  cavity,  except 
when  retraction  of  the  pelvis  renders  its  delivery  through  the  natural  passages 
absolutely  impossible. 


CHAPTER  IV. 

RHEUMATISM    OF   THE    UTERUS. 

Rheumatism  of  the  uterus,  although  studied  for  a  long  time  in  Germany, 
was  scarcely  known  in  France,  until  M.  Dezeimeris  published  in  his  journal 
(V  Experience)  a  series  of  facts  that  were  previously  known  to,  and  put  forth  by, 
the  German  authors.  About  the  same  time,  M.  Stoltz,  who  was  acquainted  with 
the  works  of  our  neighbors  on  the  subject,  devoted  particular  attention  to  this 
affection  at  the  Clinical  Hospital  of  Strasbourg,  and  communicated  the  result  of 
his  observations  to  his  pupils.  One  of  them.  Dr.  Salathe,  has  quite  recently 
defended  a  thesis  on  this  subject;  and  from  his  work,  as  also  from  the  bibliogra- 
phical researches  of  M.  Dezeimeris,  I  extract  the  following  account  of  this  dis- 
ease, which  is  unknown  to  French  nosologists. 

According  to  Radamcl,  rheumatism  may  attack  the  uterus  in  the  non-gravid 
state;  but  we  have  only  to  study  it  here  as  occurring  in  pregnant  females,  in 
whom  it  may  appear  at  all  stages  of  the  puerperal  condition.  Therefore,  after 
some  general  remarks  on  the  disease  itself,  it  will  be  necessary  to  point  out  the 
influence  that  it  may  have  over  the  gestation,  the  parturition,  and  the  lying-in. 

Causes. — Every  circumstance  calculated  to  favor  the  development  of  the  rheu- 
matic affections  in  general,  may  likewise  prove  a  source  of  rheumatism  of  the 
uterus :  thus,  a  momentary  or  a  prolonged  exposure  to  cold  and  moisture,  inade- 
quate clothing,  or  sudden  changes  from  a  very  high  to  a  very  low  temperature, 
and  all  those  other  atmospheric  constitutions  which  have  been  enumerated  by 
medical  authors,  either  as  predisposing  or  as  determining  causes  of  rheumatism, 
may  likewise  produce  that  of  the  womb.  But,  besides  these  general  causes, 
there  is  one  peculiar  to  the  disease  under  consideration ;  that  is,  the  suscepti- 
bility of  this  organ  to  the  impression  of  cold  under  the  attenuated  integuments 
of  the  abdomen  during  the  latter  months  of  gestation ;  for  the  belly  is  only 


RHEUMATISM     OF    THE     UTERUS.  763 

covered  at  that  particular  point  by  ver}-  light  clothing,  which  is  far  from  fitting 
closely,  and  the  lunibo-sacral  region  is  often  but  imperfectly  protected  by  the 
short  jackets  worn  by  the  patient. 

Si/mpfoms. — Rheumatism  of  the  uterus  is  very  often  manifested  in  persons  who 
are  constitutionally  predisposed  to  the  rheumatic  affections ;  and  it  may  coexist 
with  a  general  disorder  of  the  same  nature,  though  in  the  majority  of  cases  the 
womb,  together  with  its  appendages,  and  the  adjacent  parts,  is  alone  affected. 
Again,  it  has  oftentimes  resulted  from  a  sudden  cessation  of  a  rheumatic  pain  at 
some  other  point,  which  is  speedily  transferred  to  the  uterus.  But,  whatever 
may  have  been  the  mode  of  its  attack,  this  disease  exhibits  some  well-marked 
peculiarities,  by  which  it  can  easily  be  recognized.  The  principal  symptom  is 
pain,  or  a  distressing  sensation,  which  involves  the  whole  or  a  part  of  the  womb, 
without  any  violence  having  been  exerted  on  the  organ ;  its  intensity  varies 
from  a  simple  feeling  of  heaviness  to  the  most  painful  dragging  sensation  ;  and  it 
may  occupy  either  the  entire  womb,  or  only  one  of  its  parts,  such  as  the  body, 
the  fundus,  or  the  inferior  segment.  When  the  rheumatism  is  fixed  in  the 
fundus  uteri,  the  pain  is  particularly  apt  to  be  felt  in  the  sub-umbilical  region; 
it  is  augmented  by  pressure,  by  the  contraction  of  the  abdominal  muscles,  and 
sometimes  even  by  the  simple  weight  of  the  bedclothes;  and  in  many  cases  the 
patient  is  unable  to  bear  any  movement  whatever.  If  seated  somewhat  lower, 
she  suffers  from  acute  dragging  sensations,  that  run  from  the  loins  towards  the 
pelvis,  the  thighs,  the  external  genital  organs,  and  the  sacral  region,  along  the 
uterine  ligaments.  Finally,  when  the  inferior  segment  participates  in  the  affec- 
tion, the  seat  of  it  can  be  detected  by  the  vaginal  exploration,  which  gives  rise 
to  the  most  acute  sufferings.  But,  of  all  the  causes  that  may  exasperate  these 
pains,  there  are  none  more  distressing  than  the  incessant  movements  of  the 
child. 

Like  all  rheumatic  pains,  those  of  the  uterus  are  metastatic,  and  they  occa- 
sionally pass  rapidly  from  one  point  of  the  organ  to  another;  often,  indeed, 
they  disappear  at  once,  and  pass  off  to  some  other  organ.  This  is  particularly 
apt  to  occur  when  the  pain  was  originally  located  at  some  other  point,  and 
measures  have  been  employed  to  recall  the  affection  to  the  part  primitively  at- 
tacked. 

They  present  frequent  and  variable  exacerbations  in  their  duration  and  inten- 
sity, according  to  the  stage  of  the  disease;  sometimes  they  are  followed  by  remis- 
sions, during  which  the  patient  experiences  only  a  vague  sensation  of  weight  in 
the  part.  The  uterine  pains  are  usually  accompanied  by  a  recto-vesical  tenesmus, 
which  is  the  more  distressing  as  the  former  are  the  more  energetic,  and  are 
seated  nearer  the  inferior  segment.  The  patient  is  then  tormented  by  a  continual 
desire  to  empty  her  bladder;  the  emission  of  urine  is  attended  by  a  smarting 
sensation,  and  sometimes  by  acute  sufferings,  while  at  others  it  is  even  wholly 
impossible;  and  in  many  cases  the  attempts  to  move  the  bowels  prove  equally 
ineffectual.  Most  of  the  German  authors  attribute  this  double  recto-vesical 
tenesmus  to  a  rheumatic  affection  that  is  not  alwa^-s  exclusively  limited  to  the 
womb,  but  which  also  invades  the  neighboring  organs.     But  M.  Stoltz  appears 


7G4  DYSTOCIA. 

disposed  to  believe  that  it  is  ratlicr  the  result  of  the  close  sympathy  existinj^ 
between  these  adjacent  parts ;  for,  if  these  new  pains  were  occasioned  by  a  rheu- 
matism of  the  rectum  or  bladder,  those  of  the  uterus  ought  to  disappear  alto- 
gether, or  at  least  should  be  diminished.     (^Salathes  Thesis.) 

Analogy  would  lead  us  to  suppose  that  an  unusual  heat  and  tumefaction  must 
exist  in  the  affected  parts ;  but  the  difficulties  in  detecting  these  characters  are 
self-evident,  although  their  existence  is  quite  probable. 

Such  acute  pains,  seated  in  so  important  an  organ,  would  naturally  produce 
considerable  general  reaction ;  and  it  is  found  that  this  disease,  like  the  greater 
number  of  the  inflammatory  affections,  most  usually  commences  by  a  slight  chill, 
which  lasts  for  a  quarter  of  an  hour  or  twenty  minutes ;  the  fever  that  follows  it 
diminishes,  and  sometimes  disappears  altogether,  during  the  interval  between  the 
paroxysms;  but,  pending  their  duration,  it  is  usually  quite  intense,  the  pulse  is 
frequent  and  hard,  the  face  excited  and  flushed,  and  the  tongue  is  red  and  dry; 
the  patient  complains  of  thirst,  the  skin  is  hot,  and  she  often  suffers  from  an 
extreme  agitation  and  restlessness.  Towards  the  end  of  the  paroxysm,  a  profuse 
perspiration  generally  breaks  out,  which  seems  to  be  the  prelude  of  a  notable 
amelioration.  Then  these  general  phenomena  become  moderated,  together  with 
the  uterine  pain,  but  they  reappear  with  the  latter,  after  a  variable  period, 
ranging  from  a  few  hours  to  several  days. 

1.  Influence  of  Kheumatism  over  the  Progress  of  Gestation. — The  paroxysms 
are  apt  to  be  followed  by  uterine  contractions  in  those  cases  in  which  they  have 
persisted  for  some  time,  or  have  been  very  severe ;  and  in  this  manner  they  may 
serve  to  bring  on  a  premature  delivery.  The  patient  experiences  some  acute  and 
tensive  pains,  but  this  feeling  of  tension  is  not  uniform ;  for  it  attains,  in  turn, 
a  high  degree,  and  then  becomes  weaker  in  the  same  proportion,  progressing  in 
this  way  with  shorter  and  shorter  intervals.  At  first,  the  uterus  is  indurated  to 
a  partial  extent,  but  afterwards  throughout ;  the  os  uteri  dilates,  though  its  dila- 
tation is  at  first  slow  and  difficult,  and  its  ulterior  progress  does  not  seem  to  cor- 
respond with  the  intensity  of  the  pains.  An  abortion  is  then  imminent,  but  it 
is  far  from  being  so  frequent  as  might  bo  supposed;  and  when  it  does  occur,  it 
is  more  frequently  observed  in  the  febrile  than  in  the  apyrctic  form  of  rheuma- 
tism. The  orifice  has  been  known  to  dilate  to  the  extent  of  an  inch  in  diameter, 
and  then  the  bag  of  waters,  that  had  previously  engaged  in  this  opening,  insen- 
sibly retreated,  the  os  uteri  again  closed  up,  and  the  delivery  did  not  take  place. 
Consequently,  so  long  as  the  dilatation  of  the  os  uteri  does  not  amount  to  two 
inches,  we  may  reasonably  hope  to  make  the  labor  retrograde.  These  uterine 
rheumatic  pains  may  simulate  those  of  parturition,  and  thus  lead  the  accoucheur 
to  suspect  that  labor  has  regularly  commenced,  when  in  fact  such  is  not  the  case. 
The  characters  of  the  rheumatic  pain,  furnished  in  the  following  paragraph,  will 
aid  in  preventing  such  an  error.  It  is  probably  to  some  mistakes  of  this  kind 
that  we  must  refer  those  pretended  instances  of  prolonged  gestation,  as  well  as 
those  cases  in  which  genuine  labor  was  developed,  and  afterwards  suspended 
during  several  weeks,  and  even  months. 

2.  Influence  of  Rheumatism  over  the  Labor. — As  a  general  rule,  a  rheumatic 


RHEUMATISM     OF    THE    UTERUS.  7G5 

affection  of  the  womb  retards  the  progress  of  the  1-jbor,  and  sometimes  even  ren- 
ders the  spontaneous  expulsion  of  the  child  wholly  impossible.  Besides  the 
general  phenomena  already  pointed  out,  the  disease  here  gives  rise  to  the  follow- 
ing peculiarities : 

1st.  It  is  well  known  that  the  normal  uterine  contraction  only  begins  to  be 
painful  when  it  has  accomplished  the  greater  part  of  its  course,  and  when  it  is  at 
the  point  of  distending  and  dilating  the  uterine  orifice;  in  other  words,  the  true 
labor  pain  only  commences  at  the  instant  when  the  power  of  the  body  of  the 
womb  overcomes  the  resistance  of  the  neck.  In  rheumatism,  on  the  contrary, 
the  uterine  contraction  is  painful  from  the  very  first,  and  prior  to  any  action  upon 
the  cervix;  hence  the  cause  of  the  pain  is  not  in  the  violent  distension  of  this 
orifice,  but  rather  in  the  uterine  contraction  itself,  in  the  other  morbid  conditions, 
and  in  the  altered  relations  of  the  nerves  and  contractile  fibres  of  the  uterus. 

2d.  In  a  normal  labor,  the  contractions  begin  at  the  fundus,  and  terminate  at 
the  inferior  segment  of  the  womb ;  in  rheumatism,  instead  of  starting  at  the 
fundus,  they  begin  in  the  painful  point,  and  are  not  regularly  propagated  towards 
the  cervix.  Again,  the  rheumatic  pains  exi^t  prior  to  the  contraction  of  the 
womb,  and  they  speedily  acquire  a  high  degree  of  intensity  under  the  influence 
of  this  latter.  At  times,  their  violence  promptly  arrests  the  contractions,  even 
before  they  have  traversed  their  ordinary  cycle.  They  are  then  rapid,  short,  and 
become  more  and  more  distant. 

3d.  Towards  the  end  of  labor,  at  the  time  when  the  uterine  action  ought  to 
be  aided  by  the  voluntary  contraction  of  the  abdominal  muscles,  the  woman  re- 
frains from  exerting  these  under  the  fear  of  augmenting  the  pains,  whereby  an 
excessive  slowness  in  the  labor  results.  The  patient  is  found  in  a  state  of  ex- 
treme anxiety,  and  the  frequency  of  her  pulse,  the  heat  of  the  skin,  the  thirst, 
and  vesical  tenesmus,  are  all  greatly  augmented.  Where  these  sufferings  are 
much  prolonged,  she  falls  into  a  state  of  swooning,  which  often  proves  service- 
able, as  the  pains  are  suspended  while  it  lasts ;  a  profuse  perspiration  has  then 
been  observed  to  take  place,  which  had  the  most  salutary  influence  over  the 
ulterior  progress  of  the  parturition.  But  at  other  times  the  uterus  becomes  more 
and  more  painful,  and  it  is  rather  in  a  state  of  permanent  contraction,  or  of 
fibrillar  vibration,  than  of  normal  contraction ;  the  pulse  is  accelerated,  and  the 
woman  is  affected  with  a  metritis,  which  renders  the  labor  extremely  painful. 

3.  Ivjluence  of  Rheumatism  over  the  Puerperal  Functions. — The  reader  will 
anticipate  from  the  foregoing,  that  rheumatism  of  the  womb  may  prove  a  source 
of  difficulty  in  the  delivery  of  the  after-birth,  by  determining  irregular  or  partial 
contractions  of  the  organ  immediately  after  the  expulsion  of  the  child ;  but  that 
subject  does  not  claim  our  attention  at  the  present  time,  and  it  will  be  reverted 
to  hereafter.  In  the  healthy  state,  the  uterus  retracts  after  the  delivery,  and 
thereby  prevents  the  development  of  hemorrhage.  But  in  rheumatism,  this  re- 
traction of  the  organ  is  very  imperfect,  and  it  remains  much  larger  than  usual ; 
the  aftei'-pains  are  then  very  distressing,  and  are  prolonged  for  some  time;  the 
uterine  vessels  are  less  compressed  than  usual,  and  profuse  floodings  may  thence 
result.     On  the  other  hand,  the  suffering  state  of  the  organ  diminishes  both  the 


766  DYSTOCIA. 

lochial  discliargc  and  the  lacteal  secretion ;  and  this,  together  with  the  persist- 
ence of  the  abdominal  pains,  and  a  manifestation  of  the  phenomena  of  general 
reaction,  may  be  mistaken  for  a  peritonitis  which  does  not  really  exist. 

Fro/j)tos.''<. — Ivhcumatism  of  the  womb  is  not  a  disease  capable  of  determining 
the  loss  of  the  mother's  life;  nevertheless,  from  the  pain  that  it  occasions,  and 
the  errors  it  may  give  rise  to  in  practice,  it  does  not  the  less  merit  a  careful 
study ;  because,  during  pregnancy,  it  may  prove  to  be  a  source  of  abortion,  and, 
though  it  is  not  often  manifested  until  after  the  sixth  month,  yet  it  is  always  an 
unfavorable  circumstance  to  the  child  to  be  born  before  term.  We  have  already 
spoken  of  the  unfortunate  influence  it  may  have  over  the  course  and  character  of 
the  labor  pains;  in  fiict,  it  has  often  rendered  an  artificial  delivery  imperative. 
It  may  also  complicate  the  delivery  of  the  after- birth,  and  disturb  the  order  of 
the  phenomena  that  constitute  the  lying-in.  At  that  period  it  has  often  been 
mistaken  for  true  inflammatory  symptoms;  and,  consequently,  has  been  combated 
by  measures  that  were  more  dangerous  than  useful. 

As  regards  the  period  of  manifestation,  it  is  generally  more  unfavorable  when 
it  occurs  at  an  early  stage  of  the  gestation ;  both  because  it  then  has  a  greater 
influence  over  the  pregnancy,  which  has  not  become  fii-mly  established,  and  be- 
cause it  has  a  tendency  to  return  several  times  before  term.  Besides  which, 
most  women,  who  have  been  affected  during  the  gravid  state,  likewise  find  it  to 
reappear  again  in  the  course  of  their  parturition,  which  is  thereby  rendered  labo- 
rious. 

Treatment. — 1st.  The  measures  that  have  most  frequently  been  attended  with 
success  when  administered  for  this  disease  during  the  gestation  are :  general 
venesection  ;  the  intestinal  revulsives,  such  as  castor  oil  and  ipecacuanha  ;  bathing, 
narcotized  lotions  over  the  abdomen,  opiated  mixtures,  and  sudorific  drinks ;  and, 
in  those  eases  in  which  the  uterine  affection  had  succeeded  the  sudden  disappear- 
ance of  a  rheumatic  pain  in  some  other  organ,  the  application  of  revulsives  over 
the  part  jAimarily  affected.  2d.  During  the  labor,  the  same  means  are  employed; 
but  if  they  fail,  and  the  degree  of  dilatation  of  the  os  uteri  be  such  as  to  permit 
an  artificial  intervention,  cither  the  forceps  or  version  should  be  resorted  to,  ac- 
cording to  circumstances.  3d.  After  the  delivery,  sudorific  drinks,  opiated 
unctions  over  the  belly,  and  baths;  and,  when  the  lochial  discharge  has  failed, 
leeches  to  the  vulva,  and  ipecacuanha  combined  with  opium. 


CHAPTER  V. 

OP   CERTAIN    DISEASES    THAT    MAY    COMPLICATE    LABOR. 

Independently  of  the  various  accidents  just  studied,  which  have  a  special 
relation  to  pregnancy  and  parturition,  there  are  yet  some  other  affections  whose 
existence  at  the  time  of  labor  may  render  the  delivery  dangerous,  difficult,  or 
perhaps  altogether  impossible,  without  the  intervention  of  art.     Thus,  an  hcmop- 


DISEASES     THAT     MAY     COMPLICATE     LABOR.  767 

tysis,  a  liematemcsis,  or  an  aneurisiual  tumor;  asthma,  syncope,  the  presence  of 
a  hernia,  or  the  loss  of  strength  in  a  woman  who  is  enfeebled  by  some  chronic 
disease,  may  individually  complicate  the  delivery;  and,  therefore,  they  claim  the 
particular  attention  of  the  accoucheur. 

A.  "When  the  patient  under  care  happens  to  be  affected  with  hemoptysis  or 
hematemesis,  and  the  hemorrhage  is  inconsiderable,  there  is  nothing  to  be  done ; 
but  if  it  does  not  abate,  or  if  it  suddenly  augments  in  quantity  during  the  pains 
of  childbirth,  we  must  endeavor  to  remove  the  patient  from  the  danger  that 
threatens  her,  by  terminating  the  labor  as  soon  as  the  dilatation  or  the  dilatability 
of  the  OS  uteri  will  permit,  by  an  immediate  application  of  the  forceps  or  the 
pelvic  version,  according  to  the  particular  conditions  in  which  the  parts  of  the 
child  and  those  of  the  mother  shall  be  found. 

B.  The  same  indications  for  treatment  also  present  where  the  patient  has  a 
moderate-sized  aneurism,  more  especially  if  it  occupies  one  of  the  large  vessels  of 
the  abdomen  and  chest.  In  fact,  the  reader  must  foresee  how  greatly  the  tumor 
would  be  exposed  to  rupture,  during  the  violent  strainings  to  which  the  woman 
involuntarily  gives  way  during  the  second  stage  of  the  labor. 

Chronic  diseases  of  the  heart,  whether  consisting  in  an  hypertrophy  of  the  organ, 
or  simply  in  alteration  of  the  valves  or  contraction  of  the  orifices,  are  but  too 
often,  as  M.  Aran  has  recently  demonstrated,  the  cause  of  sudden  death,  not  to 
call  for  some  special  attention  during  labor.  It  would  seem  to  me  very  impru- 
dent to  allow  the  expulsive  stage  to  continue  too  long  in  such  cases,  and  I  should 
think  it  right  to  terminate  the  labor  artificially  as  soon  as  possible.^ 

C.  The  same  course  is  to  be  pursued  in  all  cases  where  any  considerable  ob- 
Btacle  to  the  respiration  is  found  to  exist ;  as  happens  in  asthmatic  persons  and  in 

'  I  was  requested  1o  assist  at  the  autopsy  of  a  female,  forty  years  of  age,  who  died  sud- 
denly during  labor.     She  was  the  mother  of  three  children. 

For  seven  years  past,  her  respiration  had  been  very  difficult,  and  she  coughed  habitually. 
Both  the  dyspnoea  and  cough  had  increased  of  late,  and  the  sputa  were  sometimes  streaked 
with  blood  ;  a  few  hours  after  the  membranes  were  ruptured,  and  during  a  pain,  whilst  rest- 
ing one  hand  on  the  edge  of  a  bed  and  the  other  on  the  arm  of  an  assistant,  she  fell  dead 
without  uttering  a  cry.  At  the  examination,  about  three  pints  of  serum  were  found  in  both 
pleura-;  the  lungs  were  healthy,  but  compressed;  a  considerable  amount  of  fluid  was  also 
contained  in  the  pericardium. 

On  another  occasion,  one  of  my  pupils  requested  my  attendance  at  the  autopsy  of  a  woman 
twenty-eight  years  of  age,  who  died  suddenly,  immediately  after  the  delivery  of  her  fourth 
child.  For  three  or  four  years  past  she  had  suffered  from  violent  palpitations,  and  the 
slightest  exertion,  especially  going  up  stairs,  even  slowly,  put  her  very  much  out  of  breath; 
she  coughed  continually,  and  now  and  then  spat  a  little  blood.  The  labor  was  easy  and 
rapid;  she  did  not  appear  fatigued,  and  inquired  the  sex  of  the  child.  Whilst  the  accou- 
cheur was  tying  the  cord,  he  remarked  a  few  convulsive  movements,  but  hardly  had  time  to 
run  to  her,  before  she  was  dead. 

The  uterus  was  firmly  contracted.  The  abdominal  viscera  were  healthy,  as  also  were  the 
lungs,  though  the  latter  were  engorged  with  blood  ;  the  heart  was  small,  and  very  fiaccid ; 
the  mitral  valve  was  much  thickened,  and  the  auriculo-ventricular  opening  would  barely  admit 
the  extremity  of  the  little  Jinger.  There  were  hardly  five  ounces  of  serum  in  the  peritoneal 
cavity.  (Francis  Ramsbotham,  Obst.  Med.  Surg.,  p.  608.) 


7G8  DYSTOCIA. 

women  of  small  stature,  in  whom  the  uterus  is  so  enormously  distended  as  to 
press  up  the  diaphragm  and  lungs  towards  the  upptr  part  of  the  chest,  and  in 
whom  the  respiratory  functions  have,  on  this  account,  been  disordered  during  the 
latter  months  of  pregnancy. 

D.  Where  a  hernia  exists,  every  one  must  understand,  says  Desorraeaux,  what 
disastrous  consequences  might  result  from  the  violent  throes  of  the  latter  stages 
of  labor;  and  how  much  these  tumors  must  then  be  exposed  to  an  increase  of 
size,  and  how  liable  they  are  to  become  strangulated.  The  accoucheur  ought  to 
prevent  these  accidents,  by  reducing  the  hernia  as  soon  as  possible,  if  it  is  redu- 
cible; endeavoring  to  return  it  during  the  interval  between  the  pains;  and,  when 
the  contraction  comes  on,  he  will  make  a  strong  compression  over  the  hernial 
opening  by  his  fingers,  or,  still  better,  with  a  convex  pad,  to  prevent  its  coming 
down.  But  if  it  is  irreducible,  he  should  apply  a  convex  pad,  or  merely  support 
the  tumor  with  the  palm  of  his  hand,  so  as  to  prevent  the  expulsion  of  new  parts 
during  the  pain.  Finally,  if,  notwithstanding  all  these  precautions  (which  the 
accoucheur  ought  to  attend  to  himself,  unless  he  has  an  assistant  upon  whom  he 
can  rely),  the  hernia  becomes  strangulated,  he  should  immediately  terminate  the 
labor,  as  in  the  foregoing  cases. 

E.  There  are  certain  very  delicate  or  very  irritable  females  who  are  apt  to  fall 
into  a  state  of  syncope  from  the  occurrence  of  the  most  trivial  pain.  In  such 
cases,  where  the  faintings  are  dependent  either  on  a  restricted  diet,  on  a  pre- 
vious hemorrhage,  or  on  some  former  disease,  it  is  necessary  to  keep  up  the 
patient's  strength  by  some  light  nutritive  articles  of  diet,  such  as  broth,  and  by 
a  little  generous  wine  or  cordial.  If  these  measures  prove  to  be  insufficient,  and 
the  swoonings  are  renewed  so  often  as  to  threaten  her  existence,  we  must  termi- 
nate the  labor.  However,  this  measure  is  not  to  be  prematurely  resorted  to,  for 
these  syncopes  may  be  owing  to  some  trifling  cause  or  nervous  condition,  without 
there  being  that  extreme  debility,  which  alone,  says  Gardien,  can  authorize  this 
ultimate  step  to  be  taken.  Desormeaux  says,  I  have  seen  such  faintings  renewed 
at  every  pain,  in  a  woman  who  was  pregnant  with  twins;  and  they  lasted 
throughout  the  interval  from  one  pain  to  another,  so  that  the  patient  was  only 
aroused  from  that  state  by  the  effect  of,  and  during  the  time  of,  the  contractions ; 
nevertheless,  the  labor  terminated  spontaneously  and  happily  for  both  the  mother 
and  child. 

Baudelocque  gives  the  history  of  a  woman  who  died  during  labor  after  re- 
peated syncopes ;  but  the  autopsy  proved  that  these  latter,  as  also  the  vomitings 
and  diarrhoea  that  accompanied  them,  had  been  produced,  not  by  the  labor,  but 
by  the  presence  of  a  calculus,  about  the  size  of  a  small  nut,  in  the  gall  bladder. 
It  is  really  very  difficult  to  accept  such  an  explanation  as  this,  especially  as  so 
many  examples  of  quite  as  sudden  death  are  on  record,  of  which  no  other  ex- 
planation can  be  given  than  such  as  attaches  to  the  phenomena  of  the  labor 
itself 

Dr.  Davis  relates  a  much  more  extraordinary  case  of  the  kind :  a  poor  woman 
had  been  five  hours  in  labor  at  the  Charity  Hospital ;  the  membranes  were 
ruptured,  and  a  large  quantity  of  the  waters  escaped,  but  from  that  moment  the 


OF    VERSION.  769 

patient  became  excessively  feeble ;  experiencing  an  urgent  desire  to  empty  the 
bowels,  she  seated  herself  on  the  vessel,  and  made  some  straining  efforts,  when 
she  fainted  away;  the  attendants  immediately  placed  her  in  a  horizontal  position, 
and  they  had  scarcely  time  to  get  her  into  bed  before  she  died.  Nothing  what- 
ever was  detected  at  the  autopsical  examination  that  could  give  a  clue  to  the 
cause  of  this  sudden  death. 

F.  When  the  patients  are  exhausted  by  an  antecedent  disease,  whether  acute 
or  chronic,  and  when  frequent  and  long-continued  vomiting  has  affected  nutrition 
greatl}',  and  diminished  the  strength  considerably,  I  should  think  it  prudent  not 
to  allow  the  expulsive  stage  to  continue  longer  than  an  hour  or  two.  The  efforts 
required  to  terminate  the  second  stage,  might,  in  some  cases,  exhaust  the  re- 
maining strength,  and  bring  on  immediately  after  delivery  a  rapidly  fatal  col- 
lapse. 

To  the  cases  already  known  I  might  add  another.  The  young  wife  of  a  medi- 
cal friend,  had  been  affected  with  such  obstinate  vomiting  during  the  three  last 
months  of  her  pregnancy  as  to  be  unable  to  retain  anything  on  her  stomach.  A 
constant  febrile  movement  was  the  consequence,  accompanied  by  nocturnal 
paroxysms  and  extreme  wasting  and  debility.  She  finally  reached  the  term  of 
her  painful  pregnancy.  The  labor  lasted  ten  hours  in  all,  and  the  expulsive 
stage,  during  which  I  was  obliged  to  be  absent,  four  hours.  Immediately  after 
the  spontaneous  termination  of  the  labor,  the  unfortunate  lady  fainted,  and 
although  hemorrhage  was  prevented  by  the  favorable  contraction  of  the  uterus, 
she  expired  in  three  quarters  of  an  hour,  notwithstanding  the  internal  and  ex- 
ternal employment  of  the  most  powerful  tonics. 


SECOND   DIVISION. 

OBSTETRICAL  OPERATIONS. 

In  the  preceding  division  we  carefully  detailed  the  various  indications  pre- 
sented by  the  divers  causes  of  dystocia  hitherto  studied ;  each  of  which,  as  the 
reader  has  seen,  requires  a  different  operation.  We  now  propose  to  take  up  the 
consideration  of  these  obstetrical  operations  in  this  second  division  of  our  fourth 
part. 


CHAPTER  I. 

OF  VERSION. 

Version  is  an  operation  by  which  one  of  the  two  extremities  of  the  child 
is  brought  to  the  superior  strait :  it  therefore  exhibits  two  varieties,  in  one  of 

49 


770  DYSTOCIA. 

which  the  operator  proposes  to  bring  down  the  feet,  and  hence  this  is  called 
the  pelvic  or  podalic  version  ;  while  in  the  other  he  attempts  to  deliver  by  the 
head,  which  is  on  that  account  denominated  the  cephalic  version. 

The  cephalic  version  was  almost  exclusively  practised  from  the  time  of  Hip- 
pocrates until  that  of  Ambrose  Pare,  that  is  to  say,  down  to  the  latter  half  of 
the  sixteenth  century.  Celsus  advised  that  when  the  child  is  dead,  and  the 
head  cannot  be  reached  without  too  great  difficulty,  the  feet  should  be  sought 
after.  Aetius  and  Paulus  Aegineta,  were  the  first  among  the  ancients  to  re- 
commend pelvic  version  when  the  child  is  living.  But  since  the  days  of  Pare, 
or  rather  since  those  of  Guillemeau,  his  pupil,  the  pelvic  version  has  been 
recommended  as  applicable  to  all  cases;  and  the  cephalic  reduction  was  almost 
entirely  forgotten,  until  towards  the  end  of  the  last  century,  when  Flamand, 
and,  somewhat  later,  Osiander,  exaggerating,  doubtless,  the  inconveniencies, 
difficultie.s,  and  disastrous  consequences  resulting  from  the  pelvic  version,  pro- 
posed a  return  to  the  precepts  of  Hippocrates ;  and  suggested  the  cephalic  one 
in  almost  all  cases  where  the  hand  alone  is  sufficient  to  terminate  the  labor. 
The  doctrine  of  the  Professor  of  Strasbourg  was  favorably  received  in  Germany, 
but  was  too  severely  criticised  by  the  school  of  Paris.  Indeed,  Baudelocque 
scai'cely  speaks  of  it,  and  Gardien  restricts  its  application  to  a  very  limited 
number  of  cases,  while  Madame  Lachapelle  formally  rejects  it.  But  we  shall 
see  hereafter,  when  studying  the  respective  value  of  these  two  operations,  that 
at  the  present  day  it  would  be  improper  to  embrace  either  opinion  exclusively; 
for  some  cases  are  better  suited  to  the  cephalic  version,  while  there  are  others, 
on  the  contrary,  where  the  pelvic  one  is  alone  practicable;  consequently,  both 
operations  should  be  retained  in  practice,  leaving  to  the  judgment  of  the  ac- 
coucheur to  determine  the  cases  in  which  the  one  or  the  other  ought  to  be  pre- 
ferred. 

But,  before  studying  the  cephalic  and  the  pelvic  versions  separately,  we  will 
point  out,  in  a  summary  way,  certain  precautions  that  ought  to  be  attended  to, 
which  are  common  to  both  operations,  namely : 

1.  Before  everything  else,  the  accoucheur  ought  to  forewarn  the  patient  of 
the  operation  he  is  about  to  perform,  to  make  her  understand  as  clearly  as  possi- 
ble the  necessity  for  resorting  to  it,  and  to  calm  her  anxiety,  and  remove  any 
fears  as  to  the  unfavorable  consequences  it  may  have  either  upon  herself  or  the 
child. 

2.  As  soon  as  the  woman  shall  have  consented  to  the  operation,  she  is  to  be 
placed  in  a  suitable  position,  which  position  varies  very  much  in  different 
countries,  and  even  according  to  individual  accoucheurs.  The  following  is  the 
one  generally  preferred  in  France  :  the  woman  places  herself  across  the  bed,  one 
side  of  which  rests  against  a  wall  or  some  tall  piece  of  furniture ;  several  pillows 
are  then  piled  up  under  her  back,  so  as  to  keep  the  upper  part  of  the  body 
moderately  elevated ;  and  that  the  sacrum,  by  resting  on  the  free  side  of  the 
bed,  may  leave  the  vulva  and  perineum  entirely  exposed.  The  lower  extremi- 
ties are  moderately  flexed,  the  feet  resting  on  two  chairs,  and  supported  by  two 
assistants  standing  on  the  outside  of  the  limbs.     "When  the  patient  is  very  in- 


OF    VERSION.  Mi 

tractable,  or  fears  that  she  cannot  control  her  movements,  another  assistant  holds 
the  pelvis  in  a  fixed  position  by  grasping  the  iliac  crests. 

In  England,  women  are  usually  delivered  on  the  side;  and  they  are  placed  in 
the  same  position,  whenever  it  becomes  necessary  to  resort  to  any  operation ;  the 
precaution  being  taken,  however,  to  bring  the  breech  to  the  side  of  the  bed,  and 
to  place  a  cushion  between  the  knees,  for  the  purpose  of  keeping  them  apart. 

It  were  well  worth  while,  in  come  cases  at  least,  to  adopt  this  position.  When, 
for  instance,  the  dorsal  region  of  the  foetus  is  directed  backward,  the  lateral  de- 
cubitus sometimes  allows  the  hand  to  reach  the  feet  with  greater  facility ;  in  the 
dorso-anterior  position,  on  the  contrary,  turning  is  more  easily  eflected  whilst  the 
patient  lies  upon  the  back. 

3.  As  the  little  bed  on  which  women  are  delivered  is  often  too  low,  and 
therefore  incommodious  for  the  operator,  some  practitioners  direct  a  mattress  to 
be  placed  on  a  bureau  or  any  other  article  of  furniture  of  a  proper  height,  to 
which  the  patient  is  to  be  transferred.  In  most  cases,  the  accoucheur  will,  no 
doubt,  be  obliged  to  go  down  on  his  knees  or  sit  on  a  low  chair,  which  position 
is  often  inconvenient;  but,  after  all,  it  docs  not  render  the  operation  itself  much 
more  difficult,  and  it  is  far  better  for  the  operator  to  be  a  little  annoyed  than  to 
frighten  the  patient  by  all  these  preparations.  I  repeat,  that  to  turn  the  bed  in 
such  a  way  that  one  of  its  sides  will  be  supported  against  the  wall,  and  to  place 
the  woman  crosswise  on  it,  taking  the  precaution,  if  necessary,  to  elevate  her 
breech  by  slipping  a  pillow  under  the  first  mattress,  is  such  a  simple  affair,  that 
she  will  scarcely  perceive  it,  and  it  will  not  disturb  her  in  any  way. 

4.  The  accoucheur  ought  to  throw  ofi"  his  coat,  as  the  forearm  has  to  be  intro- 
duced into  the  parts  as  far  up  as  the  elbow.  He  should,  also,  put  on  an  apron 
to  protect  himself  from  the  discharges  that  escape  from  the  woman's  organs;  and 
he  will,  likewise,  have  a  proper  number  of  napkins  prepared  and  placed  at  the 
foot  of  the  bed  to  wipe  his  hands,  and  to  envelope  the  body  of  the  child  as  it 
shall  be  extracted. 

5.  Before  operating,  he  should  again  ascertain  the  child's  position.  We  need 
only  refer  here  to  the  diagnostic  signs  in  each  presentation,  that  have  been 
pointed  out  in  describing  natural  labor. 

6.  The  position  being  clearly  recognized,  it  will  be  necessary  to  decide  on  the 
choice  of  the  hand,  by  which  the  version  is  to  be  performed.  In  the  presenta- 
tions of  the  vertex,  face,  and  breech,  we  introduce  that  hand,  which,  being  held 
midway  between  pronation  and  supination,  has  its  palmar  surface  turned  towards 
the  child's  anterior  plane;  while,  in  those  of  the  trunk,  we  introduce  the  hand 
having  the  same  name  as  the  presenting  side  of  the  foetus  (the  right  hand  for 
the  right  side,  and  the  left  hand  for  the  left  one),  whenever  we  intend  to  per- 
form the  pelvic  version.  As  to  the  cephalic  vcreion,  it  is  diificult  to  lay  down 
any  general  rule  for  the  particular  hand  to  be  used,  since  this  varies  according 
to  the  particular  case. 

The  hand  and  forearm  chosen  arc  then  covered  by  some  fatty  substance,  with 
a  view  of  facilitating  their  intr()duction,  and,  at  the  same  time,  of  protecting 
them  agai))st  the  contagion  of  any  diseases  the  woman  might  be  affected  with. 


772  DYSTOCIA. 

Care  should  be  taken  to  grease  only  the  dorsal  surface  of  the  hand,  which  alone 
comes  into  contact  with  the  mother's  parts,  the  palmar  face  having  to  apply  itself 
to  those  of  the  foetus  which  are  too  slippery  already. 

7.  In  those  cases  in  which  the  version  is  rendered  indispensable  by  some  acci- 
dent that  threatens  the  life  of  the  mother  or  child,  and,  consequently,  where  it 
is  not  possible  to  choose  our  own  time,  we  evidently  have  to  operate  as  soon  as 
the  gravity  of  the  case  renders  it  advisable ;  but  in  those  in  which  a  malposition 
of  the  infant  constitutes  the  whole  difficulty,  as  in  the  trunk  presentations,  for 
example,  the  operator  (if  attendant  on  the  patient  from  the  commencement  of 
her  labor)  should  bear  in  mind  that,  when  the  bag  of  waters  is  still  intact,  or 
else  so  recently  ruptured  that  a  considerable  quantity  of  water  still  remains  in 
the  uterine  cavity,  the  introduction  of  the  hand  and  the  evolution  of  the  foetus 
are  much  easier  than  at  any  other  time ;  and,  consequently,  he  ought  to  select 
that  moment  for  operating,  provided  always  the  os  uteri  is  sufficiently  dilated. 

ARTICLE   I. 

OF   CEPHALIC   VERSION. 

The  cephalic  version  is  an  operation  whereby  it  is  proposed  to  bring  the  sum- 
mit of  the  head  to  the  superior  strait.  This  operation  has  been  recommended 
under  very  opposite  circumstances ;  and  by  way  of  designating  the  cases  in  which 
it  may  be  resorted  to  with  advantage,  as  also  for  the  better  appreciation  of  the 
various  opinions  that  have  been  given  on  the  subject,  we  shall  successively  exa- 
mine the  cephalic  version  under  the  fullowing  heads :  1st.  In  the  inclined  posi- 
tions of  the  summit  and  face,  which,  from  not  having  been  reduced  to  free 
positions,  under  the  influence  of  the  uterine  contractions,  constitute  an  obstacle 
to  the  spontaneous  delivery;  2d,  in  the  face  positions;  3d,  in  those  of  the  trunk; 
and  4th,  in  the  positions  of  the  breech. 

In  irregular  Vertex  and  Face  Positions. — We  have  already  stated,  on  page 
G62,  et  seq.,  what  is  requisite  to  be  done  when  this  irregularity  in  the  presentation 
is  not  corrected  spontaneously.  The  operation  resorted  to  is  not,  properly 
speaking,  a  version ;  it  is  a  simple  correction  by  which  the  primitive  position  is 
rectified,  but  not  changed.  And  we  have  nothing  further  to  add  to  the  indica- 
tions then  given. 

In  Presentations  of  the  Trunk. — It  is  well  known  that  trunk  presentations  can 
only  terminate  spontaneously,  when  one  extremity  of  the  child's  long  diameter 
is  brought  artificially  to  the  superior  strait;  and  it  is  on  cases  of  this  kind, 
that  the  partisans  of  the  cephalic  version  have  endeavored  to  ground  the  prefer- 
ence they  accord  to  it  over  the  pelvic  one.  The  respective  advantages  and  dis- 
advantages of  the  two  versions  will  be  better  comprehended  by  a  systematic 
consideration  of  the  various  circumstances  under  which,  some  region  of  the  trunk 
presenting,  the  cephalic  version  has  been  recommended. 

Version  by  the  head  has  been  advised :  1st,  before  the  labor;  2d,  during  the 


OF    VERSION.  773 

labor,  and  prior  to  the  rupture  of  the  membranes;  3d,  during  the  labor,  and 
after  the  membranes  are  ruptured. 

It  is  often  possible  to  detect  a  position  of  the  trunk  in  the  latter  stages  of 
pregnancy,  by  the  shape  of  the  belly,  the  longest  diameter  of  which  is  then  trans- 
verse; by  the  child's  head,  which  is  very  clearly  felt  in  one  of  the  iliac  fossae, 
in  women  whose  abdominal  walls  are  but  little  distended,  are  thin  and  easily 
depressible  (although  in  two  cases,  reported  by  Duges  and  Velpeau,  it  was  felt 
above  the  pubis) ;  and  by  the  impossibility  of  reaching  the  presenting  part  of 
the  foetus  with  the  finger  introduced  into  the  vagina.  All  these  circumstances 
render  the  diagnosis  of  the  position  quite  easy.  Now,  if  the  child  be  movable 
in  the  amniotic  cavity,  it  is  very  possible  to  bring  the  head  to  the  superior  strait. 
For  that  purpose,  after  having  corrected  the  uterine  obliquity,  if  there  is  any,  it 
is  requisite  to  press  up  the  side  of  the  uterus  to  which  the  infant's  breech  cor- 
responds, with  one  hand,  and  to  push  back  its  head  with  the  other,  in  the  direc- 
tion of  the  superior  strait.  Well-directed  external  manipulations  have  not 
unfrequently  proved  sufiicient  to  convert  the  position  of  the  trunk  into  one  of 
the  vertex.  The  most  difficult  point  is  to  keep  the  head  thus  reduced,  for  the 
child  often  regains  its  primitive  position  after  the  reduction. 

When  labor  has  commenced,  and  the  membranes  are  '  still  intact, — supposing 
that,  by  the  aid  of  the  touch,  or  the  signs  above  indicated,  we  have  been  enabled 
to  recognize  a  trunk  presentation,  we  may  conjoin  the  introduction  of  a  finger  or 
two  into  the  os  uteri  to  the  exterior  manipulations  just  spoken  of  For  these 
fingers,  by  pressing  the  presenting  part  directly  upwards,  would  materially  aid 
the  other  hand  in  getting  the  head  out  of  the  iliac  fossa;  and  then  the  rupture 
of  the  membranes,  practised  immediately  after  the  reduction  of  the  head,  would 
permit  the  uterus  to  retract,  and  keep  the  latter  at  the  superior  strait.  I  can 
see  no  objection  to  such  attempts  when  properly  made,  more  especially  in  the 
latter  case,  when  tried  at  a  stage  of  the  labor  in  which  the  os  uteri  is  sufficiently 
dilated  or  dilatable,  to  admit  of  a  resort  to  the  pelvic  version  in  case  of  failure. 

Flamand  did  not  restrict  the  rule  to  bring  down  the  head  in  trunk  positions  to 
the  cases  just  indicated;  but  he  was  also  in  favor  of  the  performance  of  the 
cephalic  version,  even  after  the  rupture  of  the  membranes  and  the  discharge  of 
the  amniotic  liquid.  He  has  even  gone  so  far  as  to  point  out  the  particular 
manoeuvre  for  each  one  of  the  distinct  presentations  admitted  by  him,  for  the 
child's  anterior,  posterior,  and  lateral  planes  (Joiirn.  Complement,  des  Sciences 
M4dicales) ;  but  we  deem  it  useless  to  enter  into  his  long  details,  more  especially 
since  they  may  all  be  comprised  in  this :  to  grasp  the  presenting  part,  push  it  up 
above  the  strait,  and  then  carry  it  as  far  as  possible  towards  the  side  opposite  to 
where  the  head  is  found;  and  afterwards  get  hold  of  the  head,  and  bring  it  down, 
if  the  efforts  made  by  the  other  hand  through  the  abdominal  walls  have  not 
proved  sufficient  to  make  it  descend  into  the  excavation. 

Flamand  himself  acknowledges  that  this  operation  seldom  succeeds,  excepting 
when  some  region  of  the  neck  or  upper  part  of  the  thorax  presents  at  the  strait. 
For  our  own  part,  we  believe  it  would  be  difficult,  even  under  such  circumstances; 
however,  it  is  barely  possible,  especially  if  there  is  still  some  water  in  the  uterus. 


774  DYSTOCIA. 

and  the  contractions  are  not  very  energetic.  But  where  a  long  time  has  elapsed 
after  the  rupture  of  the  nieuibraues  and  the  total  discharge  of  the  amniotic 
liquid,  and  the  womb  is  strongly  contracted,  we  do  not  hesitate  to  recommend 
the  pelvic  version  in  preference ;  and  particularly  so,  in  those  cases  in  which 
some  region  of  the  lower  half  of  the  trunk  presents  at  the  centre  of  the  strait. 

In  common  with  many  of  our  cotemporaries,  we  had  hitherto  advised  cephalic 
version  in  cases  of  contracted  pelvis,  from  a  fear  of  the  diflSculties  to  which  an 
arrest  of  the  head  above  the  superior  strait  would  give  rise.  An  interesting  me- 
moir, by  Dr.  Simpson,  having  again  directed  our  attention  to  the  advantages  and 
disadvantages  of  pelvic  version,  we  subjected  the  known  facts  to  a  careful  exa- 
mination, and  now  confess  that  the  reading  of  the  memoir  has  greatly  changed 
our  opinion.  We  are,  at  present,  convinced  that  the  dangers  of  pelvic  version, 
in  cases  of  contracted  pelvis,  have  been  much  exaggerated,  and  do  not  hesitate 
to  recommend  this  operation  in  preference  to  cephalic  version,  which  would  prove 
very  diihcult  after  a  complete  evacuation  of  the  waters,  and,  after  all,  would 
require  the  forceps  to  be  applied. 

Still  more  strongly  would  we  prefer  pelvic  version,  if  the  pelvis  were  one  of 
the  kind  in  which  the  narrowing  affects  one  side  much  more  than  the  other; 
that  is  to  say,  one  in  which  the  sacro-vertebral  angle,  though  projecting  strongly 
forward,  is,  at  the  same  time,  turned  to  one  side,  as  in  the  oblique-oval  pelvis  of 
M.  Najgele,  for  it  would  enable  us  the  more  easily  to  direct  the  back,  and  the 
large  occipital  extremity  of  the  head  toward  the  most  roomy  side  of  the_  pelvis. 

When  a  trunk  presentation  is  complicated  by  the  descent  of  an  arm,  the 
cephalic  version,  recommended  by  Ruffius  (Jiumeri  repdlendi  ut  cadet  caput), 
Rhodion,  and  others,  should,  in  my  estimation,  be  wholly  rejected;  since  the 
necessity  of  a  previous  return  of  the  arm  would  then  render  the  version  by  the 
head  exceedingly  difficult,  if,  indeed,  as  before  stated,  the  premature  rupture  of 
the  membranes  did  not  constrain  us  to  abandon  it  altogether.  Consequently,  the 
pelvic  version  would  appear  to  be  far  preferable  in  cases  of  this  kind. 

We  shall  conclude  our  remarks  on  the  cephalic  version  in  trunk  presentations, 
by  saying  that  whenever  any  accident,  such  as  hemorrhage,  convulsions,  &c., 
shall  complicate  the  malpresentation,  and,  as  a  consequence,  when  it  will  be 
requisite  to  terminate  the  labor  as  soon  as  possible,  the  pelvic  version  should  be 
resorted  to  in  preference ;  and,  in  all  such  cases,  we  prefer  this  mode  of  ope- 
rating, by  means  of  which  the  patient  can  be  much  more  promptly  delivered,  to 
that  recommended  by  Flamand  and  his  pupils.  In  Hict,  the  cephalic  version, 
followed  by  an  application  of  the  forceps,  the  head  being  above  the  superior  strait, 
requires  much  longer  time,  should  a  serious  accident  require  the  labor  to  be 
terminated  promptly. 

Lastly,  as  the  cephalic  version  is  usually  resorted  to,  for  the  purpose  of  saving 
the  child,  the  death  or  non-viability  of  the  latter  would  appear  to  us  a  formal 
eontra-indication  against  this  operation. 

Presentations  of  the  Pelvic  Extremity. — "Partisans,  as  we  are,  of  the  version 
by  the  head,"  says  Flamand,  "we  are  not  prepared  to  propose  it  in  these  cases 
indiscriminately,  notwithstanding  we  are  that  way  inclined.     Cut  after  a  consi- 


OF    VERSION.  775 

deration  of  the  following  suppositions,  we  do  not  doubt  that  every  unprejudiced 
accoucheur  -will  follow  our  advice,  and  attempt  this  operation. 

"  Supposing  that  a  monstrosity  were  to  present  without  any  lower  extremities 
whatever,  or  one  having  only  a  couple  of  little  stumps  near  the  buttock,  too  small 
to  furnish  a  sufficient  hold  for  the  accoucheur's  hand  to  draw  down  the  breech, 
and  at  the  same  time  the  mobility  of  the  foetus  indicates  the  possibility  of  bring- 
ing down  the  head,  who  would  hesitate  to  attempt  the  operation  ?"  For  our- 
selves, we  should  not  hesitate  to  leave  the  delivery  entirely  to  the  powers  of 
nature;  for  what  would  be  gained  by  drawing  on  the  pelvic  extremity?  Have 
not  the  precepts  of  Madame  Lachapelle,  of  Desormeaux,  of  Dubois,  and  others, 
taught  us,  that  all  tractions  on  this  extremity  are  more  hurtful  than  beneficial  ? 
And  would  not  some  of  those  disadvantages  that  Flamand  and  his  followers  refer 
to  the  delivery  by  the  breech,  and  on  which  they  rely  for  advising  the  cephalic 
version,  would  not  they  result  in  consequence  of  such  imprudent  tractions  ? 

"  Supposing  a  woman  has  but  three  inches  and  three  lines  in  her  sacro-pubic 
diameter,  and  that  in  former  labors  she  has  lost  several  children  that  were  deli- 
vered by  the  breech ;  and  besides,  that  the  foetus  appears  sufficiently  movable  at 
the  time  of,  or  shortly  after  we  are  obliged  to  rupture  the  membranes — an  attempt 
to  effect  the  version  by  the  head  is  warrantable." 

We  likewise  believe  that,  in  such  a  case,  the  accoucheur  would  be  justified  in 
making  this  attempt  before  the  membranes  are  ruptured  ;  but  after  the  discharge 
of  the  waters,  it  appears  to  us  that  this  operation  must  be  impracticable  in  a  large 
majority  of  cases;  and  we  should  then  prefer  well-conducted  tractions  on  the 
trunk  of  the  child,  using  every  exertion  to  keep  up  the  flexion  of  the  head  at  the 
moment  when  the  latter  reaches  the  superior  strait.  The  observations  of  Madame 
Lachapelle,  and  those  published  more  recently  by  Dr.  Simpson,  afford  a  satisfac- 
tory reason  for  our  preference,  even  in  those  cases  where  the  pelvic  contraction 
results  from  the  direct  forward  projection  of  the  sacro-vertebral  angle;  and  this 
precept  would  be  still  more  applicable,  if  one  of  those  pelves  described  by  M. 
Najgele,  under  the  name  of  the  oblique-oval,  were  to  be  met  with.  For  the  trac- 
tions then  made  on  the  breech  would  have  the  effect  of  turning  the  child's  back, 
and  as  a  consequence,  the  large  occipital  extremity  of  the  head,  towards  the 
widest  part  of  the  pelvis. 

On  the  whole,  therefore,  we  believe  that  the  cephalic  version  may  and  ought 
to  be  attempted : 

1st.  In  irregular  vertex  presentations ;  when  it  is,  properly  speaking,  nothing 
more  than  a  simple  correction  of  the  head.    (Page  662.) 

2d.  In  certain  face  positions,  that  were  carefully  pointed  out.    (Page  666.) 

3d.  In  presentations  of  the  trunk,  whether  before  the  labor,  or  during  the 
labor  and  before  the  rupture  of  the  membranes;  but,  during  the  labor,  and  after 
the  membranes  are  ruptured,  we  should  give  preference  to  pelvic  version,  even 
though  the  pelvis  is  contracted. 

4th.  In  the  breech  presentations ;  but  only  prior  to  the  rupture  of  the  mem- 
branes, and  when  there  exists  a  malformation But  even  then  it  will 

generally  be  impossible. 


776  DYSTOCIA. 

From  the  foregoing  it  will  be  seen  that,  although  we  do  not  fully  indorse  the 
views  of  Flamand,  yet  we  give  to  the  cephalic  version  a  much  greater  importance 
than  has  been  accorded  to  it  by  most  of  the  French  accoucheurs.  It  is  because 
we  believe  that  to  let  alone  as  much  as  possible,  is  the  true  course  in  practice; 
and  that,  in  those  cases  where  nature  seems  to  be  incapable  of  effecting  the  deli- 
very, the  accoucheur  ought  simply  to  aid,  and  not  supplant  her  powers;  that  he 
must  conjoin  but  not  substitute  his  efforts  for  hers,  and  he  must  permit  her  to 
enjoy  all  her  rights,  as  soon  as  she  can  dispense  with  his  intervention. 

ARTICLE   II. 

OF   PELVIC   VERSION. 

This  is  an  operation,  whereby  the  pelvic  extremity  is  brought  to  the  superior 
strait,  from  which  it  had  been  more  or  less  removed.  In  describing  it,  it  will  be 
necessary  to  first  study  the  general  rules  that  are  applicable  to  all  cases  of  version 
by  the  breech  ;  after  which,  we  can  point  out  the  peculiarities  offered  by  the  ver- 
tex, face,  and  trunk  positions,  respectively.  But  there  are  certain  conditions 
necessary  to  the  performance  of  every  version,  which  must  be  described  at  the 
outset. 

§  1.  Necessary  Conditions. 

In  order  to  perform  the  pelvic  version,  it  is  requisite  that  the  os  uteri  be  dilated 
or  dilatable ;  that  the  presenting  part  be  not  engaged  too  deeply  in  the  excava- 
tion, and  more  particularly  that  it  has  not  cleared  the  neck  of  the  uterus;  finally, 
except  in  trunk  presentations,  most  authors  require  that  no  disproportion  exist 
between  the  size  of  the  head  and  the  dimensions  of  the  pelvis. 

1.  It  is  necessary,  we  say,  that  the  os  uteri  be  sufficiently  dilated  or  dilatable 
to  permit  the  ready  introduction  of  the  hand,  and  the  free  passage  of  the  child. 
The  neck  may  be  considered  as  being  properly  dilated,  when  its  orifice  offers 
nearly  two  inches  in  diameter ;  but  it  may  be  much  less  open,  and  yet  the  ver- 
sion be  still  possible,  because  it  is  then  often  sufficiently  dilatable.  In  the  latter 
case,  the  cervix  is  thick,  soft,  supple,  and  easily  distended ;  it  is  neither  tense, 
nor  contracted,  and  the  finger,  on  being  passed  over  the  divers  points  of  its  cir- 
cumference, finds  that  it  does  not  resist  in  the  least,  and  that  it  admits  of  being 
readily  enlarged.  This  dilatability  of  the  uterine  orifice  is  particularly  apt  to  be 
met  with,  when  the  presenting  part  cannot  engage  in  the  os  uteri  after  the  mem- 
branes are  ruptured,  on  account  of  its  volume  or  bad  position ;  because,  being  no 
longer  sustained,  the  margins  then  relapse  towards  its  centre,  and  thus  diminish 
its  size. 

2.  The  second  condition  is,  that  the  presenting  part  be  not  too  deeply  engaged 
in  the  excavation,  and  more  especially  that  it  has  not  cleared  the  cervix.  It  will 
presently  be  seen  that,  before  endeavoring  to  enter  the  uterus,  the  hand  of  the 
accoucheur  ought  to  push  the  part,  which  is  already  more  or  less  engaged  in  the 


OF    VERSION.  777 

excavation,  above  the  superior  strait.  Now,  it  is  evident  that  if  this  part  had 
cleared  the  os  uteri,  it  could  not  be  returned  without  the  womb  being  pressed 
back  at  the  same  time,  and  consequently  without  exposing  the  utero-vaginal  at- 
tachments to  laceration. 

3.  When  the  pelvis  is  contracted,  most  French  accoucheurs  proscribe  pelvic 
version.  Although  we  also  at  one  time  adopted  this  view,  we  now  think  that  it 
should  be  reserved  for  those  cases  only  in  which  the  narrowing  affects  all  the 
diameters  of  the  pelvis,  or  in  which  the  sacro-pubic  diameter  is  excessively  short- 
ened. An  attentive  examination  of  this  question  has  convinced  me  that  Madame 
Lachapelle,  Dr.  Simpson,  of  Edinburgh,  and  Mr.  Radfort,  of  Manchester,  were 
right  in  preferring  pelvic  version  to  the  application  of  the  forceps  in  some  cases. 
We  shall  discuss  this  important  practical  point  in  the  following  chapter,  but  we 
feel  justified  in  saying  at  present  that  version  may  be  practised  with  advantage : 
1,  in  the  oblique-oval  contractions  of  M.  Naegele ;  2,  in  those  direct  sacro-pubic 
contractions  which  present  a  diameter  of  at  least  three  and  a  quarter  inches,  espe- 
cially when  the  foetus  is  dead ;  o,  in  the  antero-posterior  contractions  of  the  infe- 
rior strait  complicated  with  a  considerable  narrowing  of  the  sub-pubic  arch. 
(See  Forceps.) 

§  2.  General  Rules  op  the  Operation. 

The  operation,  in  the  performance  of  the  podalic  version,  is  composed  of  three 
principal  stages;  namely,  the  introduction  of  the  hand,  the  evolution  of  the  child, 
and  the  extraction  of  the  latter. 

1.  Introduction  of  the  Hand. — The  patient  having  been  properly  placed,  the 
operator  sits  down  or  rests  on  one  knee  before  her,  then  presents  his  hand  at  the 
entrance  of  the  vulva,  and  endeavors  to  introduce  it  by  pressing  gently  from 
before  backwards,  and  slightly  from  above  downwards.  If  the  vulva  is  very  large, 
the  fingers  are  held  together  and  introduced,  flat  at  first,  taking  care  to  depress 
the  anterior-perineal  commissure  with  the  cubital  border  of  the  hand;  but,  if  the 
vulva  is  very  narrow,  the  fingers  arc  introduced  one  after  another,  and  then 
brought  together  in  such  a  way  as  to  form  a  kind  of  gutter,  in  which  the  thumb 
can  slip  along  their  palmar  concavity,  and  thus  enter  imperceptibly.  The  hand 
thus  forms  a  cone,  the  base  of  which  is  still  at  the  exterior,  while  its  apex  endea- 
vors to  penetrate  up  into  the  vaginal  cavity.  The  wrist  is  then  slightly  depressed, 
in  order  to  accommodate  the  direction  of  the  hand  to  the  line  of  axis  of  the  in- 
ferior strait;  and,  as  the  fingers  penetrate  deeper,  it  is  depressed  more  and  more, 
so  as  to  make  the  hand  describe  a  curve  with  its  concavity  anterior,  correspond- 
ing to  the  pelvic  axis.  The  introduction  is  facilitated  by  gently  and  moderately 
rotating  the  hand  on  its  own  axis,  with  a  view  of  effacing  the  folds  of  the  vagina. 

Whenever  possible,  the  introduction  into  the  vulva  must  be  made  during  the 
interval  between  the  pains.  Ant.  Dubois  gave  a  different  precept,  and  taught 
that  it  was  preferable  to  make  the  introduction  while  the  pain  lasted;  for,  said 
he,  the  woman,  being  engrossed  with  the  uterine  pain,  will  not  perceive  that 
caused  by  the  entrance  of  the  hand.     But  every  one  who  has  attended  a  female 


778  DYSTOCIA. 

in  labor,  and  has  made  the  vaginal  examination  during  the  contraction,  must  be 
convinced  of  the  error  of  this  celebrated  accoucheur. 

The  finders,  having  reached  the  upj^er  part  of  the  vagina,  may  find  the  os 
uteri  either  freely  dilated  or  sufficiently  dilatable.  In  the  former  case  they  can 
be  made  to  penetrate  into  the  organ  without  any  difficulty,  by  placing  them  be- 
tween the  internal  surface  of  the  uterus  and  the  presenting  part  of  the  child; 
but,  in  the  latter,  they  are  to  be  introduced  one  after  the  other,  in  such  a  manner 
as  to  form  a  cone,  the  extremity  of  which  is  entered  in  the  orifice.  Then  the 
hand  is  pushed  along,  imparting  to  it  at  the  same  time  some  gentle  rotatory  move- 
ments, and  separating  the  fingers  a  little  from  each  other,  so  as  to  make  a  mode- 
rate and  uniform  pressure  on  the  various  points  of  the  periphery  of  the  cervix. 
When  the  services  of  an  assistant  can  be  obtained,  he  should  be  directed  to  place 
both  hands  over  the  fundus  of  the  uterus,  in  order  to  prevent  it  from  being 
pressed  up  by  the  efforts  made  to  introduce  the  hand;  if  there  is  no  assistant, 
the  other  hand  of  the  accoucheur  is  placed  over  the  fundus  to  perform  the  same 
office. 

The  OS  uteri  ought  to  be  entered  during  the  interval  of  the  pains.  As  soon 
as  the  hand  has  reached  the  cervix,  it  is  necessary  to  ascertain  that  we  have  not 
been  mistaken  about  the  position  ;  and,  in  case  an  error  has  been  committed  and 
the  wrong  hand  has  been  introduced,  it  should  be  withdrawn  at  once,  and  re- 
placed by  the  other,  if  there  is  reason  to  anticipate  much  difficulty  in  the  version ; 
that  is  to  say,  if  the  membranes  have  been  ruptured  a  long  time,  the  pains  are 
strong,  and  the  waters  are  wholly  discharged;  for  we  ought  not  to  add  to  the 
difficulties  that  already  exist  by  the  choice  of  the  wrong  hand.  But,  under  op- 
posite circumstances,  we  might  use  the  hand  first  introduced,  so  as  to  spare  the 
patient  the  pain  and  repugnance  which  the  introduction  of  a  second  one  always 
occasions  her. 

When  the  hand  arrives  at  the  os  uteri,  the  membranes  may  either  be  still 
intact,  or  they  may  have  been  ruptured  for  a  long  time.  Supposing  the  former 
to  be  the  case,  the  question  arises,  are  they  to  be  ruptured  before  passing  any 
further  ?  It  is  far  better  to  insinuate  the  hand  between  the  external  surface  of 
the  membranes  and  the  internal  one  of  the  womb,  and  thus  get  it  up  to  the  point 
where,  from  the  child's  position,  we  know  the  feet  ought  to  be  found ;  and  only 
rupture  the  membranes  at  the  moment  when  the  lower  extremities  are  seized,  or 
at  least  not  until  after  the  whole  hand  has  penetrated  into  the  uterine  cavity. 
By  thus  leaving  the  membranes  unbroken  until  the  feet  are  grasped,  we  prevent 
a  too  rapid  discharge  of  the  amniotic  liquid,  for  the  forearm  being  placed  in  the 
orifice  of  the  neck  obliterates  it  completely;  and  we  have  the  great  advantage  of 
reaching  the  fundus  uteri  much  more  easily,  of  turning  the  feet  more  promptly, 
and  of  practising  the  second  stage  or  evolution  of  the  foetus  more  readily,  the 
latter  being  yet  movable  in  the  surrounding  waters.  If  the  hand  finds  the 
placenta  attached  to  one  side  of  the  organ,  as  it  advances  between  the  internal 
surface  of  the  womb  and  the  external  one  of  the  membranes,  it  is  very  necessary 
to  avoid  its  detachment,  which  might  be  done  by  passing  around  its  margin ; 


OF    VERSION. 


779 


Fi-  98. 


and,  where   this  is   impracticable,  to    rupture   the   membranes  at  the  inferior 
border  of  the  phicenta.* 

The  introduction  of  the  hand  is  far  more  difficult  when  the  membranes  are 
broken,  for  the  presence  of  another  foreign 
body  stimulates  the  contractions  still  more. 
It  is  then  advisable  to  suspend  all  attempts,  as 
much  as  possible,  and  only  renew  them  when 
the  pains  arc  a  little  calmed.  The  first  step  in 
the  process  is  to  get  hold  of  the  presenting 
part,  and  push  it  up  a  little  above  the  superior 
strait ;  then  it  is  to  be  carried  towards  one  of 
the  iliac  fossae,  where  it  is  sustained,  first  by 
the  palm  of  the  hand,  and  afterwards  by  the 
anterior  surfiice  of  the  forearm.  This  pressing 
back,  which  is  easy  when  the  foetus  is  still 
somewhat  movable,  becomes  impossible  when 
the  waters  are  entirely  discharged;  in  this  case 
our  efibrts  should  be  limited  to  gliding  the  hand 
between  the  neck  and  the  presenting  part. 
The  mode  of  reaching  the  feet  varies  according 
to  the  particular  position.  Some  accoucheurs 
have  laid  it  down  as  a  general  rule  to  pass  the 
hand  around  the  side  of  the  child  that  is 
directed  towards  the  mother's  loins,  and  then  slip  it  along  its  back  and  breech, 
and  down  along  the  posterior  surface  of  the  lower  extremities  to  the  feet.  For, 
by  following  an  opposite  course,  and  laying  it  flat  on  the  anterior  surface  of  the 
foetus,  and  thus  guiding  it  directly  to  the  feet,  nothing  would  be  easier  than  to 
mistake  the  hand  for  a  foot,  or  an  elbow  for  the  knee,  in  the  folded  up  condition 
of  the  superior  and  inferior  extremities.  There  are  some  cases  in  which  this 
direction  may  be  followed,  but  in  many  others  it  is  useless  or  impossible  to  take 
this  precaution  :  useless*,  when  a  considerable  quantity  of  water  still  remains  in 
the  cavity  of  the  uterus;  and  impossible,  where  the  membranes  have  been 
ruptured  for  a  long  time,  and  the  uterine  walls  are  forcibly  retracted  on  the 
child's  trunk;  for  then  we  must  be  content  with  slipping  the  hand  flat  along 
the  anterior  plane  of  the  foetus,  being  careful  not  to  confound  a  foot  with  a  hand. 

2.  Ecolution  of  the  Fontus. — Having  succeeded  in  finding  the  feet,  the  hand 
grasps  thorn  in  such  a  way,  that  the  index  finger  is  placed  between  the  two  in- 
ternal malleoli,  the  thumb  on  the  external  surface  of  one  leg,  and  the  three 
fingers  on  the  external  side  of  the  other.  Such  at  least,  is  the  direction  given 
by  many  medical  authors,  but  in  practice,  we  cannot  always  do  what  we  would, 
and  it  is  only  necessary  to  be  certain  that  we  have  a  firm  hold  of  them.     (See 

'  This  plan  is  reeom mended  by  Pen,  Smellie,  Deluerye,  Hamilton,  Boer,  Naigfele,  and 
]\Iadanie  Lachapelle.  The  latter  has  even  been  careful  to  suggest  another  precaution; 
namely,  to  rupture  the  membranes  during  the  relaxation  of  the  uterus,  lest  its  contractic*" 
drive  out  a  large  portion  of  the  waters. 


In  this  figure,  the  head  has  been  pu=lied 
up  into  the  left  iliac  fossa,  and  one  hand 
gets  hold  of  the  feet  while  the  other  sup- 
ports the  organ  externally. 


780 


DYSTOCIA. 


The  same  posilioii,  in  wliich  Ihe  version  is  com 
meiiccd  by  drawing  down  ihe  feet. 


Fig.  98.)  It  is  sometimes  difficult  to 
seize  both  feet  at  the  same  time  ;  and  Vfe 
must  then  be  satisfied  with  a  single  one, 
provided  the  search  after  the  second  is 
attended  with  considerable  difficulty.  The 
feet  are  then  drawn  upon  in  such  a  way 
as  to  double  up  the  foetus  on  its  anterior 
plane.  During  the  performance  of  this 
evolution,  which  is  always  to  be  done 
during  the  interval  between  the  pains,  the 
other  hand  should  be  placed  over  the  part 
of  the  abdomen  where  the  head  is  found, 
and  by  pressing  up  the  latter,  should  en- 
deavor to  make  it  ascend  towards  the 
fundus  of  the  womb.  It  sometimes  hap- 
pens, as  just  stated,  that  only  one  foot 
can  be  brought  down  iiito  the  vagina,  and 
if  this  is  the  anterior  or  sup-pubic  one, 
the  operation  might  be  terminated  without  going  in  search  of  the  other ;  but  if, 
on  the  contrary,  it  is  the  posterior  foot,  we  should,  after  having  secured  it  with 
a  fillet,'  introduce  the  hand  anew,  and  follow  the  internal  border  of  the  limb 
already  extracted,  up  to  the  root  of  the  opposite  leg ;  whence,  by  tracing  out  the 
latter,  we  finally  get  to  the  other  foot,  which  is  to  be  brought  down  in  a  line  of 
adduction. 

In  some  cases,  it  is  much  easier  to  seize  the  knees  which  present  to  the  hand 
of  the  accoucheui',  and  they  might  then  be  drawn  upon  without  inconvenience 
for  the  purpose  of  effecting  evolution. 

3,  The  extraction  is  the  only  stage  of  the  version  performed  during  the  uterine 
contraction.  In  fact,  as  the  latter  facilitates  the  tractions  made  on  the  pelvic 
extremity,  and  likewise  serves  to  keep  the  head  flexed  on  the  chest,  the  ac- 
coucheur would  be  justified  in  terminating  the  labor,  without  waiting  the  return 
of  the  pain,  only  when  there  was  a  complete  inertia  of  the  womb  conjoined  with 
some  accident  requiring  a  prompt  delivery. 

At  first,  we  must  draw  on  the  sub-pubic  limb  as  much  as  possible,  because  we 
thereby  encourage  the  rotation  of  the  anterior  plane  of  the  child  towards  the 
mother's  loins,  and  we  are  better  enabled  to  press  the  parts  backwards ;  that  is, 

'  The  fillet  usually  consists  of  a  piece  of  tape,  one  or  two  fingers'  breadth  wide  and  a 
yard  long,  made  into  a  loose  slip-knot,  which  is  applied  above  the  ankle ;  when  the  foot  is 
still  in  the  vagina,  the  knot  is  placed  on  the  dorsal  surface  of  the  hand,  and  then,  by  grasping 
the  foot,  it  is  slipped  over  it  above  the  malleoli,  and  afterwards  tightened  by  drawing  on 
the  two  extremities  of  the  tape  that  hang  down  at  the  vulva.  When  the  foot  is  high  up  in 
the  vagina,  it  is  often  very  diflicnit  to  apply  the  fillet;  in  this  case,  M.  Van  Huevel  proposes 
substituting  for  it  a  long  forceps,  the  upper  extremity  of  whose  branches  terminate  in  a  half 
ring  placed  at  right  angles  upon  the  stem.  When  the  forceps  are  closed,  we  have  a  com- 
plete ring,  by  means  of  wliich  the  leg  is  seized  above  the  malleoli.  But  why  should  instru- 
ments be  so  multiplied  without  abtolute  necessity? 


OF    VERSION. 


781 


to  get  tlicm  in  the  direction  of  tlie  axis  of  the  superior  strait,  whicli  tlicy  have 
to  traverse. 

As  the  lower  extremities  are  delivered,  the  whole  extent  of  the  disengaf^ed 
parts  are  grasped  by  the  two  hands,  taking  care  to  place  the  thumbs  on  the  pos- 
terior part  of  the  limbs,  the  index  and  medius  on  their  external  surface,  and  the 
ring  and  the  little  fingers  on  their  anterior  surface.  When  the  breech  appears 
at  the  vulva,  it  is  necessary  to  ascertain  the  state  of  the  cord ;  for  that  purpose, 
a  finger  is  to  be  slipped  up  to  its  umbilical  insertion,  when,  if  it  be  found  tense, 


Fig.  100, 


101. 


The  version  is  here  completed,  and  the  occi-  Management  of  the  cord, 

put,  which  was  placed  in  the  left  iliac  fossa, 
at  the  commencement  of  the  operation,  will 
now  come  down  behind  the  right  acetabulum. 

the  thumb  is  joined  to  the  finger,  and  by  making  a  gentle  traction  on  its  placen- 
tal extremity,  by  both,  the  loop  it  forms  will  be  enlarged  (Fig.  101).  If  the 
cord  has  slipped  over  one  leg,  and  got  into  the  fissure  between  the  thighs,  it  will 
likewise  be  necessary,  after  having  drawn  slightly  on  it,  to  disengage  the  child's 
posterior  limb,  and  place  the  cord  in  contact  with  the  perineum. 

In  case  the  version  has  been  demanded  by  an  unfavorable  position,  und  the 
child  has  been  restored  to  a  natural  one  by  the  pelvic  evolution,  the  rest  of  the 
travail  is  left  to  nature ;  provided  always  the  force  and  frequency  of  the  pains  are 
such  as  to  give  us  reason  to  anticipate  a  speedy  delivery.  But  if  the  uterine  con- 
tractions are  feeble  or  slow,  or  if  the  severity  of  the  symptoms  endangers  the  life 
of  either  the  mother  or  the  child,  the  tractions  must  be  kept  up,  and  the  patient 
be  encouraged  to  aid  them  with  all  her  remaining  strength.  The  hips,  loins,  and 
lower  part  of  the  chest  soon  come  down;  and,  as  this  delivery  progresses,  the 
accoucheur's  hands  ought  to  embrace  as  many  parts  as  possible,  constantly  seizing 
those  that  are  nearest  to  the  vulva,  and  taking  care  always  to  act  on  the  bones, 


782 


DYSTOCIA. 


102. 


not  on  tlic  soft  parts.  The  arms  are  apt  to  become  stretched  out  along  the  sides 
of  the  head,  and  thus  descend  witli  it  into  the  excavation;  when  their  disengage- 
ment must  be  effected  in  the  following  manner :  we  commence  with  the  poste- 
rior one,  which  has  only  the  resistance  of  the  soft  parts  of  the  perineum  to  over- 
come, and  therefore  will  offer  less  difficulty  than  the  sub-pubic  arm.  The  same 
hand  is  again  used  by  placing  its  index  and  middle  fingers  on  the  posterior  and 
external  side  of  the  arnj,  just  beyond  the  humero-cubital  articulation,  while  the 

thumb  rests  on  the  anterior  internal  plane  of  the 
humerus,  where  it  acts  like  a  splint;  the  axillary 
space  is  thus  found  lying  in  the  interval  that  sepa- 
rates the  thumb  from  the  two  fingers  (Fig.  102). 
The  trunk  having  been  enveloped  in  a  napkin  is 
next  carried  up  in  front  of  the  pubic  symphysis, 
either  by  the  other  hand,  or  by  an  assistant.  Then 
the  fore  and  middle  fingers,  acting  over  the  whole 
extent  of  the  arm  and  a  part  of  the  forearm,  bend 
the  latter  down  over  the  side  of  the  head  and  face 
towards  the  chest,  on  the  side  of  which  it  is  ulti- 
mately placed  after  its  complete  disengagement. 
The  sub-pubic  arm  is  next  delivered  by  support- 
ing the  child's  trunk  upon  the  other  forearm,  and 
depressing  it  towards  the  anus,  while  the  hand, 
not  the  one  engaged  in  the  previous  operation,  is 
introduced  in  a  state  of  forced  pronation ;  that  is, 
turned  over  on  its  radial  border  in  such  a  way 
that  the  thumb  can  be  still  applied  on  the  internal,  and  the  index  and  middle 
fingers  on  the  posterior  surface  of  the  arm;  and  then  this  is  brought  down  over 
the  side  of  the  head,  face,  and  front  of  the  chest,  as  was  the  posterior  arm. 

In  ordinary  cases,  the  head  descends  flexed  into  the  excavation,  the  occiput 
being  turned  towards  some  point  adjacent  to  the  symphysis  pubis,  and  the  dis- 
engagement is  effected  spontaneously  if  the  pains  are  tolerably  strong  and  fre- 
quent; and  if  necessary  to  facilitate  it,  we  have  only  to  carry  the  trunk  up  ia 
front  of  the  symphysis.  But  should  it  happen  that  the  expulsion  of  the  head  is 
somewhat  delayed,  we  must  aid  it  by  introducing  two  fingers  on  the  sides  of  the 
nose,  and  two  others  on  the  occiput,  and  then,  by  means  of  the  latter,  the  opera- 
tor pushes  up  the  occiput,  while  he  draws  down,  on  the  contrary,  with  those 
implanted  on  each  side  of  the  nose,  and  thus  determines  a  movement  of  flexion 
which  secures  the  delivery  of  the  head.  The  difficulty  would  be  much  greater 
if  the  face  was  turned  forward,  and  the  occiput  backward ;  though  even  here,  if 
the  head  is  not  very  voluminous,  and  the  pelvis  is  large,  we  might  effect  its  de- 
livery by  depressing  the  trunk  on  the  perineum,  and  by  drawing  down  the  face 
in  the  pubic  arch,  with  the  fingers  planted  on  the  sides  of  the  nose,  so  as  to  flex 
the  head;  or,  on  the  other  hand,  by  carrying  the  trunk  up  in  front  of  the  pubis, 
we  might,  in  some  exceptional  cases,  succeed  in  delivering  the  occiput  first  at  the 
anterior  perineal  commissure. 


The  delivery  of  the  posterior  arm. 


OF    VERSION.  783 

§  3.  Of  the  Difficulties  that  may  be  met  with  in  performing  the 
Pelvic  Version. 

In  common  simple  cases,  the  manoeuvre  is  accomplished  in  the  way  we  have 
just  described ;  but  it  very  frequently  happens  that  the  operator  encounters  diffi- 
culties in  its  performance,  dependent  either  on  the  mother  or  on  the  child,  which 
nest  claim  our  attention.  Those  which  the  mother's  organs  may  present,  are  an 
excessive  narrowness  of  the  vulva,  an  obstinate  resistance  at  the  uterine  orifice, 
the  spasmodic  contraction,  and  the  mobility  of  the  body  of  the  womb,  and  the 
insertion  of  the  placenta  over  the  os  uteri.  Those  appertaining  to  the  foetus,  are 
a  shortness  of  the  umbilical  cord,  the  unusual  volume  of  the  shoulders,  the  cross- 
ins  of  the  arms  behind  the  neck,  and  the  extension  of  the  head. 

A.  Narrowness  of  the  Vulca. — Unless  the  narrowness  of  the  vulva  results 
from  the  persistence  of  old  adhesions,  it  is  seldom  so  great,  even  in  first  preg- 
nancies, as  to  constitute  a  serious  obstacle  to  the  introduction  of  the  hand.  The 
only  precaution  to  be  taken,  is  to  pa.ss  in  the  fingers  one  after  the  other,  and  to 
make  the  hand  enter  gently  and  carefully. 

B.  Resistance  of  the  Uterine  Orifice. — The  causes  and  principal  indications  of 
the  resistances  which  the  uterine  orifice  may  offer  to  the  spontaneous  expulsion 
of  the  child,  have  already  been  studied  (page  623,  et  seq.~) ;  and  it  is  possible 
that  these  same  diflSculties  may  be  met  with  in  the  performance  of  the  version. 
Here,  also,  the  retraction  may  be  seated  at  the  external  or  the-internal  orifice  of 
the  neck.  Two  conditions  may  be  met  with  when  the  external  is  the  only  one 
affected ;  that  is,  the  pelvic  evolution  may  be  necessitated,  either  by  a  trunk  pre- 
sentation, or  else  by  some  accident  which,  by  compromising  the  life  of  the  mother 
or  child,  renders  a  prompt  termination  of  the  labor  imperative.  In  the  former 
case,  whatever  be  the  cause  of  the  contraction,  or  of  the  non-dilatation  of  the  ori- 
fice, all  the  means  calculated  to  facilitate  the  dilatation  will  be  brought  into  use; 
such  as  venesection,  if  the  patient  is  plethoric,  tepid  bathings,  fumigations,  and 
unctions  with  the  extract  of  belladonna  on  the  periphery  of  the  cervix;  and, 
where  these  remedies  have  been  employed  without  success,  we  should  act  as  in 
the  following  case.  In  the  latter  case,  the  necessity  of  terminating  the  labor 
promptly  does  not  permit  us  to  rely  on  the  employment  of  the  means  just  enume- 
rated, because  their  action  is  not  developed  for  some  time ;  and  our  only  resources 
are  in  a  forced  introduction  of  the  hand,  or  multiple  incisions  on  the  neck.  We 
have  hitherto  stated  that,  as  a  general  rule,  the  repeated  incisions  on  the  cervix 
appear  decidedly  preferable  to  a  forcible  introduction  of  the  hand,  which  latter 
is  always  a  slow,  difficult,  and  very  painful  operation,  whilst  the  instrument  is 
not  even  felt  by  the  patient;  besides,  it  is  not  dangerous,  and  its  results  can  be 
more  certainly  relied  on.  It  is,  however,  very  necessary  to  take  in  consideration 
the  nature  of  the  accident  which,  in  this  state  of  the  cervix,  demands  the  inter- 
vention of  art ;  for,  in  this  respect,  hemorrhage  or  eclampsia  may  present  very 
different  indications.  In  the  former,  it  is  very  probable  that  the  contraction  of 
the  orifice  is  slight,  and  capable  of  being  overcome  without  much  difficulty; 
besides,  should  it  fail,  the  attempts  at  forcible  introduction  would  have  the  effect 
to  irritate  the  organ  and  excite  the  contraction  of  the  fibres  of  the  fundus,  whose 


784  DYSTOCIA. 

inertia  had  probably  caused  tlie  flooding  wliicb  demands  the  termination  of  the 
labor.  But,  during  an  attack  of  eclampsia,  there  is  every  reason  for  supposing 
that  the  contraction  of  the  orifice  is  due  to  the  convulsions,  ■with  which  every 
muscle  of  the  body  is  affected.  Hence,  it  is  not  of  a  character  to  yield  readily  to 
attempts  at  introduction,  and,  in  case  of  insuccess,  it  may  be  feared  lest,  by  irri- 
tating the  very  sensitive  fibres  of  the  neck,  they  might  have  the  effect  to  increase 
the  general  convulsions  which  we  wish  to  remedy.  Therefore,  we  should^  in 
this  case,  give  preference  to  incisions. 

When  the  spasmodic  contraction  is  confined  exclusively  to  that  portion  of  the 
uterine  walls  which  constitutes  the  internal  orifice  in  the  non-gravid  state,  the 
hand,  after  having  penetrated  the  external  one  without  difficulty,  is  suddenly 
arrested  by  an  obstacle  that  it  cannot  surmount.  This  retraction  is  apt  to  take 
place,  in  the  presentations  of  the  cephalic  extremity,  around  the  child's  neck 
after  the  head  is  free,  but  it  is  oftener  observed  in  the  trunk  presentations.  The 
measures  that  we  shall  presently  point  out  for  combating  the  spasmodic  contrac- 
tion of  the  body  of  the  womb,  are  equally  applicable  in  cases  of  this  kind. 

C.  Insertion  of  the  Placenta  on  the  Neck  of  the  Uterus. — As  well  known,  this 
circumstance  is  an  habitual  cause  of  hemorrhage,  and  often  requires  the  pelvic 
version.  When  the  placenta  is  only  attached  by  one  margin  to  some  point  of  the 
uterine  neck,  the  hand  is  introduced  at  the  part  which  is  not  covered,  and  the 
version  presents  nothing  peculiar.  But  a  different  course  has  been  advised  rela- 
tively to  the  introduction  of  the  hand,  where  the  insertion  takes  place,  centre 
for  centre,  and  no  portion  of  the  circumference  of  the  placenta  is  detached. 
Thus,  it  has  been  recommended  to  perforate  the  centre  of  the  after-birth,  and 
introduce  the  hand  through  this  opening;  but  this  appears  to  us  a  difficult  and 
dangerous  process,  because :  1st,  a  great  number  of  umbilical  ramifications  are 
then  necessarily  torn,  and  a  hemorrhage  produced  which  may  speedily  prove  fatal 
to  the  child ;  2d,  the  force  necessary  to  effect  this  perforation  is  sometimes  suffi- 
cient to  drag  upon,  and  then  detach,  the  periphery  of  the  still  adherent  placenta; 
and,  3d,  the  central  opening  made  in  the  after-birth  will  seldom  be  spacious 
enough  to  permit  the  child's  trunk  and  head  to  pass  freely ;  whence  it  may  hap- 
pen that  the  frictions  made  by  the  movable  parts  of  the  foetus  against  the  mar- 
gins of  this  opening,  will  facilitate  a  displacement  of  the  arms  and  an  extension 
of  the  head.  Consequently,  unless  the  patient's  strength  be  already  exhausted 
by  the  flooding,  or  the  placental  adhesions  be  very  strong,  we  would  rather  detach 
some  point  of  the  circumference  of  the  placenta,  and  thus  get  the  hand  between 
its  external  face  and  the  internal  wall  of  the  uterus.  True,  by  operating  in  this 
manner,  we  should  lacerate  a  certain  number  of  utero-placental  vessels,  and 
thereby  add  to  the  sources  of  hemorrhage,  but  we  would  succeed  in  saving  the 
child's  blood ;  besides  which,  the  hand  and  forearm,  at  first,  and  then  a  little 
later  the  trunk  of  the  foetus,  by  becoming  applied  over  the  mouths  of  these  ves- 
sels, would  compress  them  like  a  tampon,  and  thus  put  an  end  to  the  hemorrhage. 

D.  Violent  Contraction  of  the  Body  of  the  Womh. — This  is  a  condition  that 
always  "makes  the  version  very  painful  and  very  difficult,  and,  in  certain  cases, 
may  even  render  it  impossible ;  it  is,  therefore,  a  sufficient  reason  for  preferring 


OF    VERSION.  785 

an  application  of  the  forceps  when  the  cephalic  extremity  presents.  But,  in  a 
case  of  trunk  presentation,  version  would  be  the  only  practicable  measure ;  and 
even  that  might  be  rendered  wholly  impossible  by  the  retraction  of  the  uterus. 
Here,  likewise,  venesection  and  tepid  bathing  prove  very  useful ;  and  the  em- 
ployment of  the  opiates  is  particularly  indicated,  for  the  aqueous  extract  of  opium, 
when  administered  in  injections,  or  by  the  stomach,  in  the  dose  of  three-quarters 
of  a  grain  to  two  grains,  or  an  equivalent  quantity  of  laudanum,  is  usually  found 
sufficient  to  overcome  the  resistance  of  the  body  of  the  womb.  Under  such  cir- 
cumstances, Dewees  highly  extols  a  resort  to  general  bleeding,  carried  to  syncope; 
and  he  makes  the  patient  stand  up  during  the  operation,  whenever  possible,  so  as 
to  produce  this  effect  more  speedily. 

I  had  an  opportunity  of  putting  the  advice  of  the  American  accoucheur  into 
practice,  for  the  first  time,  on  a  lady  in  la  Rue  du  Four-Saint-Grermain,  to  whom 
I  was  called  in  consultation  by  Dr.  Treves.  The  child  presented  by  the  left 
shoulder;  notwithstanding  which,  ergot  had  been  administered,  in  consequence 
of  an  error  of  diagnosis,  and  the  uterus  was  so  contracted  on  the  trunk  of  the 
child,  that  an  introduction  of  the  hand  was  altogether  impossible.  I  made  the 
patient  get  up,  and  had  her  supported  by  two  assistants;  the  vein  was  opened, 
and  I  permitted  the  blood  to  run  until  the  woman  fainted;  when  she  was  imme- 
diately replaced  on  her  bed,  and  the  version  was  effected  without  difficulty. 

If  these  measures  fail,  and  the  child  be  still  living,  there  is  evidently  no  other 
resource  than  to  wait  and  hope  for  a  spontaneous  evolution  from  the  expulsory 
efforts  of  the  uterus.  If  it  be  dead,  the  section  of  its  neck,  according  to  the 
plan  of  Celsus,  and  a  separate  extraction  of  the  trunk,  and  afterwards  of  the  head, 
ought  to  be  immediatel3'  practised,  with  a  view  of  sparing  the  patient  the  disas- 
trous consequences  of  a  prolonged  and  usually  a  uselessly  prolonged  labor.  (See 
Embryotomy.) 

Again,  the  contraction  of  the  uterus  very  frequently  renders  the  efforts  made 
during  the  version  to  turn  the  anterior  plane  of  the  foetus  backwards  ineffectual ; 
and  where  this  is  the  case,  it  is  not  advisable  to  operate  on  the  trunk,  by  pushing 
it  back  and  drawing  it  down  alternately,  endeavoring  to  impress  a  slight  rotation 
on  it  each  time,  as  certain  accoucheurs  have  recommended ;  for  that  would  very 
often  be  impossible,  and,  besides,  by  being  carried  too  far,  it  would  expose  the 
child's  neck  to  torsion  ;  for  the  head,  being  held  by  the  contraction  of  the  fundus 
uteri,  might  not  participate  in  the  rotation  impressed  on  the  trunk.  It  is  much 
better,  therefore,  to  renounce  it  altogether  and  permit  the  face  to  come  above. 

Inhalations  of  chloroform  have  been  recommended  by  some  persons,  as  possess- 
ing the  immense  advantage  of  quieting  these  spasmodic  contractions  of  the 
uterus,  and  of  rendering  versions  easy,  which  were  previously  impossible.  I 
have  no  personal  experience  in  this  matter,  but  upon  interrogating  that  of  others, 
I  find  that  they  have  obtained  very  different  results.  Thus,  whilst  M.  Stoltz 
thought  that  he  had  remarked  an  increase  in  the  frequency  and  force  of  the 
contractions,  and  IMr.  Murphy  states  that  he  had  never  before  met  with  so  much 
difficulty  in  a  case  of  turning,  although  the  patient  was  completely/  under  the  in- 
fluence of  the  chloroform,  we  find  Dr.  Denham  affirming  that  in  ten  cases  in 

50 


786  DYSTOCIA. 

which  chloroform  had  been  administered  previous  to  the  version,  its  use  had  faci- 
litated the  operation,  and  that  its  happy  influence  was  especially  remarked  in  the 
case  of  a  woman  in  whom  the  introduction  of  the  hand,  though  attempted  fruit- 
lessly before  the  inhalation,  was  effected  with  the  greatest  ease  immediately  after- 
ward. 

The  facts  as  yet  known,  are  too  contradictory  to  enable  us  to  judge  of  the  effi- 
cacy of  chloroform  in  these  cases.  For  even  in  those  in  which  its  use  was  fol- 
lowed by  a  relaxation  of  the  uterus,  is  it  certain  that  this  occurrence,  which  oflen 
takes  place  spontaneously  and  suddenly,  was  anything  more  than  a  simple  coin- 
cidence ?  There  seems  some  reason  for  thinking  so,  when  we  recollect  the  cases 
in  which  it  produced  no  effect.  It  is,  therefore,  an  undecided  question.  How- 
ever, I  should  hasten  to  add,  that  Mr.  Simpson,  and  other  most  conscientious  men, 
admit  that  the  inhalation  of  chloroform  must  be  pushed  to  its  fullest  extent,  and 
be  continued  for  a  long  time,  before  it  aifects  the  muscles  of  organic  life.  Mr. 
Simpson  attributes  the  suspension  of  normal  labor  to  the  abuse  and  excess  of  in- 
halation. If  such  be  the  case,  is  it  not  reasonable  to  suppose  that  it  would  be 
necessary  to  carry  the  use  of  chloroform  beyond  the  limits  of  prudence,  in  order 
to  terminate  the  abnormal  and  almost  tetanic  contractions,  and  then  is  there  not 
cause  to  fear  the  occurrence  of  one  of  those  terrible  misfortunes  which  some  sur- 
geons have  had  to  deplore  ? 

E.  Mobility  of  the  Boilrj  of  (lie  Uterus. — According  to  M.  P.  Dubois,  sufficient 
stress  has  not  been  laid  upon  this  difficulty ;  because,  if  unattended  to,  it  may 
absolutely  prevent  the  introduction  of  the  hand  as  far  as  the  fundus  uteri.  That 
is,  the  hand,  being  wedged  in  between  the  uterine  and  foetal  surfaces,  attempts  in 
vain  to  get  at  the  fcet^  since  the  womb,  the  hand,  and  the  trunk  of  the  child  then 
form  a  whole  which  turns  on  itself,  but  the  hand  does  not  progress  into  the  inte- 
rior of  the  uterine  cavity.  To  remedy  this  obstacle,  it  is  only  necessary  to  have 
the  fundus  of  the  organ  kept  steady,  by  directing  an  assistant  to  place  both  hands 
over  its  superior  and  lateral  parts. 

F.  Shortness  of  the  Cord. — Whatever  be  the  cause,  the  cord  when  very  short 
may  become  stretched,  during  the  tractions  on  the  pelvic  extremity,  and  even  to 
such  an  extent  as  to  occasion  its  rupture.  This  accident  is  to  be  prevented  by 
cutting  the  cord,  when  the  tractions  made  on  its  placental  portion  are  not  suffi- 
cient to  relax  it. 

G.  Volume  of  the  Shoulders. — As  the  loins  become  free  at  the  vulva,  the 
shoulders  engage  at  the  superior  strait ;  when  it  happens,  in  certain  cases,  that 
the  tractions,  which  up  to  that  time  had  been  efficacious,  cease  to  be  so  any 
longer,  and  some  resistance  is  experienced  in  completing  the  delivery.  This 
resistance  is  dependent  solely  on  the  fact  that  the  bis  acromial  diameter  of  the 
shoulders  corresponds  to  the  diameter  of  the  superior  strait;  and  consequently, 
from  its  width,  encounters  some  difficulty  in  clearing  the  latter.  But  this  is 
easily  relieved  by  imparting  some  oblique  movements  to  the  portions  of  the  child 
already  disengaged,  which  carry  the  breech  successively  towards  the  groin  of  one 
side,  and  the  sacro-sciatic  ligament  of  the  opposite  side ;  whereby  the  bis-acromial 
diameter  is  inclined,  and  its  two  extremities  are  made  to  engage  in  the  excavation 
one  after  the  other. 


OF    VERSION.  787 

H.    Crosshif/  of  the  Arms  hehlnd  the  Nech. — It  sometimes  happens  that  one  of 
the  arms  (ordinarily,  the  sub-pubic  one)  is  found  crossed  behind  the  neck,  when 
about  to  be  delivered.     We  have  advised  that  an  attempt  be  made  to  bring  the 
chikl's  posterior  phme  around  in  front ;  but,  in  order  to  accomplish  this,  it  is 
necessary  to  make  the  trunk  undergo  a  considerable  evolution,  during  which  the 
arms,  that  are  not  involved  in  the  movement,  might  be  displaced  by  rubbing 
against  the  womb,  and  thus  become  crossed  between  the  neck  and  the  posterior 
face  of  the  symphysis  pubis.     It  is  highly  important  to  bear  in  mind  that,  ac- 
cording to  the  observation  of  Dug^s,  this  crossing  of  the  arms  may  take  place  in 
two  ways ;  namely,  they  may  be  crossed  behind  the  neck,  after  having  been  first 
raised  up  on  the  sides  of  the  head,  and  then  the  overlapping  is  effected  from 
above  downwards  and  from  before  backwards,  relatively  to  the  foetus ;  or  it  may 
occur  from  below  upwards,  the  arms  then  mounting  up  along  the  child's  posterior 
plane,  and  becoming  placed  under  the  occiput.     This  latter  circumstance  maybe 
produced  in  the  following  way :  as  the  arms  are  usually  located  on  the  sides  of  the 
thorax,  they  may  not  participate  in  the  movement  of  rotation  impressed  on  the 
trunk,  in  making  an  attempt  to  bring  the  anterior  plane  of  the  foetus  towards  the 
mother's  loins ;  and  consequently,  one  or  both  of  them  may  thenceforth  be  found 
placed  on  the  child's  dorsal  plane.     Then,  supposing  the  tractions  on  the  breech 
are  continued,  the  arm  will  become  arrested  against  the  symphysis  pubis,  while 
the  trunk  descends  or  is  extracted,  in  such  a  way  as  to  be  still  there  when  the 
back  of  the  neck  reaches  that  point.     These  two  cases  can  be  distinguished  from 
each  other  by  remarking  that,  when  the  crossing  of  the  arms  has  taken  place 
from  above  downwards,  and  from  before  backwards,  the  inferior  angle  of  the 
scapula  is  removed  to  a  considerable  distance  from  the  median  line  of  the  spine ; 
while,  on  the  contrary,  it  will  be  quite  close  to  it  when  the  crossing  has  occurred 
from  below  upwards  along  the  back  of  the  foetus.     The  diagnosis  is  important, 
since  the  disengagement  of  the  crossed  arras  evidently  cannot  be  effected  in  the 
same  manner  in  both  cases ;  because,  as  a  general  rule,  the  arm  has  to  be  brought 
down  in  an  opposite  direction  to  the  course  it  followed  in  becoming  displaced. 
Thus,  in  the  latter  case,  it  must  be  made  to  descend  along  the  back,  by  hooking 
the  elbow  with  one  or  two  fingers;  in  the  former,  it  will  be  first  brought  over  the 
occiput,  and  then  down  along  the  side  of  the  head,  face,  and  sternum.     This 
latter  disengagement  is  sometimes  exceedingly  difficult,  for  the  occiput,  being 
strongly  pressed  against  the  symphysis,  seldom  leaves  free  space  enough  between 
it  and  the  os  pubis  for  the  operation.     When  this  occurs,  it  has  been  recom- 
mended to  press  up  the  chest  forcibly,  with  a  view  of  making  the  occiput  go  up- 
wards, and  thereby  releasing  the  arm.     It  would  certainly  be  better,  after  having 
disengaged  the  posterior  arm,  to  impress  a  movement  of  rotation  on  the  whole 
trunk  and  head  of  the  foetus,  on  its  longitudinal  axis,  which  would  carry  the 
occiput  and  the  arm  to  be  disengaged  into  the  hollow  of  the  sacrum. 

I.  Arrest  of  the  Head. — Both  contraction  of  the  pelvis  and  extension  of  the 
head  may  render  difficult  the  delivery  of  the  cephalic  extremity.  But  as  we 
have  already  pointed  out  what  is  proper  to  be  done  in  the  former  case,  we  need 
not  revert  thereto  ajrain. 


788 


DYSTOCIA. 


When  the  expulsion  of  the  fcetus  is  left  to  the  powers  of  nature,  the  head  de- 
scends, moderately  flexed,  into  the  excavation,  and  most  generally  its  disengage- 
ment presents  no  marked  difficulty.  But  when  it  becomes  extended  in  conse- 
quence of  improper  tractions  on  the  breech,  its  long  diameters  are  brought  into 
correspondence  with  the  diameters  of  the  pelvis,  and  its  further  delivery  is 
thereby  rendered  impossible.  Of  course,  in  this  state  of  extension,  the  occiput 
may  either  be  found  in  front  (though  this  seldom  happens),  or  it  may  be  found 
behind,  the  face  being  above,  which  is  by  far  the  most  common.' 

When  the  occijnit  is  in  front,  the  flexion  of  the  head  is  efi"ected  without 
trouble ;  for  it  is  generally  sufficient  to  place  two  fingers  on  the  sides  of  the  nose, 
or  else  on  the  lower  jaw  inside  of  the  mouth,  and  then  depress  the  chin  by  a 
moderate  traction  on  this  part;  whilst  two  fingers  of  the  other  hand  are  passed 


Fig.  103. 


FiiT.  104. 


The  mode  of  flexing  the'.head,  by  drawing  down 
the  chin  and  pushing  up  the  occiput. 


Mode  of  rotating  the  face  into 
the  hollow  of  the  sacrum. 


in  under  the  symphysis  and  implanted  on  the  occiput,  so  as  to  press  up  the  latter 
above  the  superior  strait.  (Fig.  103.)  When  this  manoeuvre  does  not  prove 
successful,  it  has  been  recommended,  before  having  recourse  to  the  forceps,  to 
introduce  the  hand  into  the  hollow  of  the  sacrum  and  grasp  the  face  with  its 

'  The  extension  of  the  head,  during  version,  is  far  more  common  in  those  cases  where  the 
occiput  is  turned  towards  the  sacrum.  The  reason  of  which  will  be  readily  understood  by 
giving  attention  to  the  following  circumstances,  namely :  the  tractions  are  naturally  made 
downwards  and  forwards,  while  the  os  uteri,  which  has  a  constant  tendency  to  retract,  is 
directed  somewhat  downwards  and  backwards;  whence  it  results  that  the  anterior  lip  of 
the  womb  presses  strongly  on  that  portion  of  the  child  which  is  turned  towards  the  pubis. 
Consequently,  when  the  occiput  is  in  front,  the  resistance  offered  by  this  lip  has  a  tendency 
to  flex  the  head  still  more;  but,  on  the  contrary,  when  it  is  behind,  the  chin  is  almost  inevi- 
tably caught  by  the  anterior  lip,  and  the  head  is  thereby  extended. 


OF    VERSION.  789 

palmar  concavity,  in  order  to  bring  down  the  head  into  its  normal  position  by 
effecting  a  forced  flexion. 

When  the  occqntt  is  behind,  and  its  delivery  is  not  possible,  either  by  flexion 
or  extension  (see  page  452),  it  is  advisable,  says  ^Madame  Lachapelle,  to  change 
the  position  of  the  head  and  carry  the  face  back  into  the  hollow  of  the  sacrum; 
and,  for  that  purpose,  to  introduce  that  hand  into  the  sacral  concavity  whose 
palm  would  embrace  the  occiput  most  easily  (the  right,  when  the  face  is  a  little 
to  the  right,  at  the  same  time  that  it  is  in  front;  the  left,  when  it  is  somewhat 
to  the  left;  though,  if  the  face  were  entirely  above  the  pubic  symphysis,  the 
choice  of  the  hand  would  be  a  matter  of  indifference) ;  then  the  fingers,  after 
having  passed  behind  the  head,  are  slipped  over  one  side  of  it,  and  pushed  for- 
ward as  far  as  the  mouth,  by  gliding  along  the  nearest  cheek  (Fig.  104).  The 
hand  is  then  forcibly  inclined  on  its  cubital  border,  having  the  palmar  surface 
in  front;  next,  it  draws  the  parts  on  which  the  extremity  of  the  fingers  is  ap- 
plied, that  is  to  say,  the  face,  downwards  and  backwards  towards  the  coccyx, 
when  nothing  further  remains  than  to  flex  the  head  and  extract  it  as  in  ordinary 
cases. 

§  4.  Appreciation  of  Version. 

Version,  when  performed  under  favorable  circumstances,  that  is  to  say,  when 
the  membranes  are  intact,  or  have  been  ruptured  within  a  short  time,  and  the 
child,  surrounded  by  a  considerable  amount  of  fluid,  still  possesses  a  certain  mo- 
bility, is,  in  general,  an  easy  operation,  and  but  slightly  hazardous  either  to  the 
mother  or  the  foetus.  Unhappily,  it  must  be  confessed  that  these  fortunate  condi- 
tions are  rarely  met  with  in  cases  wherein  we  are  obliged  to  perform  the  operation. 

With  the  exception  of  shoulder  presentations,  none  of  the  malpositions  of  the 
child  require  the  intervention  of  art,  until,  after  waiting  for  a  longer  or  shorter 
time  subsequent  to  the  rupture  of  the  membranes  and  the  complete  dilatation  of 
the  cervix,  it  is  ascertained  that  the  natural  efforts  are  insufiicient. 

Shoulder  presentations  themselves  are  rarely  detected  certainly  before,  or  very 
shortly  after,  the  rupture  of  the  membranes,  so  that  unless  an  experienced  accou- 
cheur should  have  attended  the  woman  from  the  commencement  of  the  labor,  he 
is  not  called  in  consultation  until  after  the  waters  have  been  dischartred  for  a  Ions: 
time.  It  is,  therefore,  mostly  necessary  to  act  under  unfavorable  circumstances. 
Now,  it  should  not  be  forgotten  that  the  requisite  manoeuvres,  which  are  serious 
as  regards  the  maternal  organs,  are  especially  fital  to  the  child.  Thus,  M. 
Riecke,  who  has  collected  3120  cases  of  version,  finds  that  GOO  women  out  of 
this  number  perished,  that  is  to  say,  1  in  104;  and  1756  children  were  lost, 
or  1  in  1-28.  This  mortality  of  the  children  is  truly  frightful,  and  yet,  consider- 
ing the  accidents  which,  in  certain  of  the  cases,  necessitated  the  version,  and 
which  of  themselves  destroyed  the  foetus,  I  think  that  these  results  are  correct, 
so  fur  as  the  influence  of  the  mere  operation  is  concerned.  I  have  often  heard 
the  venerable  Capuron  say,  that  in  difficult  cases,  two-thirds,  and,  perhaps,  even 
three-fourths  of  the  children  perished ;  and  the  results  of  my  own  practice  corre- 
spond fully  with  his  observation.    Churchill,  who  states  542  cases  of  version,  gives 


790  DYSTOCIA. 

a  mortality  of  1  in  3  for  the  children,  and  1  in  15  for  the  mothers.     It  is  true, 
that  he  makes  no  distinction  between  difficult  cases  and  others. 

The  above  mentioned  difficulties,  which,  unfortunately,  are  very  common,  ex- 
plain sufficiently  this  result.  With  experience,  and  especially  with  great  care, 
it  is  always  possible  to  overcome  them,  and,  at  the  same  time,  spare  the  mother 
the  grave  lesions  of  the  vagina  and  of  the  body  and  neck  of  the  uterus  which  an 
unpractised  and  brutal  hand  often  occasions;  but  we  cannot  always  prevent  the 
violently  contracted  organ  from  being  exceedingly  irritated  by  the  forcible  intro- 
duction of  the  hand,  nor  the  irritation  from  becoming  the  starting-point  of  puer- 
peral inflammations,  nor  the  physical  and  moral  shock  to  the  patient  from  being 
so  great  as  to  terminate  her  existence. 

It  is  only  necessary  to  have  followed  the  manoeuvre  in  difficult  cases  to  under- 
stand the  dangers  to  which  the  foetus  is  exposed.  Throughout  the  operation,  the 
timbilical  cord  is  liable  to  be  compressed  more  or  less  severely,  and  the  efforts 
required  to  disengage  the  upper  and  lower  extremities,  expose  them  greatly  to 
fracture.  Finally,  the  tractions  exerted  upon  the  pelvic  extremity,  whenever  an 
obstacle  prevents  the  ready  engagement  of  the  head,  may  very  easily  give  rise  to 
lesions  of  the  upper  part  of  the  neck  and  medulla-oblongata  incompatible  with 
the  reo'ular  establishment  of  extra  uterine  respiration. 

It  is  very  difficult,  from  an  examination  of  the  published  statistics,  to  form  an 
exact  idea  of  the  frequency  of  the  cases  in  which  version  may  be  required. 
These  cases,  in  fact,  are  not  the  same  in  all  countries,  nor  for  every  accoucheur 
in  the  same  country.  Besides,  as  the  statistics  were,  for  the  most  part,  collected 
in  hospitals,  it  is  evident  that  we  would  have  a  very  incorrect  proportion  by  de- 
cidin""  upon  a  mean  from  the  figure  of  the  versions  performed  in  any  one  institu- 
tion, because  this  figure  represents  not  only  the  versions  required  by  the  patients 
already  admitted  into  the  establishment,  but  also  the  difficult  cases  brought  there 
at  the  last  moment  from  the  city. 

The  following  resume,  to  which,  however,  I  attach  but  a  very  secondary  im- 
portance, will  at  least  serve  to  show  the  differences  in  the  statistics  according  to 
the  localities.  Thus,  whilst  in  England,  but  145  cases  of  version  are  mentioned 
for  39,539  deliveries,  or  1  in  209,  the  French  practice  gives  400  versions  for 
37,479,  or  1  in  93^,  and  the  Germans  have  performed  it  337  times  in  21,510, 
that  is  to  say,  in  one  case  in  68i. 

§  5.  Of  Version  in  the  Vertex,  the  Face,  the  Breech,  and  the 
Trunk  Presentations. 

After  the  minute  detail  into  which  we  have  just  entered  in  describing  the 
general  precepts  that  are  applicable  to  all  cases  of  version,  it  will  only  be  neces- 
sary to  point  out  the  peculiarities  attending  this  operation  in  each  of  the  ten 
positions  admitted  by  us. 

Presentations  of  the  Vertex. — Whenever  the  vertex  presents,  the  child  will  be 
placed  in  such  a  way  that  its  occiput  is  directed  either  towards  one  of  the  points 
on  the  right  lateral  half,  or  towards  one  on  the  left  lateral  half  of  the  pelvis;  that 
is,  either  in  the  left  or  the  right  occipito-iliac  position. 


OF    VERSION.  791 

1,  Left  Occipito-Iliac  Position. — In  conformity  ■^itli  the  precepts  above  given, 
we  would  here  introduce  the  left  hand ;  which,  after  having  reached  the  os  uteri, 
is  to  grasp  the  head  in  such  a  manner  that  the  palmar  face  of  the  four  fingers 
shall  be  applied  on  its  posterior  (left)  side,  and  the  thumb  on  its  anterior  one, 
the  sinciput  being  lodged  in  the  palmar  concavity.  Then,  during  the  interval 
between  the  pains,  the  head  must  be  pressed  up  towards  the  left  iliac  fossa;  after 
which,  the  thumb  is  brought  alongside  of  the  index,  and  the  hand  is  passed  suc- 
cessively along  the  left  side  of  the  head  and  neck,  and  behind  the  shoulder  and 
elbow ;  in  a  word,  it  is  made  to  traverse  the  whole  left  lateral  plane  of  the  foetus 
down  to  the  breech.  While  this  movement  is  being  effected,  it  is  advisable  to 
keep  the  head  in  the  iliac  fossa  where  it  was  originally  placed,  by  constantly 
pushing  it  up,  first  with  the  thenar  eminence  of  the  hand,  and  afterwards  with 
the  front  surface  of  the  forearm.  Having  gained  the  nates,  the  hand,  which  up 
to  that  time  had  been  kept  in  a  state  bordering  on  supination,  is  changed  into 
one  of  pronation,  in  order  to  pass  around  the  breech ;  when  it  descends  on  the 
posterior  aspect  of  the  lower  extremities,  extends  the  legs,  and  reaches  the  feet, 
which  it  seizes  as  firmly  as  possible.  Or,  as  stated  above,  we  might  guide  the 
hand  along  the  anterior  plane  of  the  foetus,  and  thus  get  directly  at  the  feet. 
(Fig.  98.) 

In  drawing  down  the  feet,  we  must  be  careful  to  curve  the  child's  trunk  in 
the  line  of  its  natural  flexure ;  whilst  the  other  hand,  placed  over  the  left  iliac 
fossa,  pushes  the  head  towards  the  fundus  uteri,  and  thus  facilitates  the  evolution 
of  the  foetus.  This  evolution  being  once  effected,  the  left  occipito-iliac  position 
is  found  to  be  converted  into  a  right  lumbo-iliac  one.  The  subsequent  progress 
of  the  delivery  offers  no  special  indication. 

2.  Right  Occipito-Iliac  Position. — In  this  case,  the  right  hand  would  be 
chosen  in  preference,  by  which  the  head  is  to  be  grasped,  as  in  the  preceding 
case,  and  then  to  be  pushed  up  towards  the  right  iliac  fussa ;  the  hand  traverses 
the  right  lateral  or  posterior  plane  of  the  foetus,  and,  after  having  seized  the 
feet,  converts  the  second  position  of  the  vertex  into  a  first  of  the  breech,  or,  in 
other  words,  into  a  left  lumbo-iliac  one. 

The  rapidity  with  which  the  extraction  is  to  be  effected,  must  depend  upon 
the  gravity  of  the  accident  which  has  rendered  it  necessary. 

Presentations  of  the  Face. — In  the  face  presentations,  we  use  the  left  hand  in 
the  right  mento-iliac,  and  the  right  one  in  the  left  mento-iliac  positions.  The 
four  fingers  are  to  be  applied  on  the  posterior  cheek,  the  thumb  on  the  anterior 
one,  and  the  face  will  be  lodged  in  the  palmar  concavity;  the  head,  after  having 
been  pushed  above  the  superior  strait,  will  be  carried  if  possible  towards  the  left 
iliac  fossa  in  the  right  mento-iliac,  and  towards  the  right  iliac  fossa  in  the  left 
mento-iliac  positions;  and  then  the  evolution  will  convert  the  former  of  these 
positions  into  a  right  lumbo-iliac,  and  the  latter  into  a  left  lumbo-iliac  position. 

Presentations  of  the  Pelvic  Extremity. — When  the  pelvic  extremity  presents, 
and  any  circumstance  whatever  demands  a  prompt  termination  of  the  labor,  it 
is  not,  properly  speaking,  a  version  that  the  accoucheur  has  to  practise,  but 
rather  a  few  simple  tractions  on  the  presenting  part. 


792 


DYSTOCIA. 


If  the  feet  or  tlie  knees  oifer  at  the  uteruie  orifice,  or  hang  in  the  vagina,  the 
accoucheur  merely  seizes  and  draws  on  theui,  conforming  to  the  rules  above 
given  :  but  where  the  lower  extremities  are  stretched  out  along  the  child's 
anterior  plane,  and  the  breech  alone  presents,  the  course  to  be  pursued  varies  a 
little,  according  as  this  part  is  more  or  less  engaged  in  the  excavation.  Thus, 
when  the  nates  are  still  above  the  superior  strait,  or  at  least  are  so  little  engaged 
that  it  is  easy  to  press  them  up,  we  must  act  in  the  following  manner:  taking 
care  to  introduce  the  left  hand  in  the  left  lumbo-iliac  positions,  and  the  right 
hand  in  the  opposite  ones,  the  buttocks  are  first  seized  by  the  whole  hand,  and 
gently  pushed  up  into  that  iliac  fossa  towards  which  the  child's  back  is  turned ; 
then  the  feet  are  sought  out,  by  following  the  posterior  aspect  of  the  lower  ex- 
tremities, and  they  are  brought  down  so  as  to  draw  upon  them  and  terminate  the 
third  stage  of  the  version.  When  the  nates  have  reached  the  pelvic  flooi',  the 
index  finger  of  one  hand  is  placed  in  the  posterior  groin,  and  the  same  finger  of 
the  other  hand  in  the  anterior  one,  and  then,  having  both  fingers  curved  like  a 
hook,  we  draw  on  the  buttocks  until  the  feet  are  entirely  clear.  Lastly,  if  the 
breech  is  so  far  engaged  as  to  be  no  longer  capable  of  being  pressed  above  the 
superior  strait,  and,  nevertheless,  has  not  yet  descended  low  enough  to  be  caught 
by  the  fingers,  a  blunt  hook  is  employed,  which  is  to  be  applied  from  without 
inwards  on  the  anterior  groin,  if  it  is  possible  to  make  it  slip  up  between  the 
anterior  hip  and  the  symphysis  pubis  (Fig.  105)  ;  in  the  contrary  case,  it  is  passed 
between  the  two  thighs,  and  made  to  penetrate  from  within  outwards  on  the  in- 
ternal part  of  the  limb;  but,  in  this  latter  case,  it 
is  necessary  to  protect  the  genital  parts,  the  scro- 
tum in  particular,  by  one  or  more  fingers  previously 
introduced,  lest  they  become  embraced  by  the 
concavity  of  the  instrument. 

Presmfidlons  of  the  Trunk. —  We  have  fre- 
quently repeated  that  the  trunk  presentations,  of 
themselves,  rccpiire  the  intervention  of  art;  and 
that  it  is  requisite  to  change  the  position  of  the 
child  as  soon  as  the  conditions  necessary  to  this 
evolution  are  met  with.  In  the  preceding  article, 
we  endeavored  to  point  out  those  conditions  under 
which  we  think  an  attempt  to  effect  the  cephalic 
version  ought  to  be  recommended ;  notwithstand- 
ing which,  the  pelvic  version  is  very  often  prac- 
tised, either  because  such  attempts  have  proved 
ineffectual  or  because  it  is  deemed  advisable  not 
to  resort  to  them. 

Nevertheless,  before  laying  down  the  rules  of 
the  operation,  we  must  remark  that  the  accoucheur 
only  resorts  to  the  pelvic  version  in  these  cases  in 
order  to  remedy  the  defective  presentation ;  and 
consequently  that,  as  soon  as  he  shall  have  con- 


Fig.  105. 


The  mode  of  usiii-j  ihe  blunt  hook  in 
ihe  breech  positions. 


OF    VERSION. 


793 


verted  this  latter  into  one  of  the  breech,  he  should  abandon  the  rest  of  the  labor 
to  the  expulsory  efforts  of  the  uterus,  unless  some  accident,  serious  enough  to 
threaten  the  life  of  either  the  mother  or  the  child,  should  require  a  more  rapid 
delivery.  As  before  stated,  the  trunk  presentations  are  two  in  number,  and  each 
side  of  the  foetus  may  present  at  the  superior  strait  in  two  diiferent  positions  : 
in  the  first  of  each,  the  head  is  in  the  left  iliac  fossa,  and  in  the  second  it  is  in 
the  right  iliac  fossa. 

The  rule  hitherto  followed  in  the  choice  of  the  hand  is  not  applicable  to  the 
trunk  presentations :  for  here  we  would  introduce  the  right  hand  in  the  positions 
of  the  right  lateral  plane,  and  the  left  in  the  positions  of  the  left  lateral  plane ; 
after  which  the  operation  is  conducted  in  the  following  manner  : 

A.  First  Position  of  the  Right  Shoulder  (left  cephalo-iliac). — The  right  hand 
is  to  be  introduced  into  the  parts  in  a  state  of  supination,  when,  after  having 
endeavored  to  push  the  shoulder  above  the  superior  strait,  and  a  little  towards 
the  left  iliac  fossa,  it  is  directed  towards  the  right  sacro-iliac  symph3rsis,  above 
which  the  child's  feet  are  found ;  the  latter  will  then  be  seized  and  brought 
down  into  the  vagina.  In  doing  this,  it  is  not  necessary  to  bend  the  foetus  in 
the  line  of  its  natural  flexure,  as  in  the  vertex  and  face  positions,  but  we  may 
draw  immediately  on  the  feet  and  bring  them  into  the  excavation;  for  this 
lateral  evolution,  or  bending  on  the  side,  is  much  more  speedily  accomplished, 
and  it  is  not  attended  with  any  inconvenience.  The  feet,  being  once  in  the 
vagina,  the  operation  is  terminated  as  in  all  other  cases. 

B.  Second  Position  of  the  Ritjht  Shoulder  (right  cephalo-iliac). — Here,  like- 
wise, the  right  hand  is  introduced  in  a  state  of  supination.  The  shoulder  is 
seized  and  pushed  up  towards  the  right  iliac  fossa,  and  then  the  hand  traverses 
the  posterior  plane  of  the  fa'tus,  by  passing  backwards  and  to  the  left;  when  it 


106. 


Fig.  107. 


Tlie  iiitroductioM  of  the  liaiid  in  llie  second 
position  of  the  ri^ht  shoulder. 


]\Iode  of  seizinif  tlie  feet  in  the  same 
position. 


reaches  the  nates,  it  gets  around  them  by  being  changed  into  a  state  of  pronation, 
and  then  comes  forward  and  to  the  left  to  grasp  the  feet,  which  are  next  brought 
down  into  the  vagina.     (Fig.  107.) 


794 


DYSTOCIA. 


Fig.  lUS. 


Mode  of  seizing  ihe  feet  in  the  second 
position  of  llie  left  slioulder. 


C.  First  Position  of  the  Left  Shoulder  (left  cephalo-iliac). — The  left  lianil 
is  introduced  in  a  state  of  supination,  and  then,  after  pressing  the  shoulder  up- 
wards and  a  little  to  the  left,  it  is  directed  along  the  child's  back  towards  the 

right  posterior  part  of  the  pelvis,  where  it  is 
passed  around  the  breech  by  turning  to  a  state 
of  pronation,  and  is  next  brought  forward  and 
to  the  right,  so  as  to  seize  the  feet. 

D.  Second  Position  of  ihe  Left  Shoiddcr 
(right  ceiihalo-iliac). — The  left  liand,  intro- 
duced in  a  state  of  supination,  pushes  the 
shoulder  above  the  superior  strait  and  some- 
what to  the  right;  and  then,  passing  towards 
the  left  side  and  posterior  part  of  the  uterus, 
it  goes  in  search  of  the  feet,  which  are  found 
there.i 

Trunk  Presentations  trith  a  Descent  of  the 
Ann.  (Presentations  of  the  arm  or  hand,  of 
authors.) — We  have  heretofore  stated  that  the 
descent  of  the  hand  in  the  shoulder  presenta- 
tions, is  nothing  more  than  an  attendant  circum- 
stance of  these  latter.     Consequently,  whether  the  band  has  been  carried  along 

'  As  the  reader  will  see,  this  operation  is  very  simple;  though  it  must  be  acknowledged, 
however,  that,  in  those  cases  in  which  the  dorsal  plane  of  the  foetus  is  directed  forwards,  it 
renders  this  plane  liable  to  be  turned  backwards  after  the  evolution  of  the  child.  Conse- 
quently, when  we  cannot  succeed  in  turning  the  belly  posteriorly  during  the  traction,  it  gives 
rise  to  all  the  inconveniences  hitherto  pointed  out,  as  occurring  in  those  instances  in  which 
the  face  looks  towards  the  pubis. 

In  order  to  remedy  these  difficulties  and  their  attendant  dangers,  ]M.  Velpeau  recominends 
that  the  positions  in  which  the  back  is  in  front  (the  first  of  the  right  shoulder,  and  the  second 
of  the  left)  be  converted  into  the  dorso-posterior  positions  before  attempting  the  evolution. 
Thus,  he  would  endeavor  to  convert  a  second  position  of  the  left  shoulder  into  a  first  of  the 
left,  by  making  the  head  pass  above  the  pubis,  or  above  the  promontory  of  the  sacrum,  ac- 
cording to  whether  it  was  originally  placed  nearer  to  the  anterior  arch  of  the  pelvis,  or  to 
the  right  sacro-iliac  symphysis ;  he  would  then  terminate  it,  as  if  it  had  primitively  been  a 
first  position  of  the  left  shoulder.  "  Should  the  meinbranes  have  been  long  ruptured,''  adds  M. 
Velpeau,  "  the  womb  strongly  contracted,  and  the  child  not  to  be  moved  but  with  very  great 
difliculty,  there  is  a  third  mananivre  that  ought  then  to  be  preferred;  it  consists  in  pushing 
the  shoulder  up  with  the  right  hand  from  behind  forwards,  as  if  to  make  the  spine  turn  upon 
its  own  axis;  then  trying  to  reach  the  right  side  by  passing  along  the  front  of  the  chest,  while 
the  womb  is  forcibly  pushed  backwards  with  the  left  hand  ;  lastly,  in  taking  hold  of  the 
feet,  the  right  one  first,  so  as  to  bring  them  down  in  the  first  position." — Meigs'  Translation, 
p.  447. 

We  have  alluded  to  this  manrruvre,  only  because  the  author's  naine  might  give  it  some 
importance  in  the  eyes  of  young  practitioners.  But  in  our  estimation  it  ought  to  be  rejected 
altogether.  In  fact,  one  of  two  things  must  then  happen ;  for  either  the  uterus  is  forcibly 
retracted  (when  this  conversion,  if  persisted  in,  appears  to  us  impracticable  and  dangerous), 
or  else  the  womb  is  inert,  and  it  woidd  therefore  be  useless.  As  we  have  already  stated 
(page  7S5),  the  reason  for  dreading  a  persistence  of  the  child's  anterior  plane  in  front,  is  not 


OF    VERSION.  795 

by  the  gusli  of  waters  which  escaped  when  the  membranes  were  ruptured,  or 
whether  it  has  been  drawn  down  by  the  accoucheur  himself,  in  order  to  make 
out  the  diagnosis,  it  constitutes  an  obstacle  of  minor  importance,  and  even  one 
which  may  render  the  pelvic  vereion  more  easy;  hence,  so  far  from  attempting 
to  push  back  the  arm  into  the  uterus,  we  ought  to  apply  a  fillet  on  the  wrist,  not 
for  the  purpose  of  drawing  upon  the  latter,  but  to  prevent  it  from  returning 
whilst  searching  after  the  feet  in  the  ordinary  way. 

"  Our  object  in  applying  this  fillet,"  says  3Iadame  Laehapelle,  "  is  to  keep  the 
hand  at  the  exterior,  lest  the  arm  should  take  a  wrong  direction ;  as  also  lest, 
being  stretched  out  as  it  is,  it  will  not  follow  the  rotation  that  turns  the  sternum 
of  the  foetus  posteriorly,  when,  by  being  arrested  by  the  pubis,  and  by  ascending 
along  the  child's  back,  it  might  become  crossed  behind  the  neck."  Finally,  let 
us  add,  that  the  hand,  or  rather  the  arm,  materially  aids  in  accomplishing  the 
rotation  of  the  trunk,  since  it  offers  an  additional  hold  for  the  tractions  made  on 
the  body,  and  obviates  the  necessity  of  delivering  one  shoulder,  which  is  very 
often  painful. 

After  what  has  just  been  said,  the  reader  will  doubtless  be  astonished  in  look- 
ing over  the  older  writers,  to  observe  the  alarm  occasioned  by  the  so-called  pre- 
sentation of  the  hand  or  ai'm,  and  he  will  be  still  more  surprised  at  the  barbarous 
procedures  employed  by  them  for  its  management.  They  were  evidently  mis- 
taken with  regard  to  the  cause  of  the  difficulties  that  are  often  met  with  in  the 
performance  of  the  version  under  such  circumstances.  However,  it  must  be 
acknowledged  that,  although  a  2^>'csentatio7i  of  the  hand  is  nothing  more  than  a 
variety  of  the  shoulder  presentation,  yet  the  descent  of  the  forearm,  and  more 
especially  of  the  arm  beyond  the  vulva,  constitutes  an  exceedingly  unfavorable 
complication.  Because,  where  this  hangs  down  at  the  exterior,  or  nearly  so,  it 
must  necessarily  happen  that  the  presenting  shoulder  is  already  forcibly  engaged 
in  the  excavation ;  an  engagement  that  can  only  take  place  when  the  whole  of 
the  waters  have  been  discharged  for  some  time,  when  the  uterine  contractions 
have  been  exerted  for  a  long  while  on  the  body  of  the  child,  and  when  the  walls 
of  the  womb  have  become  firmly  retracted  on  the  surface  of  the  foetus.  More- 
over, the  prolonged  contact  of  the  fanal  inequalities  is  then  very  apt  to  bring  on 
the  spasmodic  or  tetanic  contractions  of  the  body  and  the  neck  of  the  uterus, 
which  are  justly  considered  as  constituting  one  of  the  most  serious  complications; 
for  they  equally  prevent  the  return  of  the  presenting  part,  the  introduction  of  the 
hand,  and  the  evolution  of  the  foetus. 

Consequently,  we  are  not  to  operate  on  the  part  that  may  present  in  these 
difficult  cases;  for  a  return  of  the  arm  into  the  uterine  cavity  is  then  impossible, 

because  it  cannot  be  turned  backwards  during  the  traction,  bat  because  there  is  reason  to 
fear  lest  the  head,  by  being  arrested  by  the  contraction  at  the  fundus  of  the  uterus,  may  not 
follow  the  movement  of  rotation  impressed  on  the  thorax,  whereby  a  torsion  of  the  neck 
might  result.  Again,  if  the  organ  is  inert  enough  to  admit  of  the  preliminary  conversion 
advised  by  Velpeau,  it  would  doubtless  be  sufficiently  so  to  enable  the  accoucheur  to  direct 
his  tractions  in  such  a  way  as  to  bring  the  occiput  in  front,  and  the  face  into  the  hollow  of 
the  sacrum,  without  hazard. 


796  DYSTOCIA. 

and  of  little  service ;  to  draw  on  it  strongly,  under  a  hope  of  engaging  the 
doubled  up  trunk  in  the  excavation,  and  of  making  it  perform  a  kind  of  artifi- 
cial evolution,  is  to  commence  a  manoeuvre  that  cannot  be  carried  through,  and 
■which  must  greatly  augment  the  existing  difficulties;  to  go  in  search  of  the 
other  arm,  so  as  to  subsequently  pull  upon  it  with  a  view  of  making  the  de- 
scended shoulder  return,  presupposes  an  introduction  of  the  hand,  which  would 
be  almost  as  difficult  as  searching  after  the  feet;  and,  lastly,  to  scarify  the  arm 
or  amputate  it,  is  a  barbarous  measure  when  the  child  is  living,  and  most  gene- 
rally useless  when  it  is  dead. 

We  repeat,  it  is  not  there  that  the  genuine  obstacles  to  the  delivery  are  to  be 
found;  but  it  is  rather  against  the  violent  contraction  of  the  body  and  occasion- 
ally of  the  neck  of  the  womb,  that  we  are  to  act,  by  employing  the  measures 
recommended  above.  Should  these  fail,  the  course  to  be  pursued  will  neces- 
sarily vary,  according  to  whether  the  foetus  be  living  or  dead.  If  still  living, 
and  the  mother's  condition  does  not  absolutely  demand  a  prompt  delivery,  wo 
should  hope,  and  wait  for  a  spontaneous  evolution.  (See  Natural  Labor.)  But, 
if  her  life  is  seriously  compromised,  though  the  child  be  yet  alive,  its  viability 
may  be  considered  as  destroyed,  and  embryotomy  be  resoi'ted  to.  (See  Em- 
bryotomy.) The  reasons  for  this  course  will  be  still  more  urgent  when  there  is 
a  certainty  of  its  death. 


CHAPTER   11. 

OF  THE   FORCEPS. 

The  forceps  is  a  kind  of  pincers  composed  of  two  blades,  very  similar  to  each, 
other,  and  which  are  specially  intended  to  be  applied  on  the  head  of  the  foetus. 

The  honor  of  inventing  this  instrument  has  been  attributed  to  several  persons ; 
but,  at  the  present  day,  it  is  clearly  established  that  the  forceps  was  invented  by 
a  member  of  the  fiiraily  of  the  Chamberlens,  who,  during  the  first  half  of  the 
seventeenth  century,  pursued  the  censurable  course  of  holding  it  as  a  secret,  by 
the  aid  of  which  they  promised  to  terminate  the  most  difficult  labors.  It  would 
appear,  however,  that  it  soon  became  known  to  some  of  the  English  practitioners  ; 
for  Drinkwater,  who  practised  the  art  of  midwifery  from  1G68  to  1728,  made 
use  of  instruments  which,  if  we  may  judge  from  the  description  given  of  them 
by  Johnson,  closely  resembled  those  employed  by  the  Chamberlens. 

In  1670,  one  of  the  Chamberlens  came  to  Paris  for  the  purpose  of  selling  his 
secret;  since,  according  to  the  account  of  IMauriceau,  he  had  proposed  to  the 
king's  chief  physician  to  make  known  his  instrument  for  a  remuneration  of  ten 
thousand  crowns.  As  Chamberlen  believed  his  process  was  applicable  to  all 
cases,  he  unfortunately  promised  to  effect  the  delivery  in  a  woman  whose  pelvis 
was  deformed  to  an  extreme  degree,  and  on  whom  Mauriceau  had  deemed  the 
Ca2sarean  operation  to  be  necessary.  Consequently,  as  the  French  accoucheur 
had  foreseen,  all  the  attempts  of  Chamberlen  to  accomplish  the  delivery  proved 
inefi"octual,  and  he  returned  to  England,  abandoning  all  the  glittering  hopes  of 


THE    FORCEPS.  797 

fortune  that  he  had  expected  to  realize  on  arriving  at  Paris.  It  would  seem 
that  he  afterwards  made  a  journey  to  Hollan(f,  about  the  year  1603,  and  com- 
municated, or  rather  sold,  some  of  his  instruments  to  certain  accoucheurs  there, 
among  whom  Roonhuysen,  Euysch,  and  Bockelman,  are  particularly  mentioned. 
In  fact,  it  is  almost  certain  that  the  famous  lever  of  the  former  of  these  phj-si- 
cians  had  no  other  origin,  and  was  only  a  slight  and  defective  modification  of 
the  instrument  he  obtained  from  Chamberlen.  However  this  may  be,  the  for- 
ceps was  likewise  held  as  a  secret  for  a  long  time  in  Holland,  and  it  was  not 
until  sixty  years  afterwards,  that  is,  about  the  year  1753,  that  Visscher  and  Van 
de  Poll  brought  Roonhuysen's  lever  into  general  notice.^ 

Palfyn,  an  accoucheur  of  Ghent,  has  also  been  incorrectly  con.sidcred  as  the 
real  inventor  of  the  forceps.  He  made  several  trips  to  London  and  Germany, 
with  a  view  of  finding  out  this  wonderful  secret;  which,  according  to  Mauriceau, 
had  furnished  Chamberlen  an  income  of  more  than  thirty  thousand  livres  per 
annum  (an  enormous  sum  for  that  period)  j  and  it  is  probable  that  it  was  in  con- 
sequence of  the  information  obtained  in.  these  two  countries,  that  he  desi"-ned 
the  draw-head  (Jtire-tete),  subsequently  presented  by  him  to  the  Academy  of 
Sciences  at  Paris. ^ 

Chamberlen's  forceps  underwent  a  number  of  modifications,  after  it  became 
public  property,  that  were  generally  unimportant;  and  fortunate  indeed  was  it 
when  the  so-called  improvements  did  not  render  it  more  awkward  and  dano-erous 
than  before.  But  the  middle  of  the  eighteenth  century  opened  a  new  era  in  the 
history  of  this  instrument;  for,  about  this  period,  two  illustrious  obstetricians, 
Levret  in  France,  and  Smellie  in  England,  were  struck  with  the  necessity  of 
accommodating  the  shape  of  the  forceps  to  the  direction  and  form  of  the  pelvic 
axis;  and,  as  a  consequence,  they  thus  enlarged  the  field  of  its  application. 

'  We  may  remark  that  the  instrument  described  by  these  last-named  authors,  under  the 
title  of  Roonhuysen's  lever,  was  not  the  one  which  the  latter  had  bought  of  Chamberlen,  for 
it  is  composed  of  a  single  curved  iron  blade.  In  1747,  Rathlauw  published  a  description  of 
an  instrument  that  he  had  received  from  Van  der  Swam,  a  pupil  of  Roonhuysen,  which  was 
composed  of  two  blades,  having  fenestrcp  in  them,  and  joined  at  their  extremity  by  means  of 
a  pin. 

2  This  presentation,  made  at  a  time  when  Chamberlen's  forceps  were  scarcely  known  in 
France,  unjustly  obtained  for  Palfyn  the  reputation  of  being  its  inventor.  But,  in  our  day, 
the  question  can  no  longer  be  considered  doubtful,  for,  independently  of  the  numberless 
proofs  that  establish  the  claims  of  the  Chamberlens,  they  have  recently  been  confirmed, 
says  Dr.  Edward  Rigby,  by  a  discovery  made  in  the  ceunty  of  Essex.  It  appears  that  Dr. 
Peter  Chamberlen  purchased,  towards  the  end  of  the  seventeenth  century,  the  estate  of 
Woodhain,  Mortimer  Hall,  near  Maldon  in  Essex,  which  continued  in  the  family  till  about 
171.5,  and  was  then  sold  to  Mr.  Wm.  Alexander,  who  bequeathed  it  to  the  Wine  Coopers' 
Company.  About  the  year  1815,  the  tenant  in  occupation  discovered,  in  tlie  floor  in  the 
uppermost  of  a  series  of  closets,  which  are  built  over  the  entrance-porch,  a  trap-door.  In 
the  space  between  the  flooring  of  this  closet  and  the  ceiling  below  were  found,  among  a 
number  of  empty  boxes,  a  cabinet,  containing  a  collection  of  old  coins,  divers  trinkets,  many 
letters  from  Dr.  Chamberlen  to  different  members  of  his  family,  and  some  obstetric  instru- 
ments. These  instruments,  which  were  given  to  Mr.  Carwardine  by  the  lady  of  the  man- 
sion, and  described  by  Rigby,  exhibit  the  successive  attempts  made  by  the  Chamberlens, 
before  they  succeeded  in  perfecting  their  forceps. 


798 


DYSTOCIA. 


109.    Fig.  110.        Fig.  111. 


Chamberlen's  forceps  was  straight,  and  therefore  only  applicable  when  the  head 
was  low  down  in  the  excavation, 'and  close  to  the  perineum ;  but  both  of  these 
gentlemen  endeavored  to  render  it  capable  of  being  applied  to  the  head  whea 
still  above  the  superior  strait;  and  for  that  purpose  they  gave  it  a  curve  in  the 
direction  of  its  long  axis,  so  that  the  anterior  border  presented  a  concavity  and 
the  posterior  one  a  convexity. 

It  is  impossible  to  ascertain  which  of  the  two  had  the  priority  in  originating 
this  important  modification  of  the  forceps ;  for,  though  it  is  certain  that  Levret 
had  such  a  curved  instrument  in  1747,  and  that  Smellie  did  not  announce  his 
until  1751,  yet  the  latter  expressly  declares  that  he  had  invented  it  several  years 
previously. 

Hundreds  of  modifications  have  been  proposed  since  the  days  of  Levret  and 
Smellie,  nearly  all  of  which  have  fallen  into  oblivion ;  some  of  them  were  quite 
ingenious,  but  they  imperfectly  attained  the  end  their  authors  had  in  view;  and 
others  wei'e  really  destitute  of  value  or  utility.  Consequently,  we  shall  restrict 
what  we  had  intended  to  say  concerning  its  history  to  these  few  lines,  and  shall 
only  describe  the  forceps  now  generally  used  throughout  France,  which  is  none 
other  than  that  of  Levret,  very  slightly  modified. 

The  forceps  is  composed  of  two  branches,  each  of  which  may  be  divided  into 
three  parts,  namely :  the  blade,  the  handle,  and  the  point  of  junction,  or  the 

lock.  The  blade  is  intended  to  be  introduced  into 
the  mother's  parts,  so  as  to  embrace  the  head  of 
the  foetus  ;  presenting,  therefore  : 

1.  A  curvature  on  its  flattened  aspect,  the  in- 
ternal concavity  of  which  is  destined  to  be  applied 
to  the  side  of  the  foetal  head,  while  its  external 
convexity  slips  along  the  concave  walls  of  the 
pelvis;  2.  A  curve  on  its  edge,  having  the  con- 
cavity anteriorly,  which  is  made  for  the  purpose 
of  accommodating  the  form  of  the  instrument  to 
the  direction  of  the  pelvic  axis  ;  and  to  render  an 
application  of  the  forceps  practicable  even  when 
the  head  is  retained  above  the  superior  strait. 
The  blade  is  usually  provided  with  a  fenestra, 
which  serves  to  diminish  the  size  and  weight  of 
109.  The  male  branch  no.  The  female  ^^  instrument,  and  has  the  further  advantage  of 

branch.    111.  The  forceps  locked.  ...  . 

permitting  the  parietal  protuberances  to  engage  in 
the  void  thereby  produced,  which  engagement  compensates,  to  a  certain  extent, 
for  the  thickness  of  the  branches.  The  old  forceps  were  provided  with  a  kind 
of  bead  around  the  periphery,  and  the  internal  face  of  the  blades,  which  was 
made  quite  prominent,  and  was  intended  to  obviate  the  slipping  of  the  head. 
But  the  contusions  of  the  scalp,  produced  by  this  raised  border,  have  led  to  its 
removal,  and  those  now  in  use  have  the  inner  surface  of  the  blades  polished 
down  with  the  file.  Both  handles  of  the  instrument  are  usually  bent  to  a  slight 
degree  at  their  extremity,  in  the  form  of  a  hook.  One  of  them  is  much  more 
curved  than  its  fellow;  and  has,  near  its  end,  a  hollow  button,  which  unscrews 


THE    FORCEPS.  799 

and  serves  for  the  lodgment  of  a  sharp  hook,  while  the  curve  of  the  other  scarcely 
reaches  a  right  angle,  so  that  we  find  the  forceps,  a  blunt  and  a  sharp  hook,  in- 
cluded in  the  same  instrument.  The  handles  and  blades  are  just  alike  on  both 
branches,  which  differ  from  each  other  only  at  their  middle  or  articular  part, 
where  one  of  them  is  provided  with  a  pivot  and  the  other  with  a  mortise,  made 
either  in  the  middle  or  on  the  side  of  the  instrument,  by  means  of  which  they 
can  be  firmly  locked  after  their  application.  The  branch  bearing  the  pivot  has 
received  the  name  of  the  male  (Fig.  109),  and  the  other,  having  the  mortise, 
that  of  ih.Q  female  branch,  or  blade  (Fig.  110).  The  delicacy  of  certain  ac- 
coucheurs has  been  shocked  by  these  denominations,  and  they  have  endeavored 
to  substitute  for  them  the  titles  of  the  left  and  the  right  blades ;  but  I  cannot 
understand  why  the  old  names  of  the  pivot  blade  and  the  mortise  Hade  should 
not  be  retained;  though  I  would  willingly  accept  those  of  the  left  and  the  right 
ones,  if  it  were  clearly  understood  which  ought  to  be  called  the  left  and  which 
the  right.  But  unfortunately  such  is  not  the  fact,  for  M.  Velpeau  designates 
that  blade  as  the  right  one  which  Madame  Lachapelle  has  called  the  left,  and 
vice-versd.  This  discrepancy  of  terms  creates  great  confusion  in  the  mind  of  the 
reader,  which  we  shall  endeavor  to  avoid  by  retaining  the  names  of  the  male  and 
the  female  blades. 

Some  time  since.  Dr.  Simpson  proposed  a  new  forceps,  which  deserves  men- 
tion, if  only  on  the  score  of  its  originality.  Every  one  has  seen  those  circular 
pieces  of  leather  with  which  children  lift  bricks,  by  first  wetting  them  and  then 
pressing  them  strongly  upon  the  brick.  Now,  the  ingenious  Edinburgh  professor 
conceived  the  idea  of  applying  a  nearly  similar  piece  of  leather  to  the  convexity 
of  the  child's  head  projecting  into  the  excavation,  and  producing  its  adhesion  to 
the  scalp  by  exhausting  the  air  from  between  them  by  means  of  a  pump,  the 
body  of  the  pump  also  serving  as  a  means  of  traction  and  drawing  the  head  out- 
side of  the  genital  parts. 

This  instrument  is  very  ingenious,  but  I  doubt  much  whether  it  will  ever  come 
into  general  use.  When  the  head  is  in  the  cavity  of  the  pelvis,  I  think  that  the 
common  forceps  would  be  applied  much  more  easily;  when  it  is  high  up,  the 
application  of  Dr.  Simpson's  instrument  would  be  very  difficult,  besides  which, 
its  form  would  give  an  improper  direction  to  the  first  tractions.  I  would  also  add, 
that  if  violent  tractions  were  necessary,  it  might  cause  a  separation  of  the  scalp 
and  a  dangerous  effusion  of  blood. 

We  shall  divide  our  remarks  on  the  subject  of  the  forceps  into  three  distinct 
articles ;  in  the  first  of  which  will  be  found  the  precautions  that  ought  always  to 
be  taken  before  proceeding  to  an  application  of  this  instrument;  in  the  second, 
we  shall  point  out  the  general  rules  applicable  to  all  cases ;  in  the  third,  the  direc- 
tions peculiar  to  each  position,  and  shall  close  the  whole  by  some  general  consi- 
derations on  its  employment  and  mode  of  action. 

ARTICLE   I. 

PRELIMINARY  PRECAUTIONS. 

The  woman  is  to  be  placed  in  the  position  before  recommended  for  the  per- 


SOO  DYSTOCIA. 

formance  of  version ;  the  lower  extremities  being  supported  by  two  assistants 
standing  on  the  outside  of  the  limbs,  and  having  the  pelvis  firmly  held,  so  as  to 
prevent  her  from  giving  way  to  any  involuntary  movements  that  might  annoy 
the  operator;  of  course,  the  breech  ought  to  be  brought  to  the  edge  of  the  bed. 
The  patient  should  be  placed  in  this  position  whenever  nothing  particular  pre- 
vents, and  more  particularly  when  the  head  is  high  up,  though  it  is  not  so  neces- 
sary when  the  latter  is  at  the  inferior  strait.  In  fact,  if  she  found  it  impossible 
to  change  her  posture,  we  might  permit  her  to  remain  horizontally  on  the  bed ; 
but  it  would  then  be  requisite  to  employ  the  old  straight  forceps,  or  else  resort  to 
Smellie's,  which  is  very  short,  and  the  blades  slightly  curved.  The  English 
practitioners  place  the  patient  on  her  left  side,  the  position  in  which  the  women 
of  their  country  are  usually  delivered,  taking  care,  however,  to  bring  the  pelvis 
nearer  to  the  edge  of  the  bed  than  usual.  An  assistant,  standing  on  the  opposite 
side  of  the  latter,  holds  the  patient  steady,  while  another  raises  up  and  supports 
the  right  knee  and  thigh.  But  whatever  be  the  position,  one  attendant  is  parti- 
cularly charged  with  the  duty  of  preparing  and  handing  the  blades  to  the  accou- 
cheur, as  he  may  want  them. 

In  order  to  spare  the  female  the  disagreeable  sensation  produced  by  an  impres- 
sion of  cold,  it  is  customary  to  warm  the  instrument  by  dipping  it  into  hot  water. 
Some  care  is  requisite  not  to  leave  it  there  too  long,  and,  before  using,  it  should 
be  passed  through  the  closed  hand  so  as  to  be  certain  there  is  no  danger  of  its 
burning  the  soft  parts ;  the  external  surface  of  the  blades  should  then  be  smeared 
•with  butter,  cerate,  or  oil,  with  a  view  of  rendering  the  introduction  more  easy. 
Baudelocque  has  laid  down  a  precept  that  has  been  followed  by  most  succeeding 
authorities,  and  to  which  it  is  advisable  to  conform ;  namely,  to  exhibit  the  for- 
ceps to  the  patient,  concisely  explain  to  her  its  use,  its  object,  and  its  mechanism, 
and  to  make  her  understand  its  harmlessness.  "It  has  not  been  my  fortune," 
says  Madame  Lachapelle,  "  to  meet  with  any  one  who  was  not  tranquillized  by 
such  an  explanation,  and  I  have  often  known  persons  in  their  second  labor  to 
solicit  their  application  from  havirfg  experienced  the  relief  they  afforded  in  the 
first." 

Everything  being  prepared  for  the  operation,  we  must  next  ascertain  the  posi- 
tion of  the  head  with  the  greatest  possible  care;  for  even  though  it  had  been 
recognized  at  the  commencement  of  the  labor,  the  former  diagnosis  ought  to  be 
confirmed  by  a  fresh  examination,  lest  the  head  may  have  changed  its  position 
since  then.  By  this  exploration,  the  size  of  the  head,  its  reducibility,  and  its 
softness,  the  peii'ect  or  defective  conformation  of  the  pelvis,  the  degree  of  con- 
traction, if  any  exists,  &c.,  will  be  made  out  as  far  as  possible;  and,  as  the  dila- 
tation or  the  dilatability  of  the  os  uteri  is  even  more  indispensable  here  than  in 
the  case  of  version,  we  must  be  certain  that  this  condition  exists.  After  which 
we  are  to  proceed  to  the  introduction  of  the  blades. 

We  shall  pursue  the  course  followed  in  studying  pelvic  version,  first  stating  the 
general  rules  of  the  operation,  and  treating  in  another  article  of  the  peculiarities 
presented  by  each  particular  case. 


THE    FORCEPS.  801 

ARTICLE   II. 

GENERAL   RULES. 

1.  The  instrument  ouglit  only  to  he  appJled  on  the  head  of  the  foetus,  ■wliether 
the  latter  be  flexed  or  extended,  that  is  to  say,  in  the  vertex  and  face  presenta- 
tions; or  whether  it  alone  remains  behind,  presenting  by  its  base  after  the  deli- 
very of  the  trunk.  Certain  obstetricians  have  recommended  the  instrument  to 
be  applied  on  the  pelvis  in  the  presentations  of  the  pelvic  extremity,  where  from 
any  cause  it  may  be  desirable  to  terminate  the  labor  promptly.  But  the  bones 
of  the  pelvis  are  too  deficient  in  solidity,  and  their  articulations  o0"er  too  feeble  a 
resistance  to  be  able  to  support  the  pressure  made  by  the  forceps  without  hazard. 
Besides,  it  would  be  difficult  to  get  the  breech  in  the  hollow  of  the  blades,  with- 
out carrying  their  points  above  the  iliac  crests  against  the  soft  walls  of  the  abdo- 
men, thereby  producing  a  more  or  less  serious  contusion  of  the  abdominal  organs. 
As  a  general  rule,  the  breech  presentations  do  not  appear  to  me  to  warrant  the 
use  of  the  forceps.  I  am  aware,  however,  that  M.  Stoltz  recommends  its  em- 
ployment under  such  circumstances,  and  I  am  induced  to  believe  that  M.  P. 
Dubois  would  not  hesitate  in  resorting  thereto,  in  some  cases  where  direct  trac- 
tions on  the  pelvic  extremity  might  be  difficult. 

2.  Tlie  blades  should  he  applied  as  nearly  as  ptossihle  on  the  sides  of  the  head, 
in  such  a  icay  that  the  concavity  of  their  margins  shall  he  directed  toivards  that 
part  of  the  head  ichich  is  to  he  hrovght  under  the  symphysis  pubis. — This  rule 
is  not  always  feasible,  for  it  will  be  seen  hereafter  that  it  is  impossible  to  carry  it 
out  in  some  cases  of  transverse  positions,  in  which  we  are  obliged  to  seize  the 
head  over  the  forehead  and  occiput;  but  these  exceptions  are  rare,  and  the 
operator  should  endeavor  to  follow  the  rule  in  all  cases.  When  the  forceps  is 
thus  applied,  each  blade  bears  on  the  lateral  parts  of  the  cranium ;  the  parietal 
protuberances  are  found  in  the  opening  of  the  fenestras,  at  the  point  where  the 
blades  are  the  most  widely  separated  from  each  other;  and  the  occipito-mental 
diameter  corresponds  very  nearly  to  a  line  drawn  from  the  extremity  of  the  blades 
towards  the  pivot. 

3.  As  a  general  ride,  the  posterior  blade  ought  to  he  introduced  first. — As  the 
head  is  placed  in  a  transverse  or  a  diagonal  position  in  a  vast  majority  of  cases, 
one  of  its  sides  will  look  forwards  and  the  other  backwards;  and,  therefore,  one 
of  the  blades  will  be  at  the  fore  and  the  other  at  the  hinder  part  of  the  pelvis, 
since  we  have  just  seen  that  it  is  requisite  to  apply  them  on  the  sides  of  the  head. 
Now  it  is  the  one  that  goes  to  the  back  part  of  the  pelvis  that  we  recommend  to 
be  generally  introduced  first.  In  theory,  this  is  even  admitted  as  the  absolute 
rule,  since  it  is  considered  to  be  the  most  generally  applicable ;  for  everybody 
acknowledges  that  the  positions  in  which  the  occipito-frontal  diameter  corre- 
sponds to  the  left  oblique  one  of  the  pelvis  are  the  most  frequent  of  all.  But  it 
must  be  borne  in  mind,  that  in  practice  there  is  no  invariable  law,  and  the  one 
we  lay  down  is  subject  to  very  numerous  exceptions.  If  desirable,  however",  to 
establish  a  universal  principle  for  the  operation,  we  might  say,  that  the  blade,  the 
application  of  which  presents  the  greatest  difficulty,  ought  to  be  introduced  first. 

51 


802 


DYSTOCIA. 


After  all,  it  must  be  left  to  the  skill  and  tact  of  the  accoucheur  to  decide  at  the 
bedside  of  the  patient  which  branch  must  be  introduced  first,  for  it  is  out  of  the 
question  to  anticipate,  in  a  book,  or  even  to  imitate  on  the  manikin,  all  the  pecu- 
liarities that  may  there  influence  his  decision.  For  instance,  ■when  the  head  is 
high  up  in  the  excavation,  it  would  sometimes  be  better  to  reverse  the  rule,  and 
introduce  the  anterior  blade  first. 

4.  The  male  blade  is  always  to  he  held  in  the  left  hand,  and  is  to  be  aj->plied 
at  the  Ifft  side  of  the  pelvis ;  the  female  blade  is  to  be  held  in  the  riyht  hand, 
and  is  always  to  be  ajyplied  at  the  right  side  of  the  j^elvis. 

Mr.  Hatin  has  lately  suggested  a  method  which  bears  considerable  resem- 
blance to  that  employed  by  Flamand  in  some  exceptional  cases.  It  consists  in 
the  introduction  of  both  branches  by  the  same  hand.  The  left  hand,  prefer- 
ably, is  carried  to  the  fundus  of  the  uterus,  or  at  least  to  the  parts  to  which  the 
forceps  are  to  be  applied.  The  first  branch  having  been  introduced  along  the 
hand  which  serves  as  a  guide,  the  latter  without  quitting  the  head  of  the  foetus, 
passes  around  it,  and  places  itself  on  the  opposite  side,  to  receive  and  guide  the 
second  branch  of  the  instrument. 

This  process,  represented  by  M.  Hatin  to  be  the  easiest,  and  especially  the 
least  dangerous  for  both  mother  and  child,  does  not  appear  to  me  to  possess  all 
the  advantages  claimed  for  it  by  Flamand  and  M.  Ilatin.  As  M.  Stoltz  judi- 
ciously remtu-ks,  it  can  have  no  advantage  except  when  the  head  is  movable,  or 
previously  rendered  so,  above  the  superior  strait,  in  which  case  we  have  already 

seen  that  pelvic  version  is  prefer- 
able, even  though  the  pelvis  be 
slightly  contracted. 

When  the  head  is  wedged  in  the 
superior  strait,  or  more  or  less  en- 
gaged in  the  excavation,  it  seems 
to  me  that  the  ordinai-y  process  is 
iucontestably  superior. 

5.  The  free  hand,  or  the  one  not 
en(joijcd  in  holdincj  the  blade,  should 
always  he  introduced  first,  so  as  to 
direct  the  latter. — When  the  head 
is  at  the  inferior  strait,  it  is  usually 
sufficient  to  insert  two  or  three  fin- 
gers between  the  side  of  the  head 
and  the  pelvis  (see  Fig.  112);  but 
whenever  it  is  high  up,  the  entire 
hand  must  be  introduced  into  the 
vagina,  taking  the  precaution  to 
j)lace  the  ends  of  the  fingers  be- 
tween the  head  and  the  os  uteri, 
so  as  to  be  certain  that  the  blade, 
by  slipping  along  the  palmar  surface 


Fig.  112. 


Introduction  of  the  first  branch. 


THE     FORCEPS.  803 

of  the  hand  -will  got  into  the  uterine  cavity,  and  not  pass  externally  to  the  cervix, 
perforate  the  cul-de-sac  of  the  vagina,  and  penetrate  into  the  peritoneum.  The 
convex  surface  of  the  blades  glides  along  the  palmar  surface,  and  the  convex 
margin  along  the  cubital  border  of  the  hand ;  in  a  word,  this  previous  introduc- 
tion of  the  latter  is  intended  to  protect  the  vaginal  wall  from  the  contact,  of 
the  instrument. 

6.  At  icJtat  part  of  the  pelvis  aliouhl  the  hlade  he  first  introduced  ? — This 
question  has  been  variously  answered  :  thus,  Baudelocque  directs  it,  in  nearly  all 
cases,  immediately  on  the  point  where  it  is  to  remain  after  the  locking.  Levret 
(and  M.  Velpeau  adopts  nearly  the  same  view)  recommends  that  the  two  blades 
be  introduced  at  the  posterior  quarter  of  the  pelvis;  that,  in  the  diagonal  posi- 
tions, one  of  them  be  left  in  front  of  the  sacro-iliac  symphysis,  but  that  the  other 
be  brought  forward  opposite  to  the  cotyloid  cavity  which  corresponds  with  the 
anterior  side  of  the  head,  by  making  it  traverse  the  whole  lateral  half  of  the 
pelvis  from  behind  forwards.  Lastly,  Madame  Lachapelle  has  proposed  a  mixed 
method,  composed,  in  part,  of  both  of  the  preceding  :  namely,  both  branches 
are  first  introduced  in  front  of  the  sacro-sciatic  ligament,  and  then  the  one  which 
should  remain  posteriorly  is  pushed  directly  up  to  the  sacro-iliac  articulation ; 
but  the  other  is  brought  forward  at  once  opposite  to  the  cotyloid  cavity  in  the 
following  manner:  "I  insinuate  the  extremitj'  of  the  blade  just  in  front  of  the 
sacro-sciatic  ligament;  then,  as  it  passes  in,  I  gradually  depress  the  handle  be- 
tween the  thighs,  until  it  is  inclined  much  below  the  level  of  the  anus;  by 
this  manoeuvre,  the  point  of  the  blade  is  made  to  describe  a  spiral  movement, 
which  is  directed  and  completed  by  the  fingers  introduced  into  the  vagina.  By 
this  movement,  the  blade  is  carried  upwards  and  forwards  at  the  same  time,  so 
that  it  is  made  to  pass  around  the  head  in  an  oblique  direction,  which  would  be 
represented  by  a  line  extending  along  the  interior  of  the  pelvis  from  the  sacro- 
sciatic  ligament  to  the  horizontal  branch  of  the  pubis,"  This  mode  of  procedure 
is  also  adopted  by  M.  P.  Dubois,  and  is  the  one  which  appears  to  us  the  easiest 
of  all.  It  should  be  understood,  however,  that  it  is  only  applicable  when  the 
head  is  already  engaged  in  the  excavation.  The  reader  will  see,  hereafter,  that 
above  the  superior  strait  the  branches  are  applied  on  the  sides  of  the  pelvis  with- 
out any  particular  reference  to  the  position  of  the  head.  Finally,  some  of  the 
German  accoucheurs  recommend  the  blades  to  be  placed  on  the  sides  of  the 
pelvis  in  all  cases,  without  regard  to  the  position  of  the  head.  This  precept  is 
followed  as  a  matter  of  necessity  when  the  head  is  high  up  But  when  engaged 
in  the  excavation,  it  will  be  found  better  in  the  majority  of  cases  to  follow  the 
rule  which  we  have  given. 

7.  llie  second  hlade  is  always  introduced  ahnve  and  in  front  of  the  first ;  so 
that,  in  some  instances,  the  male  branch  is  found  over  the  female  one,  as  in 
Fig.  113  ;  i.  e.,  between  it  and  the  symphysis  pubis.  It  will  then  be  necessary, 
in  locking  the  blades,  to  cross  the  handles,  by  making  the  female  one  pass  above 
the  male.  Attempts  have  been  made  of  latter  time  to  avoid  this  crossing,  and 
a  particular  kind  of  forceps  has  been  devised  by  Tureaux,  Tarsitani,  and  some 
others,  for  the  purpose,  which   can   be  made   to   lock  whatever  may  be  the  ic- 


804 


DYSTOCIA. 


lative  position  of  the  handles. 
This  Is  doubtless  an  advantage, 
but  its  importance  has  cer- 
tainly been  greatly  exagge- 
rated. 

8.  JVo  force  should  ever  he 
used  m  pushing  (he  hladesitp. 
— The  obstacles  met  with  du- 
ring their  introduction  are  near 
]y  always  created  by  folds  of 
thescalp  orvagina,  in  which  the 
point  of  the  blade  becomes  en- 
tangled; or  else  the  diificulty  is 
owing  to  the  circumstance  that 
the  blade,  being  improperly  di- 
rected, is  not  pushed  up  in  the 
line  of  the  pelvic  axis,  and  con- 
sequently strikes  against  the  va- 
ginal walls.  These  are  easily 
obviated  by  varying  the  direc- 
tion of  the  instrument  a  little, 
or  by  carrying  its  handle  to- 
wards one  or  the  other  thigh, 
and  by  depressing  or  eleva- 
ting it  in  a  slight  degree.  Force  is  always  useless  and  may  be  injurious.  Thus, 
if  the  point  of  the  male  blade  was  arrested  by  a  fold  of  the  scalp,  the  instru- 
ment should  be  partially  withdrawn,  and  its  handle  be  carried  towards  the  right 
thigh,  whereby  the  extremity  of  the  blade  would  be  somewhat  removed  from  the 
head,  and  could  thus  pass  beyond  the  obstacle ;  but  if,  on  the  contrary,  it  were 
ari'ested  by  one  of  the  transverse  folds  of  the  vagina,  the  handle  should  be  car- 
ried towards  the  left  thigh,  so  as  to  make  the  point  rest  against  and  slip  over  the 
head. 

The  introduction  of  the  second  branch  is  geaerally  the  most  difficult,  and  the 
difficulty  is  generally  greatest  when  it  is  necessary  to  introduce  it  the  first. 
When  attempts,  prudently  made,  prove  fruitless,  there  should  be  no  hesitation  in 
withdrawing  both  branches,  and  beginning  again  with  the  one  which  before  was 
introduced  last.  It  were  much  better  to  renew  the  operation  two  or  three  times, 
than  to  strive  pertinaciously  against  difficulties  which  could  never  be  surmounted 
without  endangering  to  a  greater  or  less  extent  the  life  of  the  foetus,  or  the  inte- 
grity of  the  maternal  organs. 

In  withdrawing  the  branches,  they  should  be  made  to  describe  a  curve  the 
opposite  of  that  which  they  followed  during  their  introduction;  the  handle  of 
the  male  branch,  for  example,  should  be  gradually  raised  above  the  pubis,  and 
reclined  obliquely  upon  the  left  groin. 

9.  In  general,  the  locking  is  easily  effected,  by  bringing  the  two  branches 


Introduction  of  the  second  branch. 


THE    FORCEPS. 


805 


114. 


The  forceps  applied  and  locked. 


together  after  their  introduction  and  adjusting  the  pivot  in  the  mortise  (Fig. 
114),  when  an  assistant  turns 
the  former;  but  this  part  of  the 
operation  demands  a  perfect 
parallelism  between  the  two 
portions  of  the  forceps  which, 
unfortunately,  does  not  always 
occur.  For  it  frequently  hap- 
pens that  the  pivot  does  not  fit 
into  the  mortise  exactly,  either 
because  one  or  both  blades  are 
turned  outwards,  or  because  one  • 
has  penetrated  deeper  than  the 
other.  In  the  former  case,  we 
should  endeavor  to  correct  the 
deviation  gently,  by  grasping 
the  handles  with  the  whole  hand, 
and  in  the  latter  by  withdraw- 
ing or  pushing  up  one  of  them.  But  in  none  of  these  attempts  should  much 
force  ever  be  used;  for  when  considerable  difficulty  is  met  with,  it  is  probably 
owing  to  an  improper  adjustment  of  the  instrument,  and  it  is  far  better  to  extract 
one  or  even  both  blades  than  to  force  their  locking., 

10.  We  must  he  mt!><fied  that  the  head  is  2»'operli/  secnred,  and  that  it  alone 
is  included  in  the  clams  of  the  instrument. — To  be  convinced  that  no  part  of 
the  mother's  organs  is  pinched  between  the  head  and  the  forceps,  it  is  only 
requisite  to  make  a  moderate  pressure  on  the  handles,  after  the  locking,  when,  if 
the  patient  does  not  complain  of  pain,  the  operation  may  be  continued  without 
danger;  if  the  contrary  is  the  case,  the  forceps  ought  to  be  unfastened,  and  the 
included  part  be  removed  by  the  finger.  A  few  gentle  tractions  made  by  the 
forceps,  without  compressing  the  head  too  much,  will  serve  to  show  whether  the 
latter  is  properly  secured,  and  that  the  instrument  does  not  slip. 

11.  The  tractions  ought  to  he  made  in  the  direction  of  the  pelvic  axis. — If  the 
head  is  at  the  superior  strait,  we  must  first  draw  downwards  and  backwards  as 
much  as  possible ;  then,  as  it  descends  into  the  excavation,  the  handles  are  gra- 
dually elevated,  so  that,  by  the  time  it  reaches  the  inferior  strait,  they  are  found 
directed  forwards  and  somewhat  downwards;  and  the  tractions  will  then  be  made 
in  this  latter  direction.  But,  whilst  the  head  is  undergoing  its  movement  of 
extension,  the  instrument  must  be  carried  up  in  front  of  the  symph}'sis  pubis, 
and  afterwards  of  the  jibdomen,  so  that,  after  the  complete  delivery  of  the  head, 
the  forceps  shall  be  lying  almost  horizontally  over  the  woman's  belly. 

In  performing  the  tractions,  the  right  hand  is  placed  near  the  clams  and  above 
the  instrument,  the  left  hand  in  front  of  the  articulation  and  beneath.  But,  as 
soon  as  the  disengagement  is  to  be  effected  by  raising  the  instrument  above  the 
pubis,  the  position  of  the  hands  must  be  changed,  and  the  left  one  always  be 


806  DYSTOCIA. 

placed  in  front  of  the  pivot,  but  above,  and  the  right  one  belovF  the  extremity  of 
the  branches. 

The  tractions  are  to  be  made  during  a  pain  whenever  possible,  and  the  patient 
should  be  encouraged  to  bring  the  abdominal  muscles  into  play,  in  aid  of  the 
uterine  contractions  and  the  efforts  of  the  accoucheur.  As  soon  as  the  head  has 
cleared  the  inferior  strait,  and  when  it  only  has  the  resistance  from  the  soft  parts 
to  overcome,  the  vulva  being  at  the  same  time  freely  dilated,  all  tractive  force 
should,  as  a  general  rule,  be  abandoned,  and  the  rest  be  left  to  the  powers  of 
nature;  for  the  mere  presence  of  the  head  at  the  external  parts,  by  the  tenesmus 
it  gives  rise  to,  will  most  certainly  bring  on  a  sufficient  degree  of  contraction  to 
effect  the  delivery. 

Be  satisfied,  then,  with  facilitating  the  process  of  extension,  by  carrying  the 
handles  up  in  front  of  the  pubis  during  the  mother's  bearing  down  efforts;  the 
dilatation  of  the  vulva,  being  thus  slow  and  gradual,  will  be  accomplished  with- 
out any  danger  of  rupture,  especially  if  you  are  careful  to  sustain  the  perineum, 
or,  still  better,  to  have  it  supported  by  an  assistant;  for,  had  you  continued  the 
tractions,  such  a  rupture  could  scarcely  have  been  avoided.  Madame  Lacha- 
pelle  even  advises  the  instrument  to  be  withdrawn  altogether;  but  I  think  it  is 
better  to  leave  it  in  situ,  for  the  double  interest  of  the  patient  and  the  accou- 
cheur; of  the  patient  because,  in  some  cases,  a  few  tractions  may  yet  be  neces- 
sary; and  of  the  physician  because,  if  he  remove  the  forceps  from  prudential 
motives,  and  with  a  view  of  saving  the  parte,  before  the  final  delivery  of  the 
head,  he  might  be  regarded  by  the  woman  and  her  attendants  as  a  bungler,  who 
had  failed  in  his  operation.  Pie  should,  therefore,  leave  it  applied,  and  allow  the 
patient  to  expel  it  and  the  head  together. 

In  cases  attended  with  difficulty,  we  might  doubtless  draw  on  the  handles  with 
a  certain  amount  of  force;  but  the  example  of  some  practitioners  who,  taking  a 
point  of  support  by  placing  a  foot  against  some  solid  body,  hang,  as  it  were,  on 
the  handles  of  the  forceps,  and  then  pull  away  with  all  their  strength,  should 
never  be  followed.  It  is  only  necessary  to  use  the  arms,  and  the  operator  should 
take  such  a  position  that  his  body  would  always  arrest  any  sudden  slipping  of  the 
blades.  In  fact,  it  is  this  precaution  which  sometimes  renders  an  application  of 
the  forceps  so  excessively  fatiguing  to  him. 

12.  Ill  the  oblique  or  transverse  positions,  such  a  movement  of  rotation  is 
to  he  imparted  to  the  head  as  shall  hring  the  concave  margin  of  the  blades 
directly  in  front. — This  rotation  ought  to  be  performed  during  the  tractions,  just 
as  the  head  is  approaching  or  clearing  the  inferior  strait.  But  there  is  no  occa- 
sion for  any  violent  exertions,  for  most  generally  the  head  turns  in  its  descent, 
carrying  the  instrument  along  with  it  in  the  rotation.  Sometimes,  also,  an  appli- 
cation of  one  or  both  blades  is  all  that  is  necessary  to  effect  this  change. 


THE    FORCEPS.  807 


ARTICLE    III. 


SPECIAL  RULES. 


"We  have  already  stated  that  the  forceps  may  be  applied  in  the  vertex  and  face 
presentations,  and  on  the  head  when  left  behind  after  the  delivery  of  the  trunk. 
Its  application  is,  therefore,  to  be  studied  in  these  three  varieties ;  and,  as  the 
greater  or  less  elevation  of  the  head  greatly  influences  both  the  course  to  be  pur- 
sued and  the  degree  of  facility  ■with  which  the  operation  is  accomplished,  we 
shall  examine  those  cases  successively  in  which  it  has  reached  the  inferior  strait, 
in  which  it  is  still  engaged  at  the  superior  strait,  and  in  which  it  is  entirely  above 
the  latter. 

§  1.  Application  of  the  Forceps  in  Vertex  Positions,  ■\viien  the 
Head  has  reached  the  Inferior  Strait. 

The  vertex,  having  descended  to  the  inferior  strait,  may  be  found  in  corre- 
spondence with  the  various  points  of  its  circumference;  and,  therefore,  to  meet 
every  possible  case,  we  shall  have  to  admit  eight  principal  positions  of  it: 
thus,  the  occiput  may  be  in  relation  with  both  extremities  of  the  coccy-pubal 
diameter  (the  occipito-anterior  and  the  occipito-posterior  positions) ;  with  both 
extremities  of  each  oblique  diameter  (the  left  anterior  and  the  right  posterior 
occipito-iliae,  and  the  right  anterior  and  the  left  posterior  occipito-iliac  positions)  ; 
and  with  both  extremities  of  the  transverse  diameter  (the  left  and  right  trans- 
verse occipito-iliac  positions). 

A.  Occipito-anterior  Position. — In  this  position,  the  occiput  is  placed  behind 
or  under  the  lower  part  of  the  symphysis  pubis  ;  the  sides  of  the  head  corre- 
sponding to  those  of  the  pelvis.  The  male  blade  will  here  be  introduced  first, 
because  it  will  be  found  underneath  in  the  locking.  Two  or  three  fingers  of  the 
right  hand  having  been  passed  into  the  vagina,  this  branch  is  seized  by  the 
left  hand,  either  with  the  fingers,  like  a  writing-pen,  or,  still  better,  with  the 
whole  hand  (though  in  both  cases  close  to  the  pivot),  and  it  is  held  inclined 
obliquely  over  the  right  groin ;  the  point  of  the  blade  is  then  entered  at  the 
vulva  in  the  direction  of  its  axis,  and  is  slipped  up  along  the  palmar  surface  of 
the  fingers ;  as  the  blade  is  passed  into  the  vagina,  the  handle  is  gradually  de- 
pressed between  the  woman's  thighs  (of  course,  always  approaching  towards  the 
median  line)  in  such  a  way  as  to  direct  the  point  of  the  blade  in  the  direction  of 
the  axis  of  the  excavation.  The  blade  is  thus  directed  at  once  upon  the  side  of 
the  head,  and  along  that  of  the  pelvis,  where  it  is  ultimately  to  be  placed. 
While  this  manoeuvre  is  being  efi'ected,  the  convex  border  of  the  blade  ought  to 
rest  upon  and  glide  along  the  ring  finger  of  the  right  hand,  which  is  in  the 
vagina,  whilst  at  the  same  time  its  concave  surface  should  bear  exactly  on  the 
convexity  of  the  head,  and  follow  its  outline.    The  female  blade  is  then  introduced 


DYSTOCIA. 


Fi-   115. 


The  forceps  applied  on  the  child's 


in  the  same  manner  precisely.  Two  or  three 
fingers  of  the  left  hand  are  first  passed  in  on  the 
right  side  of  the  pelvis;  the  branch  being  held 
obliquely  by  the  right  hand  in  front  of  the  left 
groin,  with  its  point  resting  on  the  palmar  surface 
of  the  left  hand,  is  presented  at  the  vulvar  orifice; 
and,  as  its  extremity  is  made  to  enter,  the  handle 
is  depressed,  and  brought  towards  the  median  line 
by  degrees,  the  blade  being  thus  passed  up  on  the 
right  side  of  the  pelvis,  with  the  same  precautious 
as  in  the  former  case. 

When  both  blades  have  penetrated  to  the  same 
depth,  they  ought  to  be  parallel  with  each  other, 
the  pivot  corresponding  to  the  mortise  exactly  ; 
and  the  locking  is  then  completed  without  diffi- 
culty. 

As  the  head  is  at  the  inferior  strait,  the  first 
hend  in  iheoccipito-anterior  position,  t^actions  will  havc  to  be  made  in  the  direction  of 

at  llie  jiifenor  strait. 

the  axis  of  this  strait,  that  is  to  say,  a  little  down- 
wards and  forwards ;  then,  as  soon  as  the  occiput  has  passed  under  the  sub- 
pubic ligament,  and  the  head  has  commenced  its  movement  of  extension,  the 
instrument  is  to  be  gradually  carried  upwards  in  front  of  the  symphysis  and 
abdomen. 

B.  Ocn'pito-posterior  Position. — The  blades  are  applied  and  locked  as  in  the 
preceding  case.  But  here,  notwithstanding  the  head  is  at  the  inferior  strait,  we 
are  not  to  draw  in  the  line  of  axis  of  this  strait;  because,  in  these  occipito-poste- 
rior  positions,  the  occiput  has  to  be  delivered  first  at  the  anterior  perineal  com- 
missure. (See  Natural  Labor.)  To  effect  this  object,  it  is  necessary  to  carry 
the  handles  a  little  upwards  at  the  very  outset  of  the  tractions,  so  as  to  flex  the 
head  on  the  chest  more  completely;  being  careful  to  operate  in  such  a  way  that 
the  artificial  aid  may  bear  particularly  on  the  larger  extremity  of  the  head. 
When  the  occiput  has  gained  the  perineal  commissure,  the  traction  is  discon- 
tinued, or  rather,  if  there  is  any  further  occasion  for  it,  we  may  draw  mode- 
rately, at  the  same  time  depressing  the  handles  of  the  instrument  towards  the 
anus. 

C.  L^ft  Anterior  Occipito- Iliac  Position. — In  this  position,  one  side  of  the 
head  looks  forward  and  to  the  right,  the  other  backward  and  to  the  left;  and 
the  blades  are  to  be  applied  in  a  corresponding  manner  on  the  sides  of  the  head. 
The  posterior  blade,  which  should  be  entered  first,  will  at  the  same  time  be  on 
the  left,  and,  therefore,  the  one  that  is  always  passed  on  the  left  side  of  the 
pelvis,  that  is  to  say,  the  male  blade,  will  be  introduced  first.  This  is  held  in  the 
left  hand  just  in  front  of  the  right  groin;  and  its  point,  placed  in  front  of  the 
left  sacro-sciatic  ligament,  is  to  be  pushed  directly  backwards  as  far  as  the  sacro- 
iliac articulation,  whilst  the  operator  depresses  the  handle  and  draws  it  towards 
the  median  line.     In  carrying  the  handles  down  between  the  mother's  thighs, 


THE     FORCEPS. 


809 


Fi^.  116. 


it  is  highly  important  to  keep  the  blade  slightly  everted.  Being  once  intro- 
duced, the  handle  is  given  to  an  assistant,  who  holds  it  near  the  internal  surface 
of  the  left  thigh. 

The  female  blade  is  to  be  placed  behind  the  right  cotyloid  cavity,  where  the 
side  of  the  head  is  found,  by  making  it  describe  the  spiral  movement  alluded  to 
when  speaking  of  the  general  rules  of  the  operation.  The  operator  accomplishes 
this  by  taking  it  in  the  right  hand,  in  the  usual  way,  and  entering  the  point  of 
the  blade  just  in  advance  of  the  right  sacrosciatic  ligament;  then,  pushing  it  in 
this  direction  for  about  an  inch,  he  suddenly  changes  the  position  of  his  hand  so 
as  to  get  hold  of  the  instrument  from  above,  when,  by  strongly  depressing  its 
handle  along  the  internal  surface  of  the  left 
thigh,  he  makes  the  blade  execute  a  see-saw 
movement,  by  which  it  is  at  once  carried  from 
the  right  sacro-sciatic  ligament  up  opposite  to 
the  cotyloid  cavity  of  the  same  side ;  and 
then  the  locking  is  effected.  (Fig.  116.) 
During  the  early  tractions  he  should  endea- 
vor to  rotate  the  head  so  as  to  bring  the  oc- 
ciput behind,  and  then  under  the  symphysis 
pubis.  The  rest  of  the  operation  is  completed 
as  in  the  first  variety  (a). 

D.  Riijht  Posterior  Occipito-lJiac  Position. 
— The  forceps  are  applied  here  exactly  in  the 
same  way  as  they  were  in  the  preceding  case; 
the  blades  being  entered,  the  one  behind  and 
to  the  left,  the  other  in  front  and  to  the  right 
(see  Fig.  IIG);  their  concave  margins  look- 
ing towards  the  forehead.  As  this  latter  part 
must  be  brought  in  front,  the  object  of  the 
rotation  will  be  to  get  it  behind  the  sym- 
physis pubis,  and  the  occiput  into  the  hollow  of  the  sacrum  ;^  and  the  labor  is 
then  terminated  just  as  in  an  original  occipito-posterior  position  (b). 


Application  of  the  forceps  in  the  right 
posterior  occipito-iliac  position,  (-llh  posi- 
tion.) 


'  No  attempts  should  be  made,  in  the  occipito-posterior  positions,  to  bring  the  occiput  in 
front;  for  although  it  is  true  that  this  movement  is  accomplished  in  natural  labors,  yet  in 
them  the  trunk,  on  which  the  contraction  of  the  womb  is  still  exerted,  participates  in  the 
rotation  of  the  head.  But,  should  we_  attempt  to  imitate  this  movement  by  the  forceps,  it  is 
nearly  certain  that  the  child's  body  would  be  so  firmly  retained  by  the  retracted  uterus  that 
it  could  not  participate  in  the  rotation,  and  that  an  excessive  twisting  of  the  neck,  with  the 
mortal  lesions  following  in  its  train,  would  be  the  almost  inevitable  consequence.  There- 
fore, as  a  general  rule,  the  forehead  should  be  brought  behind  the  symphysis  pubis;  but 
this  is  not  always  possible,  as  the  following  case  of  my  own  will  exemplify. 

A  young  woman,  pregnant  with  her  first  child,  having  reached  her  full  term  without  ac- 
cident, was  taken  with  her  first  pain  on  the  29th  of  October,  at  nine  P.M.  The  pains,  though 
feeble,  were  yet  so  frequent  as  to  prevent  her  sleeping.  At  six  o'clock  on  the  morning  of  the 
30th,  I  foimd  the  neck  completely  effaced,  and  the  thinned  edges  circumscribing  an  orifice 
of  about  the  size  of  a  dime.     The  pains  occurred  every  ten  minutes.     I  found  the  vertex 


810  DYSTOCIA. 

E.  Rlijht  Anterior  Occipito-lliac  Position — In  this  case,  tlic  female  blade  is 
entered  just  iu  advauce  of  the  right  sacro-iliac  articulation.      Then  the  male 

presenting,  but  could  not  make  out  the  position.  The  pains  continued  all  day,  the  30th,  but 
quite  as  feeble  and  distant.  At  four  o'clock  in  tlie  evening  they  became  stronger  and  more 
frequent,  and  at  eight  o'clock,  the  diameter  of  the  orifice  was  rather  less  than  that  of  half  a 
dollar.  The  membranes  being  flattened  and  applied  closely  to  the  head,  enabled  me  to  dis- 
cover the  biparietal  [coronal)  suture  running  (jirectiy  from  before  backward,  and  on  several 
different  occasions  I  distinctly  felt  the  anterior  fontanelle  presenting  directly  forward,  and 
corresponding  nearly  with  the  upper  third  of  the  posterior  surface  of  the  pubis.  I  had  to 
deal  with  what  had  never  before  occurred  to  me,  a  direct  occipito-sacral  position,  engaged  in 
the  upper  third  of  the  excavation.  I  hoped  in  vain  for  its  spontaneous  conversion  into  a 
posterior  diagonal  position,  for,  notwithstanding  very  frequent  and  powerful  contractions, 
things  were  still  in  statu  quo  the  next  day,  the  31st,  at  six  o'clock.  The  orifice  was  at  this 
time  dilated  to  the  size  of  a  dollar.  At  noon,  the  dilatation  was  almost  complete,  and  finally, 
at  two  o'clock,  the  head  assumed  a  diagonal  position.  ,1  detected  very  positively  the  anterior 
fontanelle  in  front  and  to  the  left,  and  hoped  that  the  movement  of  rotation  would  continue, 
I  was  doomed  to  be  disappointed.  I  then  ruptured  the  membranes,  but  this  was  followed 
by  the  escape  of  but  a  few  spoonfuls  of  fluid.  At  four  o'clock,  the  anterior  fontanelle  had 
approached,  I  thought,  somewhat  nearer  the  left  extremity  of  the  transverse  diameter,  and  I 
encouraged  the  poor  patient  to  believe  that  her  labor  would  soon  be  terminated ;  but,  un- 
fortunately, instead  of  continuing  to  pass  backward,  the  anterior  fontanelle  underwent  a 
movement  in  the  opposite  direction,  and,  notwithstaniling  all  my  efforts  to  push  it  back,  it 
again  came  forward,  and  fixed  itself  opposite  the  horizontal  ramus  of  the  pubis,  froin  which 
it  did  not  stir  afterward.  At  ten  o'clock  in  the  evening,  things  being  in  the  same  condition, 
I  determined  to  apply  the  forceps,  as  much  in  the  interest  of  the  mother  whose  strength  was 
exhausted,  and  who  begged  me  to  deliver  her,  as  in  that  of  the  child. 

The  head  was  then  very  near  the  inferior  strait,  and  the  forceps  were  applied  without 
difiiculty  upon  its  sides.  I  made  traction,  with  theobject  of  disengaging  the  occiput  in  front 
of  the  perineum,  but  the  contractions  were  feeble,  and  the  woman  being  exhausted  with 
fatigue,  was  unable  to  assist  the  eflbrts  of  the  uterus,  and  being  thus  reduced  to  the  mere 
tractions  with  the  instrument,  I  could  not  make  the-head  advance.  In  spite  of  all  my  eff'orts, 
I  was  unable  to  overcome  the  great  resistance  of  the  perineum  which  was  very  thick  and 
unyielding,  so  that  my  atteinpts  were  altogether  fruitless.  If  I  abandoned  the  operation,  I 
had  nothing  to  rely  upon  but  the  resources  of  nature,  which  here  were,  unfortunately,  jiower- 
less,  or  else  the  performance  of  craniotomy.  I  had  waited  long  enough  to  test  the  powers 
of  the  organism,  besides  which,  a  more  prolonged  expectation  would  not  be  devoid  of 
danger  to  both  the  mother  and  child.  Therefore,  before  deciding  on  craniotomy,  I  deter- 
mined to  try  whether  it  would  not  be  possible  to  bring  the  occiput  in  front.  I  left  oif  the 
tractions,  and  rotated  the  forceps  on  its  axis,  and  carrying  the  head  along  in  this  movement, 
I  had  soon  directed  the  concavity  of  the  edges  of  the  instrutnent  toward  the  internal  surface 
of  the  left  thigh.  I  then  withdrew  the  instrument,  and  found  that  the  longitudinal  suture 
was  directly  transverse.  Introducing  the  female  branch  behind  and  to  the  left  side,  I  used 
it  as  a  lever,  and  succeeded  with  it  in  bringing  the  occiput  almost  directly  behind  the  right 
acetabulum.  The  male  branch  was  then  placed  behind  the  left  acetabulum,  and  the  forceps 
being  locked  after  imcrossing  the  branches,  I  brought  the  occiput  first  behind,  then  beneath 
the  symphysis  pubis,  and  finished  the  extraction  of  the  head  by  the  usual  movement  of  ex- 
tension. 

The  child  was  born  in  an  evident  state  of  congestion.  I  allowed  the  cord  to  bleed  before 
tying  it,  and  it  was  soon  restored.  Two  weeks  afterward  it  was  strong  and  well.  The 
lying-in  was  unattended  with  accidents  and  the  mother  recovered  quickly.  The  whole 
duration  of  the  labor  was  fifty  hours. 


THE    FORCEPS. 


811 


blade  is  introduced  in  front  of  the  left  saero  sciatic  ligament,  and  is  made  to 
describe  the  spiral  movement  before  indicated,  by  which  it  becomes  placed 
opposite  to  the  left  cotyloid  cavity.  The  movement  of  rotation  will  be  effected 
from  right  to  left,  and  the  occiput  be  brought  under  the  pubic  arch. 

F,  Left  Posterior  Occqiifo-I/iac  Position. — The  blades  are  introduced  in  a 
similar  order,  and  in  the  same  way,  as  the  preceding  case.  The  movement  of 
rotation  is  also  effected  in  the  same  direction,  but  here  it  will  bring  the  forehead 
instead  of  the  occiput  behind  the  symphysis.  The  handles  of  the  instrument 
are  next  carried  up  a  little  in  front  of  the  pubis,  with  a  view  of  freeing  the  occi- 
put first  at  the  anterior  perineal  commissure.  After  this  is  accomplished,  the 
handle  is  to  be  depressed  towards  the  anus,  so  as  to  assist  the  head  in  its  move- 
ment of  extension. 

G.  Left  Transverse  Occipito-lliac  Position.  —  In  this  variety,  the  occiput 
corresponds  to  the  left  extremity  of  the  transverse  diameter  of  the  pelvis;  one 
side  of  the  head  looks  directly  forward,  and  the  other  backward.  Here  also  the 
posterior  blade  is  to  l^e  introduced  first :  now  to  distinguish  which  will  be  the 
posterior  one  under  such  circumstances,  we  must  ascertain  to  what  part  of  the 
pelvis  the  present  posterior  side  of  the  head 
will  correspond  after  the  rotation  shall  have 
been  completed.  As  this  process  of  rotation, 
in  the  transverse  positions,  must  always  bi'ing 
the  occiput  in  front,  the  left,  or  posterior  side 
of  the  head,  will  then  look  towards  the 
mother's  left  ilium,  and  consequently  the  left 
or  male  blade  is  entered  first.  This  blade  is, 
therefore,  pu.shed  towards  the  left  sacro-iliac 
articulation,  and  when  it  has  penetrated  to 
the  proper  depth  it  is  pressed  into  the  hollow 
of  the  sacrum  by  bearing  on  its  concave  mar- 
gin with  the  fingers  already  in  the  vagina. 
The  female  blade  is  next  to  be  passed  up  by 
means  of  a  spiral  movement,  behind  the  right 
acetabulum  ;  and  then  the  hand  itj  the  parts 
must  endeavor  to  work  it  towards  the  median 
line,  by  pressing  on  its  convex  margin,  so  as 
to  get  it  just  behind  the  symphysis  pubis. 
From  the  extent  of  the  rotation  to  be  effected,  of  course  the  accoucheur  must 
be  very  careful  to  operate  slowly  and  gently. 

When  the  head  is  in  a  transverse  position,  it  is  occasionally  still  high  up  in 
the  excavation,  even  though  it  has,  in  a  great  measure,  cleared  the  superior  strait; 
and  when  this  occurs,  it  is  often  exceedingly  difficult  to  apply  one  of  the  blades 
in  front  and  the  other  behind;  in  some  cases  even,  we  are  obliged  to  enter  them 
on  the  sides  of  the  pelvis,  that  is,  to  seize  the  head  by  the  forehead  and  occiput. 
This  is  always  an  unfavorable  circumstance;  although  it  may  possibly  happen 


The  forceps  apiilied  .ind  locked  in  the 
left  transverse  occipito-iliac  position. 


812  DYSTOCIA. 

that  the  mere  application  of  the  instrument  will  be  sufficient  to  give  the  head 
an  oblique  or  even  a  direct  antero-posterior  direction ;  and  when  this  movement 
does  not  take  place  at  the  time  the  blades  are  entered,  it  is  often  effected  after- 
wards by  their  locking,  or  during  the  JSrst  tractions.  Again,  when  the  forceps 
is  thus  applied,  the  head  may  occasionally  clear  the  inferior  strait  in  a  transverse 
position  ;  but,  having  reached  the  vulvar  orifice,  it  then  turns  between  the  blades, 
or,  as  I  have  several  times  observed,  carries  the  instrument  along  with  it  in  the 
movement  of  rotation,  in  such  a  way  that,  when  the  occiput  is  turned  forwards, 
the  concave  border  of  the  blades  looks  towards  one  side.  In  this  latter  case, 
some  practitioners  recommend  the  instrument  to  be  withdrawn  as  soon  as  the' 
head  has  nothing  but  the  resistance  of  the  soft  parts  to  overcome,  and,  if  neces- 
sary, to  reapply  them  to  the  sides  of  the  head.  I  think  it  would  be  better  to 
remove  the  forward  or  sub-pubic  blade  only,  for  its  presence  might  retard  the 
process  of  extension,  but  to  leave  the  perineal  one  applied,  because,  in  case  of 
necessity,  it  may  act  as  a  lever  in  facilitating  the  extension. 

The  difficulty  experienced  in  applying  the  forceps  on  the  parietal  protube- 
rances in  the  transverse  positions  engaged  in  the  excavation,  often  becomes  (see 
hereafter)  an  impossibility,  when  the  head  is  aYrcsted  at  the  superior  strait  or 
above  it.  To  render  the  biparietal  application  possible,  M.  Baumers,  of  Lyons, 
has  constructed  a  new  forceps,  which  I  have  had  occasion  to  try,  and  which  ap- 
pears to  me  to  overcome  the  difficulty  mentioned.  I  am  convinced  that  the 
biparietal  application  of  the  blades,  which  is  impossible  with  the  ordinary  forceps, 
is  sometimes  easy  with  that  of  M.  Baumers,  and  I  think  it  right  to  recommend 
their  application  in  the  transverse  positions.  They  differ  from  Levret's  forceps 
in  being  curved  on  the  side,  instead  of  the  edge,  so  that  the  general  curvature  of 
one  of  the  branches  is  concave,  and  that  of  the  other  convex.  (For  further 
details  respecting  this  instrument  and  the  mode  of  applying  it,  see  the  Gazette 
Medicale  des  14  et  21  Juiilet,  1849.) 

This  modification  of  M.  Baumers  is  altogether  similar  to  that  suggested  by 
Uytterheoven.  This  Belgian  surgeon,  it  is  stated  by  M.  Van  Huevel,  con- 
structed, forty  years  ago,  a  forceps  with  the  blades  curved  forwards  on  their 
sides,  as  the  others  are  on  the  edges.  (See  the  Atlas  accompanying  the  Belgian 
edition  of  this  work.  Fig.  194.) 

II.  R!(jht  Transverse  Occipito-lliac  Position. — In  this  position,  the  applica- 
tion of  the  forceps  scarcely  differs  from  the  one  just  described,  excepting  that 
the  female  branch  is  introduced  first,  and  the  movement  of  rotation  is  to  be  made 
from  right  to  left,  and  from  behind  forwards.  When  the  occiput  gets  behind 
the  symphysis  pubis,  the  labor  is  to  be  terminated  as  in  the  preceding  case. 

§  2.  Application  op  the  Forceps  in  the  Vertex  Positions,  where 
THE  Head  is  merely  engaged  at  the  Superior  Strait. 

Whenever  the  head  is  engaged  or  locked  in  the  superior  strait,  and  the  ver- 
tex occupies  the  whole  upper  part  of  the  excavation,  the  rules  for  guiding  us  in 
the  application  of  the  forceps  are  the  same  as  those  already  laid  down  for  its  use 
at  the  inferior  strait.     We  must  remark,  however,  that  its   elevated  position 


THE    FORCEPS.  813 

renders  an  introduction  of  the  whole  hand  into  the  vagina  more  necessary  than 
ever;  that  the  points  of  the  fingers  ought  to  be  carefully  placed  between  the 
head  and  the  cervix  uteri,  so  as  to  direct  the  blade,  which  is  slipped  along  the 
palmar  surface  of  the  hand,  directly  into  the  uterine  cavity ;  that,  as  it  is  higher 
up  than  usual,  the  blades  are  to  be  pushed  further  in,  in  order  to  grasp  it  freely  j 
and  lastl}',  that,  as  the  head  is  not  yet  clear  of  the  superior  strait,  the  first  tractions 
must  be  made  in  the  direction  of  the  axis  of  that  strait,  or,  in  other  words,  as  far 
backwards  and  downwards  as  possible. 

But,  although  the  theoretical  precepts  remain  unchanged,  it  must  not  be  sup- 
posed that  the  difficulties  are  no  greater  here  than  in  the  former  case  ;  for  the 
elevation  of  the  part  renders  the  application  of  the  forceps  more  difficult  and  less 
certain,  as  it  is  not  an  easy  matter  to  apply  the  blades  on  the  sides  of  the  head, 
in  the  oblique  and  more  especially  in  the  transverse  positions.  In  a  word,  the 
higher  up  it  is,  the  more  likely  are  we  to  encounter  those  difficulties  and  dangers 
about  to  be  described  in  applying  the  instrument  on  a  movable  head  above  the 
brim  of  the  pelvis. 

§  3.  Application  of  the  Forceps  in  the  Vertex  Positions,  when  the 
Head  is  movable  above  the  Superior  Strait. 

There  are  many  circumstances  that  may  require  the  intervention  of  art,  even 
while  the  head  is  still  above  the  superior  strait;  and,  as  the  nature  of  these 
causes  of  dystocia  may  have  a  bearing  on  the  operative  procedure  for  terminating 
the  labor,  we  must  here  take  them  into  consideration. 

The  intervention  of  our  art  may  be  rendered  necessary  by  any  accident  that 
endangers  the  life  of  the  mother  or  child,  such  as  hemorrhage,  convulsions,  or  a 
descent  of  the -cord,  &c.,  as  also  by  a  contracted  pelvis  or  an  excessive  volume  of 
the  head.  In  the  latter  case,  a  resort  to  the  forceps  is  proper,  provided  the  dis- 
proportion between  the  pelvic  dimensions  and  the  size  of  the  head  be  not  very 
great;  since  it  has  elsewhere  been  shown  (see  Deformities  of  the  Pelvis)  that, 
whenever  the  smallest  diameter  of  the  pelvis  amounts  to  three  inches,  there  is 
reason  to  expect  that  delivery  can  be  effected  by  means  of  the  forceps. 

The  question  arises  whether  version  or  an  application  of  the  forceps  is  to  be 
resorted  to  in  those  cases  in  which  the  pelvis  is  properly  formed,  but  some  acci- 
dent has  taken  place  that  requires  a  speedy  termination  of  the  labor  ?  Under 
such  circumstances,  we  do  not  hesitate  to  recommend  pelvic  version;  but,  as  this 
is  not  the  universally  received  opinion,  we  extract  from  Madame  Lachapclle  the 
following  reasons  on  which  we  ground  our  preference. 

"  An  application  of  the  instrument  upon  a  head  which  is  still  above  the  supe- 
rior strait  is  both  a  difficult  and  a  dangerous  operation.  Difficult,  1st,  because 
its  elevation  renders  the  diagnosis  of  the  position  obscure,  and  often  leaves  us 
operating  in  the  dark;  2d,  from  its  mobility  it  escapes  from  the  forceps,  and,  not 
unfrequently,  it  is  merely  held  by  the  points  or  margin  of  the  blades ;  so  that,  as 
soon  as  any  resistance  is  met  with  from  the  first  tractive  efforts,  it  slips  put  just 
like  a  cherry-stone  when  squeezed  between  the  fingers;  and,  3d,  because  at  this 
height  it  is  impossible  to  apply  the  blades  on  the  sides  of  the  head,  since  the  latter 


814  DYSTOCIA. 

is  usually  found  either  in  an  oblique  or  in  a  transverse  position.  Now,  to  conform 
to  the  rule  generally  laid  down,  we  should  apply  one  blade  in  front  and  the  other 
behind,  but  this  is  obviously  impracticable,  for  the  curvature  of  the  pelvic  axis 
prevents  the  forceps  from  passing  far  enough  in,  unless  the  blades  are  introduced 
along  the  sides  of  the  pelvis.^  Dangerous,  because  the  hold  on  the  head,  being 
very  imperfect,  in  consequence  of  the  difficulties  just  enumerated,  the  instrument 
may  slip;  and,  should  such  slipping  take  place  while  we  are  making  strong  trac- 
tions on  the  handles,  the  edges  of  the  forceps,  acting  like  a  cutting  instrument, 
might  seriously  wound  the  cervix." 

We,  therefore,  prefer  version  in  the  case  under  consideration.  However,  there 
is  one  instance  which  might  demand  the  use  of  the  forceps ;  that  is,  where  the 
uterus  is  so  contracted  on  the  child's  body  after  the  discharge  of  the  waters,  as  to 
render  an  introduction  of  the  hand  or  an  evolution  of  the  foetus  absolutely  impos- 
sible ;  but,  fortunately,  in  such  a  case,  the  head  would  be  so  firmly  held  at  the 
strait,  during  the  strong  contractions  of  the  organ,  as  to  be  nearly  immovable. 

On  the  whole,  then,  the  application  of  the  forceps  above  the  superior  strait 
should  be  limited  to  those  cases  of  pelvic  deformity  in  which  the  shortest  dia- 
meter of  the  pelvis  does  not  exceed  three  to  three  and  a  quarter  inches,  and  to 
those  in  which  the  uterus  is  firmly  contracted. 

Mode  of  Application. — Unless  the  position  is  directly  antero-posterior,  which 
is  extremely  rare,  no  attempt  should  be  made  to  apply  the  blades  upon  the  parietal 
protuberances,  but  they  should  be  passed  along  the  sides  of  the  pelvis.  It  is, 
however,  very  unusual  for  this  precept  to  be  followed  in  practice,  and  for  the 
blades  to  be  really  placed  upon  the  two  extremities  of  the  transverse  diameter; 
when  the  head  is  diagonal,  the  blades  are  naturally  directed  toward  the  two  ex- 
tremities of  one  of  the  oblique  diameters.  Now  in  the  directly  transverse  posi- 
tions, this  is  what  generally  happens,  even  when  the  surgeon  wishes  to  place 
them  at  the  sides  of  the  pelvis;  for  at  this  elevation,  and  especially  in  the  sacro- 
pubic  contractions,  which  are  the  most  common,  the  head  is  almost  always  in  a 
transverse  position ;  now,  according  to  the  remark  of  Eamsbotham  and  of  Simp- 
son, and  notwithstanding  the  formal  precept  always  to  apply  the  blades  to  the 
sides  of  the  pelvis,  it  is  found  after  delivery  that  the  head  has  not  been  seized 
from  the  forehead  to  the  occiput.     The  marks  of  the  blades  are  almost  always  to 

'  When  an  attempt  is  made  to  apply  them  over  the  parietal  regions,  the  perineum  presses 
the  instrument  forwards,  and  gives  it  such  a  degree  of  obliquity  with  regard  to  the  superior 
strait,  that  there  is  not  room  enough  between  the  fenestrse  for  the  reception  of  the  smallest- 
sized  head.  The  latter,  being  placed  above  the  abdominal  strait,  has  its  long  diameter 
situated  very  nearly  in  the  line  of  the  axis  of  that  strait ;  but  as  the  long  axis  of  the  liead 
ought  to  correspond  vvitli  that  of  the  blades,  it  therefore  follows  that  the  forceps  must  be  in- 
troduced in  the  direction  of  the  axis  of  the  upper  strait;  and,  consequently,  that  the  articular 
part  of  the  instrument  is  to  be  depressed  beyond  the  point  of  the  coccyx.  But  the  perineal 
resistance  will  evidently  prevent  this,  where  one  blade  is  entered  behind  the  pubis  aiHl  the 
other  in  front  of  the  sacrum.  Therefore,  we  are  obliged  to  introduce  the  blades  along  the 
sides  of  tlie  pelvis;  that  is,  to  seize  the  head  by  the  forehead  and  occiput  in  the  transverse 
positions,  and  by  the  coronal  and  occipital  protuberances  in  the  oblique  positions.  IM.  Bau- 
mer"s  instrument  might  in  some  cases  overcome  these  dilTiculties. 


THE    FOUCEPS.  815 

be  discovered  upon  one  of  the  occipital  protuberances  and  tbe  parietal  projection 
opposite.  It  is  natural,  in  fact,  if  the  head  is  transverse,  for  its  long  diameter 
to  correspond  with  the  transverse  diameter  of  the  pelvis.  Now,  as  the  latter  is 
narrowed  from  before  backward,  the  blades  can  be  applied  readily,  only  by  direct- 
ing one  of  them  behind  the  acetabulum,  and  the  other  in  front  of  the  sacro-iliac 
symphysis,  which  are  the  only  points  not  occupied  by  the  head.  This,  there- 
fore, is  the  direction  which  should  be  given  them  in  all  cases. 

As  soon  as  the  forceps  are  applied,  it  would  in  most  cases  be  advisable  to  tie 
the  handles  together  before  drawing  upon  them.  At  first,  the  tractions  should 
be  made  as  far  back  as  possible,  and  the  instrujnont  ought  to  be  gradually  brought 
forward  as  the  head  descends  into  the  excavation.  The  head,  seized  by  one 
coronal  boss  and  the  opposite  occipital  protuberance,  will  soon  reach  the  inferior 
strait.  In  thus  traversing  the  whole  excavation,  the  head  may  possibly  turn 
within  the  blades  and  become  converted  into  an  antero-posterior  position ;  but  it 
may  also  happen  that  this  spontaneous  version  does  not  take  place  at  all.  If, 
therefore,  the  obstacle  exists  at  the  superior  strait  alone,  and  the  uterine  forces 
appear  adequate  to  the  prompt  termination  of  the  labor,  we  may  withdraw  the 
instrument  and  trust  the  rest  to  nature.  But  in  other  cases  I  think  it  would  be 
proper  to  endeavor  to  transfer  the  blades  to  the  sides  of  the  head,  or  even  to  re- 
apply them  in  accordance  with  the  precepts  before  given  for  their  application  at 
the  inferior  strait.  It  is  evident  that,  with  the  assistance  of  Baumer's  forceps, 
the  latter  inconvenience  would  be  avoided. 

§  4.  Application  of  the  Forceps  in  the  Face  Positions. 

When  the  face  presents,  an  application  of  the  forceps  may  become  necessary, 
either  when  the  head  has  descended  to  the  inferior  strait,  when  it  is  engaged 
at  the  superior  one,  or  when  it  is  still  movable  above  the  brim  of  the  pelvis. 

1.  Whe7i  the  Head  is  at  the  Inferior  Sirail. — If  both  the  head  and  the  pelvis 
retain  their  usual  size,  the  f:\ce  can  only  reach  the  perineal  floor  by  descending 
with  the  chin  directly  forwards,  or  nearly  so.  (See  Mechanism  of  Face  Posi- 
tions.) As  the  application  of  the  forceps  in  these  three  different  cases  does  not 
differ  in  the  least  from  that  described  in  the  corresponding  vertex  positions,  we 
deem  it  useless  to  pass  over  the  same  ground. 

But  the  face,  without  having  reached  the  perineal  strait,  may,  nevertheless, 
be  low  down  in  the  excavation ;  and  the  process  of  rotation,  whereby  the  chin 
should  be  brought  under  the  pubic  arch  in  all  cases,  may  not  have  commenced 
at  all,  or  it  may  either  be  partially  accomplished  or  fully  completed.  "We  might, 
therefore,  have  to  apply  the  forceps  in  a  mento-anterior  or  pubic,  in  a  left  or  a 
right  anterior  mento-iliac,  or  in  a  left  or  a  right  transverse  mento-iliac  position. 

Since  it  is  absolutely  necessary,  in  the  face  positions,  for  the  chin  to  come 
under  the  pubic  arch,  the  instrument  is  always  to  be  applied  with  its  concave 
edges  looking  towards  the  chin,  taking  care  to  introduce  the  posterior  blade  first. 

By  way  of  example,  let  us  suppose  that  the  face  is  situated  in  a  left  anterior 
mento-iliac  position,  and  is  low  down  in  the  excavation.  Here,  iu  conformity 
with  the  directions  before  given,  the  male  blade  will  be  placed  posteriorly  and 


816 


DYSTOCIA. 


to  tlie  left,  near  the  left  sacro-iliac  articulation,  and  the  female  blade  just  behind 
the  right  anterior  arch  of  the  pelvis ;  when  locked,  the  concave  edges  of  the 
blades  will  look  forwards  and  to  the  left.  The  rotation  is  then  effected  from  be- 
hind forwards,  and  from  left  to  right,  so  as  to  bring  the  chin  behind  the  sym- 
physis; and  when  this  is  accomplished,  we  draw  directly  forwards,  and  a  little 
downwards,  in  order  to  free  this  part  from  the  pubic  arch ;  and  then,  after 
having  secured  its  delivery,  the  handles  are  gradually  carried  up,  at  the  same 
time  drawing  moderately,  with  a  view  of  promoting  the  flexion  and  disengage- 
ment of  the  head. 

2.  Whe7i  the  Head  is  at  the  Supcrio7'  Strait. — The  face  may  be  found  in 
every  possible  relation  with  the  different  parts  of  this  strait.  Should  the  chin 
correspond  to  any  portion  of  its  anterior  half,  the  forceps  may  be  applied  without 


Fig.  118. 


FiL'.  119. 


Application  of  the  forceps  in  the  left  anterior 
menlo-iliac  position.  (First  position  of  the  face.) 


Application  of  the  forceps  in  the  mento- 
posterior position. 


any  jjarticular  difficulty ;  but  if  the  face  is  in  a  mento-posterior  position,  the  pelvic 
or  cephalic  version,  whenever  possible,  ought  to  be  chosen  in  preference  (see 
page  66G).  For  when  the  forceps  is  once  applied,  the  object  would  evidently 
be  to  bring  the  chin  behind  the  symphysis  pubis ;  but,  as  the  body  is  probably  held 
motionless  by  the  contraction  of  the  womb,  it  will  not  participate  in  the  rotation 
of  the  head  produced  by  the  instrument,  and  hence  luxation  would  occur  at  the 
joint  between  the  first  and  second  cervical  vertebra;,  which  does  not  admit  of 
movement  beyond  a  quarter  of  a  circle. 

When  the  face  is  situated  in  a  mento-posterior  position,  and  has  descended  so 
far  into  the  excavation  that  it  is  altogether  impossible  to  return  it  above  the 
superior  strait  with  a  view  of  performing  the  cephalic  or  the  pelvic  version,  the 
use  of  the  forceps  becomes  a  matter  of  necessity.    Under  such  circumstances,  we 


THE    FORCEPS.  817 

should  therefore  apply  them  for  the  purpose  of  relieving  the  mother  from  her  threat- 
ened danger;  not  to  bring  the  chin  in  front,  but  merely  with  the  intention  of  flex- 
ing the  head,  and  converting  the  face  position  into  one  of  the  vertex.  To  accom- 
plish this,  the  blades  are  to  be  placed  on  the  sides  of  the  head,  and  in  operating,  the 
handles  should  be  depressed  as  far  backwards  as  possible,  so  as  to  act  chiefly  on 
the  vertex,  until  the  occiput  is  brought  down  under  the  pubic  arch  ;  if  the  chin 
were  directly  posterior,  such  a  movement  of  rotation  might  be  given  to  the  head, 
prior  to  any  tractive  effbrt,  as  would  carry  the  former  into  the  great  sciatic  notch  on 
one  side  or  the  other.  This  appears  to  me  the  most  feasible  operation.  I  must  ob- 
serve, however,  that,  according  to  M.  Mascarel  (^T/iesis,  page  84),  M.  P.  Dubois 
has  proposed  another;  or  rather  he  inquires  whether  it  would  not  be  possible  to 
convert  a  mento-posterior  into  a  mento-anterior  position.  It  maybe  objected,  he 
continues,  that,  if  the  head  is  forced  to  undergo  too  great  a  rotation,  and  the  body  does 
not  turn  simultaneously,  the  child's  neck  would  be  twisted;  but  as  the  only  thing  to 
be  done,  if  this  will  not  answer,  is  to  perforate  the  cranium,  and  consequently  to 
sacrifice  the  infant,  he  considers  the  former  measure  preferable ;  more  especially 
as  the  chin  might  escape  under  the  ischio-pubic  ramus,  without  the  necessity  of 
getting  it  exactly  beneath  the  pubic  arch.  I  know  that  this  method  has  some- 
times succeeded,  and  M.  Blot  informed  me  quite  recently,  that  he  had  delivered 
three  times,  by  bringing  the  chin  in  front. 

In  1850,  M.  Danyau  read  a  paper  before  the  Academy,  in  which  he  gave 
preference  to  this  operation ;  he  recommended,  however,  that,  unless  the  straight 
forceps  are  used,  the  curvature  of  the  edges  should  be  turned  toward  the  chin, 
as  was  practised  by  Campion.  He  claims  to  have  succeeded  several  times,  and 
even  to  have  delivered  children  alive.  I  have  already  mentioned  a  case  in 
which  this  rotary  movement  had,  apparently,- proved  fatal  to  the  foetus.  I  am 
disposed  to  regard  the  cases  mentioned  by  M.  Danyau  as  exceptional  ones ;  for*, 
most  probably,  the  body  of  the  foetus  had,  under  the  influence  of  the  uterine 
contractions,  partaken  of  the  rotation  of  the  head  produced  by  the  forceps. 
Long  ago,  Smellie  recommended  that  efibrts  be  made  to  bring  the  chin  in  front, 
and  I  confess  that,  if  the  cases  reported  by  the  English  author  confirmed  his 
theoretical  views  on  this  point,  his  opinion  would  shake  my  convictions;  but, 
unfortunately,  such  is  not  the  fact.  For  on  reference  to  the  voluminous  record 
of  observations  published  by  him,  I  found  but  four  cases  of  face  presentation,  in 
which  the  chin  was  low  down  in  the  excavation,  and  directed  posteriorly ;  in  all 
of  them  he  first  endeavored  to  push  up  the  head,  and,  failing  in  that,  had  re- 
course to  the  forceps.  In  one  only  of  these  four  cases  could  he  bring  the  chin 
in  front;  in  a  second,  he  was  merely  enabled  to  flex  the  head  by  the  instrument, 
but  succeeded  in  delivering  the  vertex  and  occiput  first  under  the  pubic  arch ; 
in  the  two  others,  he  was  obliged  to  have  recourse  to  the  crotchet ;  the  same 
occurred  in  another  instance  reported  to  him  by  one  of  his  former  pupils.  Thus, 
in  five  cases,  one  only  permitted  the  rotation  forward,  while  in  all  the  others  it 
was  impracticable. 

It  is  possible  that  the  shape  of  the  instrument  may  be  one  of  the  principal 
sources  of  difficulty,  and  that  the  operation  might  be  rendered  easier  by  the  em- 

52 


818  DYSTOCIA. 

ployment  of  a  straight  forceps  :  this  suggestion,  which  I  believe  was  first  thrown 
out  by  M.  Dubois,  is  worthy  of  consideration. 

In  estimating  the  value  of  the  various  mocles  of  procedure  which  have  been 
mentioned  for  effecting  delivery  in  these  difficult  cases,  we  must  not  be  too  ex- 
clusive; for  experience  shows  that  the  plan  which  succeeds  in  one  case,  fails  in 
another,  without  our  being  able  fully  to  account  for  the  difference;  often,  indeed, 
after  having  tried  them  all  fruitlessly,  it  is  necessary  to  have  recourse  to  cranio- 
tomy. 

3.  W/ten  the  face  is  still  above  the  snperior  strait,  an  application  of  the 
forceps  is  only  to  be  attempted  when  the  pelvic  version  is  altogether  impossible. 
In  fact,  it  is  well  known  that  the  face  is  then  usually  found  in  a  transverse  posi- 
tion. Besides,  as  previously  stated,  when  the  head  is  so  high  up,  the  blades  are 
necessarily  applied  along  the  sides  of  the  pelvis;  consequently,  one  of  them 
would  come  into  contact  with  the  vertex,  the  other  with  the  neck,  and  the  pres- 
sure made  on  this  latter  part  would  most  assuredly  compromise  the  life  of  the 
child.  We  were,  therefore,  right  in  saying  that  the  forceps  ought  only  to  be 
used  as  an  extreme  measure,  and  that  before  using  it,  unless  Baumer's  forceps 
are  tried,  an  attempt  should  be  made  to  convert  the  face  position  into  one  of  the 
vertex  by  the  cephalic  version,  and  then  apply  the  forceps  on  the  head  in  this 
rectified  position. 

§  5.  When  the  Head  remains  behind  after  the  Body  is  expelled. 

When  the  head  is  retained  in  the  mother's  parts,  after  a  natural  delivery  by 
the  breech,  or  after  the  pelvic  version,  an  application  of  the  forceps  is  rarely 
indispensable,  for  the  hand  alone  is  usually  sufficient  to  effect  the  delivery;  more 
particularly  in  those  cases  where  -an  extension  of  the  head  is  the  sole  cause  of 
difficulty.  But  when  the  manual  operation  has  failed,  or  the  base  of  the  cranium 
is  arrested  by  a  contraction  of  the  pelvis,  the  forceps  may  certainly  be  very  use- 
ful, Madame  Lachapelle  to  the  contrary  notwithstanding. 

Whenever  an  application  of  the  instrument  is  decided  upon,  the  rules  for  ope- 
rating are  nearly  the  same  as  in  the  vertex  positions ;  here,  also,  the  blades  are 
placed  as  nearly  as  possible  on  the  sides  of  the  head,  having  their  concave  edges 
always  directed  towards  the  part  that  is  to  come  under  the  pubic  arch,  &c.  We 
may  further  add,  that  it  should  be  entered  along  the  sternal  plane  of  the  child, 
as  also,  that  the  body  is  to  be  supported,  and  carried  towards  that  side  where  the 
occiput  is  situated,  /.  e.  directly  forward  and  upward  in  the  occipito-pubic  posi- 
tions, forward  and  to  the  left  in  the  left  anterior  occipito-iliac  positions,  &c.  &c. 

The  blades  having  been  introduced  in  the  usual  manner,  we  are  next,  as  a 
general  rule,  to  attempt  the  disengagement  of  the  head  by  a  movement  of  flexion, 
having  the  nape  of  the  neck  as  its  centre;  which  is  situated  at  times  under  the 
symphysis  pubis,  and  at  others  at  the  perineal  commissure. 

In  one  case  only  would  the  accoucheur  be  warranted  in  entering  the  forceps 
along  the  dorsal  plane  of  the  child,  and  freeing  the  head  by  a  process  of  rota- 
tion. We  mean,  where  the  face  is  above,  the  occiput  being  behind;  but  this 
manoeuvre,  which  was  recommended  by  Madame  Lachapelle,  does  not  always 


THE    FORCEPS. 


819 


120. 


Application  of  the  forceps  where  the 
hoad  is  retained  afler  the  delivery  of  the 
body. 


succeed ;  for  other  practitioners  are  not  as  fortunate  as  that  skilful  midwife  in 
turning  the  face  into  the  hollow  of  the  sa- 
crum. We  rather  believe,  with  M.  Velpeau, 
that,  relying  on  the  result  of  the  cases  re- 
ported by  Eckard  and  Michaelis  (see  page 
452),  it  might  be  possible,  by  means  of  well- 
directed  tractions,  to  free  the  occiput  at  the 
anterior  perineal  commissure,  after  which  the 
delivery  of  the  head  would  be  completed  by 
its  extension. 

But  a  much  more  difficult  case  maybe  met 
•with  in  consequence  of  an  arrest  of  the  head 
above  the  superior  strait ;  whether  arising 
from  an  unusual  extension,  incapable  of  being 
remedied  by  Madame  Lachapelle's  manceuvre, 
or  from  a  contraction  of  the  pelvis,  too  in- 
considerable of  itself  to  require  the  use  of 
the  forceps.  Both  Smellie  and  Baudelocque, 
who  were  as  skillful  as  fortunate,  have  suc- 
ceeded in  its  application  under  such  cir- 
cumstances ;  but,  notwithstanding  the  great 
authority  of  their  names,  cases  of  this  kind  may  well  be  dreaded  when  such 
a  man  as  Dewees  has  always  failed  in  the  operation  !  In  fact,  what  a  series  of 
difficulties  are  here  met  with  !  Thus,  not  to  speak  of  the  obstacle  to  the  opera- 
tion caused  by  the  trunk  filling  up  the  vulvar  orifice,  we  must  remark  :  '*  1.  That, 
when  the  head  is  lodged  transversely  with  regard  to  the  pelvis,  as  frequently 
happens,  the  forward  inclination  of  the  upper  strait  makes  it  iinpossible  to  apply 
the  blades  on  the  sides  of  the  head;  2.  That  the  vertical  diameter  of  the  head 
will  necessarily  be  placed  in  the  direction  of  the  axis  of  the  blades,  and  that  the 
latter  will  consequently  be  applied  upon  the  two  extremities  of  a  long  diameter, — 
a  circumstance  tending  strongly  to  defeat  the  operation;  3.  That  on  account  of 
•the  elevation  and  position  of  the  head,  it  is  often  imperfectly  grasped  by  the 
instrument,  which  is  liable,  upon  the  first  tractions,  to  slip  and  wound  the  parts 
of  the  m-other.  It  is,  however,  the  extreme  resource,  and  must  be  attempted 
whenever  tractions,  as  strong  as  are  compatible  with  the  life  of  the  child,  have 
proved  unavailing. 

The  rules  for  its  accomplishment  are  very  simple;  namely,  to  carry  the  trunk 
towards  the  part  corresponding  with  the  occiput ;  to  depress  the  chin  as  much  as 
possible,  with  a  view  of  diminishing  the  extension  of  the  head;  to  enter  the 
blades  on  the  sides  of  the  pelvis ;  and  lastly,  to  operate,  as  far  as  practicable,  in 
the  direction  of  the  pelvic  axes. 

Should  the  base  of  the  cranium  present  after  the  accidental  or  designed  sepa- 
ration of  the  head  from  the  bcdy,  it  would  be  proper,  provided  the  pelvis  were 
well  formed,  to  apply  the  forceps,  after  having  taken  the  precaution  of  placing 
the  head  in  a  proper  position;  that  is,  with  its  smallest  diameters  corresponding 


82D  DYSTOCIA. 

with  the  plane  of  the  pelvis,  and  the  occipito-mental  diameter  with  the  direction 
of  its  axis.  Should  the  deformity  be  too  great,  the  embryotomy  forceps  will  be 
the  only  resource.     (See  Craniotomy.) 

§  6.  General  Coxsiderations  on  the  Employment  of  the  Forceps. 

Although  an  exceedingly  useful  instrument  when  employed  by  skilful  hands 
in  proper  cases,  the  forceps,  by  being  badly  directed  or  improperly  applied  in 
those  in  which  it  is  not  indicated,  may  give  rise  to  the  most  serious  disorders. 
It  is  particularly  important,  therefore,  in  closing  this  article,  to  point  out  the 
cases  in  which  it  may  be  advantageously  employed.  Besides,  this  short  review 
will  serve  to  illustrate  the  precepts  just  given,  and  render  its  mode  of  action 
more  intelligible. 

The  forceps  has  been  recommended  :  1st,  in  cases  of  irregular  or  inclined  ver- 
tex and  face  positions,  which  are  neither  corrected  spontaneousl3'  nor  can  be  by 
the  unaided  hand.  2d.  Where  a  disproportion  exists  between  the  pelvic  dimen- 
sions and  the  size  of  the  head ;  whether  dependent  on  an  excessive  volume  of 
the  latter  or  a  contraction  of  the  former.  3d.  Where  any  accident,  serious 
enough  to  compromise  the  life  of  the  mother  or  child,  occurs  during  the  labor, 
which  is  not  remediable  by  version.  4th.  Lastly,  where  the  head  has  descended 
to  the  pelvic  floor,  and  is  there  arrested  either  by  the  resistance  of  the  soft  parts 
or  by  shortness  of  the  cord. 

1.  Inclined  Vertex  or  Face  Positions. — As  heretofore  stated,  we  consider  an 
application  of  the  forceps  preferable  to  the  use  of  the  vectis  (or  lever)  in  these 
cases,  after  the  inefficiency  of  the  natural  powers  has  been  fully  determined  by  a 
delay  of  seven  or  eight  hours.  The  retraction  of  the  uterus  would  render  ver- 
sion too  difficult.  In  fact,  we  believe  that  a  prompt  delivery  is  equally  demanded 
for  the  benefit  of  the  mother  and  the  child,  and  that  the  forceps  alone  can  ac- 
complish this  result.  Moreover,  as  the  inclined  lateral  or  parietal  positions  are 
nearly  always  transverse,  it  is  unnecessary  to  add,  after  what  has  been  elsewhere 
said,  that  the  blades  are  to  be  entered  on  the  sides  of  the  pelvis ;  and  that,  as 
the  head  descends  into  the  excavation,  it  will  probably  undergo  rotation,  whereby 
it  will  be  converted  into  an  antero-posterior  position.^  By  proceeding  in  this 
manner,  we  will  avoid,  according  to  Duges,  the  difficulties  of  a  direct  antero-pos- 
terior introduction  as  regards  the  pelvis,  and  the  dangers  to  the  foetus  frcm  a  bi- 

'  Tins  phenomenon  occurred  in  a  lady,  in  La  Rue  St.  Paul,  to  whom  I  was  called  by  Dr. 
Dncros,  about  seven  o'clock  in  the  evening.  The  membranes  had  been  rupiured  since  eight 
A.M. ;  the  head  was  situated  in  a  transverse  occipito-iliac  position,  and  was  inclined  on  its 
anterior  parietal  region;  it  had  not  made. the  least  progress  since  morning,  and  was  so  in- 
considerably engaged  at  the  superior  strait,  that  I  was  forced  to  introduce  nearly  the  whole 
hand  for  the  purpose  of  ascertaining  the  position  :  the  waters  had  escaped,  and  I  attempted 
in  vain  to  effect  a  reduction  ;  but  an  a[)plication  of  the  forceps,  made  in  the  manner  above 
indicated,  was  attended  by  the  happiest  results. 

The  head  descended,  and  rotated  within  the  blades,  and  in  less  than  five  minutes  the 
child  was  born  living. 

The  lying-in  exhibited  nothing  unusual. 


THE    FORCEPS.  821 

parietal  application;  for  it  must  be  obvious  that,  if  the  inclination  were  consider- 
able, one  of  the  blades  would  bruise  the  upper  part  of  the  neck. 

2.  Contractions  of  the  Pelvis. — The  ultimate  limit  to  which  we  restricted  the 
use  of  the  forceps,  was  three  inches;  because  any  reduction  we  could  hope  to 
obtain  in  the  diameters  of  the  head  beyond  that,  would  not,  as  a  general  thing, 
be  great  enough  to  permit  it  to  pass  through  the  contracted  diameter  of  the 
pelvis.  In  truth,  the  enlarged  experience  of  Baudelocquc  has  proved  that,  when 
the  forceps  is  applied  in  the  direction  of  the  biparietal  diameter,  the  greatest 
reduction  obtainable,  without  compromising  the  child's  life,  is  not  more  than 
half  an  inch.  Now,  this  diameter,  on  a  well-formed  head,  avei'agcs  from  three 
and  a  half  to  three  and  three-quarter  inches,  and  even  supposing  that  we  can  re- 
duce it  half  an  inch,  there  will  still  be  left  three  inches  at  the  least. 

Certain  practitioners,  having  observed  that  the  head  became  gradually  moulded 
to  the  shape  and  dimensions  of  the  pelvic  cavity,  by  the  efforts  of  the  womb  alone, 
,in  some  cases  in  which  the  pelvis  was  contracted  to  less  than  three  inches,  have, 
therefore,  imagined  that  the  resources  of  art  could  accomplish  what  nature  alone 
sometimes  effects ;  that  by  the  forceps  a  similar  reduction  in  the  diameters  of  the 
head  might  be  obtained;  and,  consequently,  that  the  instrument  could  be  use- 
fully applied  when  the  contracted  diameters  are  even  less  than  three  inches. 
But  they  have  instituted  a  comparison  between  two  forces  that  are  wholly  dis- 
similar. Indeed,  there  can  be  no  doubt  that  the  expulsory  efforts  of  the  womb 
have  succeeded  in  forcing  the  head  through  the  pelvis  where  the  smallest  diame- 
ter did  not  exceed  two  and  three-quarter  inches;  but  this  result  was  only  effected 
after  a  tedious  labor  of  thirty,  or  forty,  or  even  of  sixty  hours ;  and  where  the 
slow  and  gradual  compression,  to  which  the  head  was  then  subjected,  has  enabled 
the  brain  to  accommodate  itself  thereto  by  degrees.  On  the  contrary,  the  reduc- 
tion obtained  by  the  forceps,  is  produced  by  a  force  that  does  not  extend  beyond 
half  an  hour  or  an  hour  at  the  most.  Now,  everybody  knows  that  a  tumor,  whose 
development  extends  over  a  period  of  several  years,  may  exist  within  the  cranial 
cavity  without  giving  rise  to  any  serious  disturbance,  whilst  a  little  drop  of  blood, 
suddenly  effused,  brings  on  paralysis  at  once.  Consequently,  the  pressure  made 
by  the  forceps  may  kill  the  child  by  its  sudden  action,  notwithstanding  the  reduc- 
tion is  absolutely  less  than  what  nature  herself  sometimes  produces  after  several 
hours  of  suffering. 

But,  when  the  pelvic  diameters  exceed  three  inches,  the  forceps  may  prove 
very  useful ;  though  I  am  induced  to  believe  that  the  character  of  its  action  has 
been  misunderstood,  by  supposing  that  it  is  to  serve  both  as  an  instrument  of 
traction  and  as  one  calculated  to  reduce  the  dimensions  of  the  head  by  its  pres- 
sure. Let  it  be  understood  that  the  forceps  merely  acts  here  as  an  instrument  of 
traction. 

In  fact,  the  contraction  usually  exists  at  the  superior  strait,  where  it  is  parti- 
cularly apt  to  affect  the  saero-pubic  diameter;  and,  as  the  head  always  has  a 
tendency  to  present  its  long  diameters  to  those  of  the  pelvis,  when  retained  above, 
it  is  generally  found  in  a  transverse  or  an  oblique  position  (more  frequently  the 
former).  '  Its  biparietal  diameter  will,  therefore,  correspond  to  the  smallest  one 


822  DYSTOCIA. 

of  the  strait,  and  of  course  the  blades  of  the  forceps  should  be  applied  in  the 
direction  of  this  diameter;  but  we  have  shown  that  such  an  application  is  not 
possible  in  any  case,  and  this  impossibility  is  still  more  evident  when  contraction 
exists.  For,  as  Dr.  Collins  observes,  if  the  sacro-pubic  diameter  amounts  to  but 
three  inches,  it  would  be  impossible  to  apply  an  instrument,  the  interval  between 
whose  blades,  when  closed,  is  from  three  and  a  half  to  three  and  three-quarter 
inches. 

The  forceps  will,  therefore,  have  to  be  applied  laterally ;  but  it  is  evident  that 
the  pressure  exerted  by  it  will  bear  upon  the  occipito-frontal  diameter.  Now, 
although  the  experiments  of  Baudelocque  may  have  proved  that  the  head,  when 
flattened  in  one  direction,  is  not  very  sensibly  enlarged  in  another,  it  cannot  be 
supposed  that  a  reduction  effected  in  the  occipito-frontal  diameter  would  at  the 
same  time  diminish  the  biparietal  one,  which  is  perpendicular  to  it  ?  How,  then, 
does  the  forceps  act  ?  Simply  by  its  tractive  power,  which,  conjoined  with  the 
uterine  contractions,  induces  the  head  to  engage  in  the  excavation ;  when,  of 
course,  as  the  parietal  protuberances  correspond  with  the  anterior  posterior  dia- 
meter, the  biparietal  one  becomes  compressed  between  the  pubis  and  sacrum; 
the  pelvis  itself  acting  here  as  the  compressory  agent,  and  not  the  forceps,  which 
latter  merely  facilitates  the  process  by  its  tractions.  The  pressure  exerted  by 
the  instrument,  would  certainly  be  more  hurtful  than  useful,  by  preventing  what- 
ever elongation  the  occipito-frontal  diameter  is  capable  of  receiving  during  the 
forcible  reduction  of  the  bi-parietal  one.  This  view  of  the  action  of  the  forceps 
has  at  least  the  advantage  of  demonstrating  the  uselessuess,  if  not  the  danger,  of 
the  powerful  efforts  sometimes  resorted  to  by  certain  accoucheurs  for  the  purpose 
of  compressing  the  head,  and  reducing  its  size ;  for  when  the  head  is  well  grasped 
by  the  instrument,  all  that  is  requisite  is  to  tighten  the  latter  enough  to  prevent 
it  from  slipping  during  the  operation.  If  the  forceps  can  ever  be  used  as  a  mean 
of  reduction,  it  is  only  when  the  head  is  arrested  by  a  shortening  of  the  bis- 
isehiatic  diameter. 

The  limits  just  assigned  to  the  application  of  the  forceps,  are  the  consequence 
of  experiments  upon  the  dead  body,  and  of  the  most  frequently  observed  cases; 
but  we  shall  have  occasion  to  prove  hereafter  that  they  cannot  be  regarded  as 
absolute.  When  the  smallest  diameter  of  the  contracted  pelvis  is  less  than  three 
inches,  we  are  still  almost  obliged  to  try  the  forceps  before  having  recourse  to 
craniotomy  or  symphyseotomy  (see  Symphyseotomy),  and  it  has  several  times 
been  the  means  of  extracting  a  living  child  through  a  diameter  of  but  two  and 
three-quarter  inches,  for  example. 

But  are  the  forceps  the  only  resource  left  before  having  recourse  to  a  bloody 
operation  in  cases  of  contracted  pelvis?  We  long  thought  that  it  was,  and,  not- 
withstanding the  impression  made  upon  our  mind  by  the  perusal  of  the  observa- 
tions of  Madame  Lachapelle,  we  shared  on  this  important  practical  point  the 
opinion  of  the  majority  of  French  accoucheurs,  and  proscribed  pelvic  version  in 
cases  of  contracted  pelvis,  except  in  the  oblique  oval  variety,  in  which  it  was 
admitted  by  all  to  have  undoubted  advantages. 

The  recent  publication  of  Drs.  Simpson  and  Radfort  led  us  to  a  fresh  exami- 


THE    FORCEPS.  823 

nation  of  the  question,  and  it  has  ah'eady  been  seen  that  our  opinion  was  mate- 
rially changed  thereby. 

''  On  reading  cases  of  contraction  of  the  pelvis,"  says  Dr.  Simpson,  "  I  was 
struck  with  the  fact,  that  the  labor  in  certain  malformed  females,  was  much 
easier  and  more  fortunate  when  the  child  had  presented  by  the  feet  than  when 
the  head  was  the  first  to  offer.  In  several  cases  even,  which  would  have  required 
craniotomy,  the  presentation  of  the  feet  or  pelvic  version  enabled  me  to  eifect 
the  delivery  in  a  succeeding  pregnancy.  Five  observations  of  this  kind  are  re- 
corded by  Smellie." 

"According  to  my  tables,"  says  Madame  Lachapelle,  "of  fifteen  children  deli- 
vered by  the  forceps,  on  account  of  contracted  pelvis,  seven  lived,  and  eight 
-perished;  whilst  of  twenty-five  delivered  by  the  feet,  fifteen  survived."  The 
proportion  of  success  is,  therefore,  two-thirds  for  version,  and  rather  less  than 
one-half  for  the  forceps.  "  These  fortunate  results  of  version,"  adds  the  illus- 
trious midwife,  "  are  doubtless  due  to  the  greater  facility  with  which  we  are  able, 
whilst  drawing  upon  the  pelvic  extremity,  so  to  direct  the  head  of  the  foetus  as 
to  place  its  transverse  diameter  in  correspondence  with  the  shortened  antero-pos- 
terior  one.  When,  on  the  contrary,  the  head  presents  first,  it  is,  in  fact,  gene- 
rally situated  transversely  j  but  it  may  possibly  occupy  much  more  unfavorable 
positions,  and  those,  too,  of  a  kind  which  the  forceps  is  incapable  of  altering." 

Supposing  the  head  to  be  situated  transversely  above  the  shortened  sacro-pubic 
diameter,  would  it  traverse  the  passage  with  any  more  ease  if  presenting  the  top 
of  the  head,  than  when,  after  the  extraction  or  spontaneous  expulsion  of  the 
body,  the  base  of  the  cranium  is  presented  to  the  shortened  diameter  ?  Here, 
theory  seems  to  be  quite  in  accordance  with  the  above-mentioned  facts.  The 
head,  regarded  as  a  whole,  represents  a  cone,  whose  base  is  the  biparietal  dia- 
meter, amounting  to  from  three  and  a  half,  to  three  and  three-quarter  inches, 
and  the  top  of  the  head  by  the  bimastoid  diameter,  amounting  to  but  from  three, 
to  three  and  a  quarter  inches.  This  latter  diameter  is  irreducible,  whilst  the 
former  is  susceptible,  under  the  influence  of  pressure  applied  for  a  longer  or 
shorter  time,  of  being  shortened  to  the  extent  of  three-eighths,  or  even  five- 
eighths  of  an  inch.  Now,  when  the  top  of  the  head  presents  first,  the  base  of 
the  cone  which  it  represents  is  brought  in  relation  with  a  shorter  diameter  than 
its  own,  and  all  the  efibrts  of  the  womb  as  well  as  the  tractions  by  the  forceps, 
can  have  but  the  single  result  of  flattening  the  vault  of  the  cranium  against  the 
opening  of  the  pelvis,  and  consequently,  of  increasing,  instead  of  diminishing 
the  biparietal  diameter.  If,  on  the  contrary,  we  suppose  the  cone  represented  by 
the  head  to  engage  by  its  point,  that  is  to  say,  by  its  bimastoid  diameter,  the 
tractions  upon  the  body  of  the  child  might  have  the  following  effects,  namely,  if 
the  shortened  pelvic  diameter  presents  at  least  from  two  and  three-quarters  to 
three  and  a  quarter  inches,  it  will  present  no  serious  obstacle  to  the  engagement 
of  the  bimastoid  diameter,  and  from  that  time,  the  compression  upon  the  sides  of 
the  parietal  protuberances  produced  by  the  resisting  symphysis  pubis  and  sacro- 
vertebral  angle,  tends  to  force  them  nearer  together,  that  is  to  say,  to  shorten  the 
biparietal  diameter,  and  the  head  drawn  down  by  the  accoucheur  will  engage  in 


824  DYSTOCIA. 

the  contracted  part  of  the  pelvis  like  a  wedge,  the  base  of  which  is  compressible. 
In  short,  the  resistance  of  the  bones  of  the  pelvis  in  the  presentation  of  the  top 
of  the  head,  tends  to  lessen  the  occipito-frontal  or  occipito-mental  diameter,  whilst 
in  foot  presentations,  it  tends  to  diminish  the  transverse  diameter,  that  is  to  say, 
the  only  one  which  it  is  important  should  be  reduced.  (Simpson.) 

A  greatly  prolonged  labor  ought,  doubtless,  be  regarded  as  one  of  the  most 
dangerous  circumstances  affecting  the  welfare  of  both  mother  and  child,  for  the 
lives  of  both  are  hazarded  in  proportion  to  the  lengthening  out  of  the  expulsive 
stage ;  now,  according  to  Dr.  Simpson,  version  affords  the  immense  advantage  of 
enabling  us  to  terminate  the  labor  more  quickly.  What,  indeed,  is  the  course 
generally  pursued  when  it  is  proposed  to  apply  the  forceps  in  these  cases  of  eon- 
traction  ?  It  is,  evidently,  to  wait  before  acting,  in  order  to  determine  the  inca- 
pacity of  the  uterine  efforts,  and  it  is  not  until  after  five,  six,  or  eight  hours  of 
expectation,  that  .the  instrument  is  used.  In  the  meanwhile,  the  head  is  com- 
pressed powerfully,  and  the  maternal  organs  are  so  seriously  contused  as  to  expose 
them  to  gangrene,  or,  at  least,  to  those  inflammations  of  the  uterus  or  of  the  cel- 
lular tissue  of  the  pelvis,  so  dangerous  during  the  lying-in.  On  the  contrary, 
when  turning  is  intended,  the  most  favorable  moment  can  be  chosen  in  many 
cases,  which  is  immediately  after  the  membranes  are  ruptured  and  the  neck  com- 
pletely dilated.  The  term  of  expectation  would  be  still  longer  in  presence  of  a 
pelvis  so  contracted  as  to  require  embryotomy;  for,  unless  the  foetus  is  found  to 
be  dead,  the  operation  is  deferred  until  it  shall  have  perished,  or  at  least  until 
the  labor  shall  have  lasted  so  long  as  to  render  its  viability  exceedingly  doubtful. 

If  regard  be  had  only  to  the  interests  of  the  mother,  version,  as  affording  op- 
portunity to  act  immediately  after  the  membranes  are  ruptured,  should,  therefore, 
be  preferred;  but  is  the  case  the  same  as  respects  the  foetus?  If  we  compare 
the  results  of  podalic  version  with  those  of  embryotomy,  the  reply  is  ready,  for 
the  facts  mentioned  by  Madame  Lachapelle,  and  some  authors,  afford  us  at  least 
the  hope  of  sometimes  saving  the  child  by  turning,  whilst  its  death  is  the  inevi- 
table consequence  of  any  other  operation.  But  do  not  the  forceps,  within  the 
rational  limits  which  we  have  fixed  for  their  employment,  afford  greater  chances 
to  the  foetus  than  the  extraction  by  the  feet  ?  Madame  Lachapelle  and  Drs. 
Radfort  and  Simpson,  do  not  hesitate  to  declare  for  the  turning.  Notwithstand- 
ing the  facts  collected  by  the  illustrious  midwife,  and  whilst  admitting  with  the 
English  accoucheurs,  that  the  compression  is  less  dangerous  to  the  foetus  when 
exerted  on  the  sides  of  the  head  than  when  its  tendency  is  to  shorten  the  occipito- 
frontal diameter,  we  confess  that  we  cannot  share  their  preference  when  the  top 
of  the  head  presents  in  a  favorable  position.  The  arrest  of  the  base  of  the 
cranium  above  the  contraction,  the  possible  extension  of  the  head,  the  stretching 
of  the  cervical  region  to  which  the  tractions  made  on  the  body  necessarily  expose 
it,  the  possible  compression  of  the  umbilical  cord  during  the  time  occupied  in  the 
extraction  of  the  child,  are,  indeed,  very  unfavorable  circumstances  for  the  latter, 
and,  unfortunately,  greatly  to  be  feared  during  version.  But  when,  with  a  short- 
ened diameter  of  three  and  a  quarter  inches,  there  coincides  an  unfavorable  pre- 
sentation, as  those  of  the  face  or  of  the  trunk,  and  when,  before  the  application 


THE    FORCEPS."  825 

of  the  forceps  it  is  first  necessary  to  perforin  the  cephalic  version  ;  or  when,  the 
top  of  the  head  presenting,  it  is  so  situated  that  its  longitudinal  diameter  corre- 
sponds to  the  contracted  one,  we  are  of  their  opinion,  and  prefer  version  to  the 
use  of  the  instrument. 

When  the  antero-posterior  diameter  of  the  pelvis  amounts  to  but  from  two  and 
three-quarters  to  three  and  a  quarter  inches,  and  the  child,  being  still  alive,  is 
placed  in  the  conditions  just  mentioned,  we  also  think  that  version  should  be 
preferred. 

If,  after  several  fruitless  attempts  made  with  the  forceps  upon  a  favorably- 
situated  head,  the  heart  is  heard  to  beat  distinctly  and  regularly,  we  should,  if 
the  pelvis  has  at  least  two  and  three-quarter  inches,  attempt  the  pelvic  version 
before  resorting  to  craniotomy. 

We  would  add,  with  Madame  Lachapelle,  that  version  is  also  preferable  to  the 
use  of  the  instrument,  when  the  inferior  strait  is  contracted  transversely,  and  the 
pubic  arch  is  narrow  and  angular.  When,  in  fact,  the  head  is  the  first  to  be 
delivered,  the  occiput  appears  first  beneath  the  pubis,  and  its  disengagement 
under  these  circumstances  is  very  difficult,  and  sometin)es  even  impossible. 
When,  on  the  contrary',  the  extraction  takes  place  by  the  feet,  the  occiput  places 
itself  behind  the  pubis,  the  forehead  is  the  first  to  appear  in  front  of  the  peri- 
neum, and  only  the  hack  of  the  neck,  engages  in  the  arch  of  the  pubis. 

To  recapitulate,  when  the  pelvis  has  at  least  two  and  three-quarter  inches  in 
its  sacro-pubic  diameter,  the  forceps  should  be  used  if  the  top  of  the  head  pre- 
sents in  a  transverse  position.  The  pelvic  version  should  be  preferred :  1,  in 
direct  antero-posterior  positions;  2,  in  inclined  or  irregular  positions  of  the  top 
of  the  head ;  3,  in  face  and  trunk  presentations ;  4,  in  contractions  of  the  infe- 
rior strait  attended  with  narrowing  of  the  sub-pubic  arch.  It  were  useless  to 
recall  the  important  distinction  which  we  have  established  for  the  oblique  oval 
pelves.  (See  page  585.) 

3.  Accidents. — It  is  only  necessary  to  recall  the  conditions  in  which  the 
version  is  practicable,  to  show  the  part  the  forceps  may  play  in  those  accidents 
that  require  a  speedy  termination  of  the  labor.  We  need  not  mention  the  dila- 
tation or  dilatability  of  the  os  uteri,  for  this  is  indispensable  to  both  operations. 
Should  a  completion  of  the  delivery  be  deemed  imperative,  when  the  head  has 
cleared  the  cervix,  or  is  low  down  in  the  excavation,  we  would  apply  the  forceps; 
but,  on  the  contrary,  if  it  be  but  little  or  not  at  all  engaged  at  the  superior  strait, 
the  version  would  be  preferable  (see  page  77G),  unless  the  pelvis  was  very  nar- 
row, or  the  womb  was  so  firmly  contracted,  as  to  render  an  introduction  of  the 
hand  unusually  painful,  or  even  impossible. 

4.  The  Resistance  of  the  Periiieal  JJitsclcs  is  one  of  the  most  common  reasons 
for  resorting  to  the  instrument;  for,  nine  out  of  every  ten  applications  of  the 
forceps  are  made  for  the  purpose  of  extracting  the  head,  which  has  been  detained 
at  the  pelvic  floor  for  four,  five,  six,  or  seven  hours;  indeed,  if  the  measures  re- 
commended on  page  591  have  proved  ineffectual,  this  is  our  only  resource.  But, 
even  here,  it  is  possible  that  obstetricians  have  been  in  error  with  regard  to  its 
modus  operandi,  since  every  one,  who,  like  myself,  has  frequently  had  occasion 


8£6  DYSTOCIA. 

to  apply  it,  must  have  been  struck  with  the  flict  of  how  Httle  effort  is  required, 
under  such  circumstances,  to  effect  the  delivery  of  the  head.  For,  where  this 
part  has  been  retained  at  the  same  point  for  seven  or  eight  hours,  notwithstand- 
ing the  most  energetic  contractions  of  the  organ,  and  all  the  uterine  forces  have 
been  expended  on  an  apparently  insurmountable  obstacle,  the  young  accoucheur, 
in  resorting  to  his  instrument,  may  anticipate  the  necessity  of  using  some  con- 
siderable force ;  and  yet,  as  soon  as  a  few  slight  tractions  are  made,  this  great 
resistance  seems  to  give  way  at  once,  the  uterine  contractions  that  were  so  long 
ineffectual  are  henceforth  adequate,  and  the  patient  soon  expels  the  head  and 
forceps  together.  Far  different  would  be  the  result,  if  the  arrest  of  the  head 
were  altogether  dependent  on  an  over-resistant  perineum;  for  the  exertion  re- 
quisite in  those  cases,  where  this  part  has  been  rendered  less  extensible  by 
abnormal  bands  or  cicatrices  is  well  known.  Doubtless,  this  resistance  from  the 
pelvic  floor  is  the  first  source,  but  it  is  far  from  being  the  whole  cause  of  the 
difficulty. 

In  my  opinion,  the  following  is  the  true  state  of  the  case ;  when  the  head, 
urged  on  by  the  uterine  contractions,  reaches  the  floor  of  the  pelvis,  it  is  already 
in  a  state  of  flexion,  which  must  certainly  increase  as  the  pains  become  stronger, 
and  the  perineum  more  resistant;  for,  being  placed  between  two  opposite  forces, 
it  will  necessarily  be  flexed  on  the  chest  to  the  greatest  possible  extent.  Now, 
it  is  this  excessive  flexion  that  constitutes  the  most  serious  difficulty,  for,  in  this 
position,  the  spinal  column  abuts  directly  on  the  occiput,  and  every  espulsory 
effort  transmitted  by  it  has  a  tendency  to  depress  the  latter,  and  to  flex  the  head; 
but  here  its  extension  can  alone  effect  the  delivery.  The  question  recurs,  how 
then  does  the  forceps  operate  ?  I  answer,  in  a  very  simple  manner;  by  the  first 
tractions  it  extends  the  head,  changing  this  part  to  a  more  favorable  position 
relatively  to  the  spine,  and  thus  restores  the  efficacy  of  the  uterine  contractions, 
which  latter  are  quite  sufficient  for  the  subsequent  completion  of  the  delivery. 

Hence,  the  reader  will  understand  that,  although  the  perineal  resistance  is, 
without  any  doubt,  the  original  cause  of  the  arrest  of  the  head,  yet,  in  a  vast 
majority  of  cases,  it  merely  acts  by  producing  an  exaggerated  flexion ;  and  that, 
as  soon  as  this  is  created,  it  alone  constitutes  the  whole  difficulty ;  a  proof  of 
which  is  satisfactorily  afforded  by  the  ease  and  rapidity  of  the  termination  of  the 
labor,  after  the  first  moderate  tractions  made  b}"  the  instrument  have  effected  <a 
partial  extension. 

5.  Lastly,  it  has  been  shown  how  a  shortening  of  the  cord  may  become  a  cause 
of  dystocia.  Where  this  happens,  the  forceps  is  a  hazardous  resource,  that  ought 
to  be  avoided;  but  the  real  source  of  the  delay  is  generally  unknown,  and,  even 
if  it  were  not,  I  know  of  nothing  better  to  be  done,  if  the  head  is  low  down  in 
the  excavation. 

The  period  of  labor  for  applying  the  forceps  varies  with  the  cause  that  de- 
mands its  use.  When  any  accident  whatever  renders  it  advisable  to  produce  a 
speedy  delivery,  and  the  forceps  be  deemed  appropriate,  the  time  for  operating 
will  be  judged  of  by  the  danger  of  the  accident  itself;  for  we  are  evidently  to 
interfere  as  soon  as  there  is  reason  to  fear  that  the  life  of  either   the  mother  or 


THE     FORCEPS.  827 

child  is  involved.  When  the  head  is  arrested  above  the  superior  strait  by 
a  contracted  pelvis,  we  might  wait  in  ordinary  cases,  as  elsewhere  stated,  for 
six,  seven,  or  even  eight  hours  after  the  membranes  are  ruptured  and  the  os 
uteri  is  fully  dilated ;  but  a  longer  delay  would  expose  both  mother  and  child 
to  the  most  serious  hazard.  Again,  when  the  arrest  of  the  head  is  depen- 
dent on  the  resistance  of  the  soft  parts,  the  pressure  thereby  created  on  the 
vaginal  walls  and  sometimes  even  upon  the  parietes  of  the  womb,  might  eventu- 
ally determine  a  gangrene  of  those  parts,  and  render  the  patient  liable  to  the 
vesical  and  recto-vaginal  fistulas,  which  often  result  in  consequence.  Besides 
which  the  foetus,  being  subjected  for. a  long  time  to  compression,  may  suffer 
from  it;  and  from  the  disorder  thereby  created  in  the  omphalo-placental  circula- 
tion ;  and  the  uterus,  having  exhausted  its  energy  against  resistances  which  it 
cannot  overcome,  falls  into  a  state  of  inertia  that  continues  after  the  delivery, 
and  becomes  then  a  source  of  hemorrhage;  and,  lastly,  the  inflammation  of  the 
womb  or  vagiqal  walls  that  occasionally  takes  place,  may  extend  to  the  peri- 
toneum after,  or  even  during  the  labor,  and  speedily  prove  fatal.  All  these 
dangers  are  easily  obviated  by  the  proper  application  of  the  forceps ;  and  though, 
on  the  one  hand,  the  abuse  of  the  instrument,  by  employing  it  too  early,  as 
some  practitioners  are  in  the  habit  of  doing,  is  to  be  avoided,  yet,  on  the  other, 
we  must  not  virtually  interdict  its  use  by  trusting  too  long  to  the  powers  of 
nature.  We  must  again  allude  to  what  was  previously  stated  in  regard  to  the 
importance  of  observing  the  stage  of  the  labor  at  which  the  delay  occurs;  thus 
the  time  that  has  elapsed  prior  to  the  rupture  of  the  membranes,  can  have  but 
little  influence  on  the  mother's  condition,  and  none  on  that  of  the  child,  so  that, 
even  where  the  labor  has  lasted  from  thirty  to  thirty-six  hours,  there  is  often 
nothing  to  be  done;  though  if  the  head  were  low  down  in  the  excavation,  and  it 
had  made  no  progress  for  seven  or  eight  hours,  the  forceps  ought  to  be  applied. 
But  this  rule,  which  is  applicable  to  most  cases,  admits  of  some  exceptions;  and 
it  would  seem  useless  to  add  that  the  state  of  the  patient's  health,  the  strength 
or  feebleness  of  the  uterine  contractions,  the  slowness  and  intermission,  or  the 
regularity  of  the  foetal  pulsations,  &.C.,  must  influence  the  time  of  its  application. 
The  accoucheur  would  be  justly  liable  to  censure  for  not  acting  soon  enough,  and 
equally  so  for  recurring  too  early  to  the  use  of  instruments. 

Statistics,  and  General  View  of  the  Operation. — We  find  the  same  difficulty 
in  furming  an  exact  idea  of  the  frequency  of  the  cases  requiring  the  application 
of  the  forceps,  as  we  did  of  the  cases  demanding  version,  for  they  vary  much  in 
diff"ercnt  countries,  and  even  in  the  practice  of  accoucheurs  of  the  same  locality. 
Thus,  on  consulting  the  statistics  cullected  by  Churchill,  we  find  for  England, 
120  forceps  cases  in  42.196  labors,  or  about  1  in  351 ;  whilst  in  France,  the  in- 
strument has  been  used  277  times  in  44,776  labors,  or  abouf  1  in  162;  and  in 
Germany,  1702  times  in  261,224  labor.s,  or  about  1  in  153. 

It  is  still  more  difficult  correctly  to  estimate  the  danger  of  the  operation  to  the 
mother  and  child,  for  the  statistics  generally  represent  only  the  number  of 
mothers  and  children  who  perished,  without  stating  the  cause  requiring  the  in- 
tervention of  art,  and,  consequently,  leaving  us  uninformed  as  to  the  probable 


8S8 


DYSTOCIA. 


danirer  of  the  operation  in  any  civen  case.  Thus,  tlie  risks  to  which  the  mother 
and  child  are  subjected  when  the  use  of  the  forceps  is  demanded  only  by  the 
resistance  of  the  soft  parts,  is  not  comparable  to  that  which  threatens  them  when 
the  head  is  arrested  by  a  contraction  of  the  pelvis.  The  lenj^th  of  time  which 
elapses  between  the  discharge  of  the  waters  and  the  intervention  of  art,  neces- 
sarily influences  greatly  the  result  of  the  operation  :  now,  with  the  exception  of 
Dr.  Collins,  whose  statistics,  though,  unfortunately,  too  limited,  prove  that  the 
mortality  is  greater  in  proportion  to  the  lateness  of  the  operation,  very  few 
authors  have  noted  this  particular  point.* 

There  can  be  no  doubt  that  the  use  of-the  forceps  increases  the  dangers  of  the 
delivery .'*  Beside  its  being  always  prejudicial  to  interfere  with  the  operations 
of  nature  when  they  are  going  on  regularly,  the  application  of  the  forceps,  though 
apparently  of  the  simplest  character,  may  prove  dangerous  to  the  mother,  and 
especially  to  the  foetus.  The  too  rapid  depletion  of  the  uterus,  exposes  the  woman 
to  hemorrhage  from  inertia.  The  dilatation  of  the  soft  parts  takes  place  with 
far  less  regularity  when  the  head  is  extracted  by  the  forceps,  and  the  perineum 
is,  therefore,  much  more  liable  to  laceration,  however  carefully  the  tractions  are 
performed.  Finally,  I  shall  not  speak  of  the  lesions  of  the  cervix  and  of  the 
perforation  of  the  vagina,  since  it  is  always  possible  to  avoid  them  by  conforming 
to  the  precepts  already  given. 

Therefore,  the  instrument  should  be  had  recourse  to  only  when  the  insuffi- 
ciency of  the  powers  of  nature  shall  have  been  well  ascertained,  and  we  are  con- 
vinced that  a  longer  expectation  would  be  injurious  to  the  mother  or  to  the  child. 

On  the  other  hand,  the  compression  of  the  child's  head  by  the  instrument 
may  be  prejudicial  to  its  health  or  even  to  its  life,  and  we  have  to  point  out  as 
possible  occurrences,  cerebral  effusions,  fractures,  and  depressions  of  the  bones  of 
the  skull,  exophthalmia,  the  contusion,  laceration,  t)nd  separation  of  the  scalp, 
the  compression  of  the  umbilical  cord  between  the  head  and  the  blade  of  the  for- 
ceps; and  lastly,  paralysis  of  the  flieial  nerve,  on  which  we  shall  make  some 
remarks. 

Quite  recently,  M.  Landousy  has  called  attention  to  the  facial  paraly.sis  of  new- 
born children,  that  often  follows  an  application  of  the  forceps;  and  JM.  P.  Dubois 
has  also  alluded  to  the  same  fact  in  his  lectures.  This  palsy,  which  affects  only 
one  side  of  the  face,  is  caused  by  the  pressure  of  the  blade  on  the  seventh  pair 
of  nerves.  Owing  to  the  nearly  total  absence  of  the  mastoid  process,  and  the 
defective  development  of  the  auditory  canal,  such  a  compression  of  the  fiicial 
nerve  just  as  it  escapes  from  the  stylo-mastoid  foramen  may  occur  very  easily. 
The  affection  is  easily  recognized  immediately  after  birth,  by  the  following  cir- 
cumstances :  the  commissure  of  the  lips  is  drawn  out  of  place ;  the  nostril  is 

'  Dr.  Collins  jjives  the  following  as  regards  the  mothers.  When  the  labor  was  terminated 
in  24  hours,  but  one  woman  tlied  out  of  13 ;  between  the  23d  and  30th  hour,  there  was  one 
death  for  6  cases ;  between  the  37th  and  the  48th,  one  death  in  4  ;  and  beyond  48,  one 
death  in  2  cases. 

2  In  natural  labors,  the  mortality  was,  for  the  mothers,  1  in  340,  and  for  the  children,  1  in 
31 ;  in  deliveries  by  the  forceps,  it  was,  for  the  mothers,  1  in  22,  and  for  the  children,  1  in  4'3. 


THE    VECTIS.  829 

neither  so  dilated  nor  so  movable  as  its  fellow  of  the  opposite  side;  the  eyelids 
are  open,  while  those  on  the  sound  side  arc  closed;  the  whole  side  of  the  face  is 
distorted,  and  this  deformity,  heightened  by  the  infant's  cries,  gives  it  a  very 
peculiar  expression.  As  soon  as  the  crying  is  over,  the  deformity  is  so  slight  as 
scarcely  to  be  noticed,  if  the  eye  on  the  sound  side  happens  to  be  open ;  but 
when  the  child  cries  again,  the  want  of  symmetry  in  the  features  is  once  more 
observable.  This  difference  in  the  phenomena  of  the  disease,  dependent  on  the 
condition  of  repose  or  agitation  of  the  fiice,  is  much  better  marked  than  it  is  in 
the  facial  hemiplegia  of  adults.  The  difference  is  particularly  striking  just  before 
it  cries,  for  its  face  then  exhibits  alternatives  of  rest  and  excitement  such  as 
those  just  described.  In  the  course  of  a  week  or  ten  days  these  symptoms  nearly 
all  disappear,  and  the  equilibrium  between  the  two  sides  is  gradually  restored. 
When  the  compression  of  the  nerve  has  been  moderate,  the  hemiplegia  does  not 
last  so  long,  and  occasionally  disappears  in  a  few  hours;  but  in  other  instances 
it  may  persist  for  a  month  or  two.  Hitherto,  this  affection  has  never  terminated 
in  death,  having  always  passed  off,  even  where  no  active  medication  has  been 
employed. 

The  only  precautions  necessary  in  such  cases,  are  to  protect  the  eye  from  the 
light;  and,  when  the  sucking  is  interfered  with  by  the  paralysis,  as  it  occasion- 
ally is,  to  find  a  nurse  having  a  well-formed  nipple. 


CHAPTER  III. 

OF   THE    VECTIS. 

The  vectis  (or  lever),  which  Burns  proposed  calling  the  tractor,  was  formerly 
much  used,  though,  at  the  present  day,  it  is  scarcely  ever  resorted  to,  since,  in 
nearly  all  the  cases  in  which  it  has  been  recommended,  the  forceps  may  be  ad- 
vantageously substituted.  It  was  employed  to  effect  the  correction  of  the  head 
in  cases  of  inclined  vertex  presentations,  to  depress  the  occiput  in  face  positions, 
to  force  the  head  to  descend,  and  to  free  it  from  the  genital  organs.  One  of  the 
Chamberlens  appears  to  have  been  the  inventor  of  this  instrument  likewise,  but 
it  has  undergone  numerous  modifications  since  it  became  public.  The  one  now 
in  use  resembles  a  branch  of  the  forceps ;  the  blade  is  provided  with  a  fenestra, 
and  is  curved  on  one  side  so  as  to  adapt  itself  to  the  convexity  of  the  child's 
head;  being  terminated  below  by  a  long,  flat  stem,  which  becomes  narrower  and 
rounded,  so  as  to  fit  in  a  wooden  handle,  which  latter  is  either  continued  out  in 
the  same  line,  or  else  is  slightly  bent  in  the  opposite  direction  from  the  blade. 

Those  authors  who  still  recommend  the  vectis,  make  use  of  it  in  two  ways, 
and  to  accomplish  two  different  purposes.  At  times,  they  merely  desire  to  cor- 
rect the  head,  and  then  abandon  the  rest  of  the  delivery  to  nature;  at  others,  by 
using  the  vectis  as  a  forceps,  they  endeavor  to  extract  it.  In  the  latter  case, 
which  presupposes,  according  to  the  acknowledgment  of  M.  Velpeau  himself, 


830 


DYSTOCIA. 


121. 


that  tlie  head  is  already  down  in  the  excavation,  I  know  of  no  reason  for  not 
using  the  forceps. 

When  the  correction  of  the  head  is  the  only  object  to  be  secured,  the  hand 
will,  most  generally,  suffice.  Nevertheless,  if  the  vectis  is  employed  for  this 
purpose,  the  following  is  the  proper  mode  of  operating :  After  having  introduced 
it,  according  to  the  rules  laid  down  for  the  forceps,  we  next  endeavor  to  slip  it 
over  that  part  of  the  head  on  which  it  is  to  act — over  the  occiput,  \^hen  the 
object  is  to  flex  the  head,  or  upon  one  of  the  parietal  regions  in  the  lateral  ia- 
clined  positions.  When  it  is  properly  placed,  the  hand,  which  is  already  in  the 
vagina,  and  which  has  served  to  guide  the  instrument  up  to  its  place,  grasps  it 
near  the  middle,  so  as  to  form  a  fulcrum,  as  it  were,  whilst  the  other  hand  having 
hold  of  the  handle,  draws  in  a  direction  opposite  to  the  one  the  head  is  to  take ; 
thus  making  the  instrument  act  as  a  lever  of  the  first  kind.     In  some  cases,  the 

hand  at  the  exterior  serves  as  the  fulcrum  by 
fixing  the  handle,  while  the  other,  acting  on 
the  middle  of  the  lever,  gives  the  blade  the 
requisite  movement ;  the  instrument  then  acts 
as  a  lever  of  the  third  kind. 

As  hitherto  stated,  the  lever  might  prove 
very  serviceable  in  some  of  the  posterior  posi- 
tions of  the  face,  when  too  far  engaged  to  admit 
of  version.  When  it  it  used  for  flexing  the 
head  and  depressing  the  occiput,  it  is  passed 
like  a  blade  of  the  forceps  directly  upon  the 
vertex,  and  as  much  as  possible  on  the  occiput. 
(Fig.  121.)  Then,  by  operating  in  the  manner 
just  indicated,  we  attempt  to  convert  the  face 
presentation  into  one  of  the  vertex. 

M.  Boddaert,  who  has  constituted  himself 
the  advocate  of  the  vectis  in  Belgium,  states 
that  he  has  employed  it  successfully  in  some 
cases  of  deformity  of  the  pelvis,  after  the  for- 
ceps had  failed.  When  others  think  of  having 
recourse  to  craniotomy,  he  extracts  the  child 
alive  by  means  of  this  instrument.  We  are  of 
M.  Van  Huevel's  opinion,  that  the  vectis  can  never  substitute  the  forceps  or 
version  in  deformities  of  the  pelvis. 

Some  practitioners  are  in  the  habit  of  attaching  a  loop  near  the  middle  of  the 
instrument,  either  to  give  it  a  point  iV appui  other  than  the  symphysis  pubis,  or 
to  convert  it  into  a  lever  of  the  third  kind;  the  fillet,  drawn  by  one  hand, 
becoming  the  active  power. 


The  mode  of  using  the  lever  to  pull  down 
the  occiput,  or  lo  flex  the  head. 


INDUCTION    OF    PREMATURE    LABOR.  831 

CHAPTER   IV. 

INDUCTION    OF    PREMATURE    LABOR. 

The  title  of  premature  artificial  delimrij  is  applied  to  a  labor  that  is  design- 
edly brought  on  prior  to  the  ordinarj^  term  of  pregnancy,  but  not  before  the  fuetus 
is  viable. 

No  obstetrical  operation  has  ever  been  more  warmly  or  more  profoundly  criti- 
cised than  this.  In  fact,  it  has  been  supported  or  condemned  by  the  leading 
accoucheurs  of  all  countries,  and  as  a  consequence  of  this  disagreement  among 
the  masters  of  our  art,  no  part  of  obstetrical  science  has  ever  been  studied  with 
greater  care.  To  trace  out  the  first  dawning  of  the  induction  of  premature  labor, 
we  should  have  to  go  back  through  the  gropings  that  characterize  all  human 
works^  to  the  manoeuvres  of  Aspasia,  to  the  forced  dilatations  of  the  os  uteri  re- 
commended by  Louise  Bourgeois  and  J.  Guillemeau,  or  to  the  more  gradual  pro- 
cedure of  Puzos.  But,  in  all  of  these  methods,  the  principle  differs  wholly  from 
the  operation  under  consideration;  for,  "in  &  premature  delivery,  nature  accom- 
plishes nearly  everything,  art  merely  contributing  a  slight,  though  certain  im- 
pulse; whilst  in  ih.Q  forced  labors,  art  acts  almost  alone,  for  all  .that  nature  vields 
must  be  drawn  from  her  by  continuous  efforts."     (Ritgen.') 

Under  this  important  distinction,  we  believe  there  can  no  longer  be  any  doubt 
that  the  induction  of  premature  labor  had  its  origin  in  England.  According  to 
a  few  writers,  Mary  Donally,  a  midwife  of  that  country,  first  performed  it  in 
1738 ;  but  most  of  the  English  authors  look  upon  this  as  a  gratuitous  assertion. 
The  judicious  Denman  states  "that,  about  the  year  1756,  there  was  a  consul- 
tation of  the  most  eminent  men  at  that  time  in  London,  to  consider  the  moral 
rectitude  of,  and  advantages  which  might  be  expected  from  this  practice,  which 
met  with  their  general  approbation.  The  first  case  in  which  it  was  deemed 
necessary  and  proper,  fell  under  the  care  of  the  late  Dr.  Macaulay,  and  it  termi- 
nated successfully."     His  example  was  soon  followed  by  numerous  imitators.* 

From  Grreat  Britain,  this  operation  shortly  passed  to  Germany,  where  it  was 
proposed  by  A.  Mai,  of  Heidelberg,  in  1799,  but  Wenzel  first  put  it  in  practice 
in  1801.  Owing  to  his  success,  and  the  publication  of  Reisinger's  remarkable 
work,  it  has  since  been  supported  by  numerous  and  zealous  partisans.  It  has 
been  performed  a  number  of  times  in  Holland  by  Salomon,  Welenbergh,  and 
Schow;  Lovati  has  been  equally  fortunate  in  Italy;  and  the  periodical  works  of 
Denmark,  of  America,  Switzerland,  and  Poland,  have  severally  reported  interest- 
ing cases  of  delivery  before  term. 

'  The  first  idea  of  the  induction  of  premature  labor  is  found  in  Eaphaiil  Moxius  (Liv.  II, 
chap.  16,  p.  495);  he  recommends  the  provocation  of  labor  with  the  object  of  saving  the 
mother,  at  two  different  periods  of  pregnancy.  In  the  first  months,  before  the  fa;tus  becomes 
animated,  and  in  the  two  last  months,  because  then  "  ftEtus  etiam  si  per  vim  ab  utero  extru- 
datur,  vivere  tamen  potest,  aut  saltem  non  defraudatur  vita  animoe,  quia  Vivus  nascitur  et 
baptizari  potest." 


833  •  DYSTOCIA. 

In  France,  the  reception  of  this  operation  into  practice  is  quite  modern ; 
indeed,  for  a  long  time  prior  to  its  admission  as  a  valuable  resource,  it  was 
rejected  as  a  crime.  Roussel  de  Vauzesme  proposed  it  as  early  as  1779,  though 
it  then  received  but  little  attention.  It  was  imperfectly  understood  for  a  very 
long  period,  and  we  may  doubtless  attribute  the  blind  and  passionate  opposition 
of  Baudelocque  and  his  pupils  to  their  want  of  a  clear  and  definite  idea  of  what 
might  be  expected  from  its  employment.  Fodere,  however,  persisted  in  recom- 
mending the  premature  delivery,  on  several  occasions,  notwithstanding  the  ana- 
themas of  this  celebrated  school.  In  1830,  M.  Burchardt,  in  a  remarkable 
thesis  on  this  subject,  sustained  its  propriety  at  Strasbourg,  and,  finally,  in  1831, 
Professor  Stoltz  performed  this  operation  for  the  first  time  in  France,  and  with 
the  most  perfect  success.  Since  then  all  doubts  have  gradually  vanished,  and 
most  of  the  French  accoucheurs  have  at  length  adopted  a  practice,  which  has 
now,  for  nearly  a  century,  rendered  such  important  services  to  humanity.* 

Being  once  rid  of  the  question  of  its  morality,  which  for  so  long  a  period 
deterred  some  practitioners,  who  did  not  hesitate  about  the  Ca)sarean  operation 
or  symphyseotomy,'^  we  have  only  to  resolve,  at  the  present  day,  the  two  following 
questions:  In  what  cases  is  premature  labor  to  be  induced?  And  which  is  the 
best  method  of  eifecting  this  object? 

ARTICLE   I. 

CASES   REQUIRING   A   PREMATURE   DELIVERY. 

A.  "When  summing  up  the  indications  presented  by  the  pelvic  deformities,  it 
was  stated  that  a  premature  labor  might  be  brought  on  where  the  smallest  dia- 
meter of  the  pelvis  did  not  exceed  three  and  three-quarter  inches,  and  where  it 
was  not  less  than  two  and  a  half  inches ;  but  we  must  now  explain  this  proposi- 
tion more  fully. 

It  should  be  remembered  that  this  operation  is  always  resorted  to  for  the 

'  The  French  works  on  this  subject  are  as  yet  quite  few  in  number;  but  their  authors, 
Burchardt,  Dezeimeris,  P.  Dubois,  Stoltz,  Ferniot,  and  Lacour,  have  scrupulously  examined 
the  objections  raised  at  various  periods  against  the  induction  of  premature  labor,  and  have 
endeavored  to  ascertain  the  precise  indications  for  its  performance :  but  neither  of  tliem  has 
thought  of  imitating  certain  accoucheurs  of  neighboring  countries,  who  make  no  scruple  of 
trespassing  on  the  domain  of  other  obstetrical  operations.  They  have  attempted  to  prove 
that  each  of  these  operations  has  its  own  special  indications,  which  cannot  be  substituted  for 
any  other ;  and  hence,  in  our  country,  the  induction  of  premature  labor  has  always  been 
governed  by  these  rigorous  data.  For  fuller  details,  the  reader  is  referred  to  the  cases,  now 
quite  nimierous,  performed  by  the  French  accoucheurs.  We  have  had  occasion  to  perform 
it  ourselves  six  times.     Three  of  the  children  were  born  living,  but  only  one  still  survives. 

2  It  is  really  Wonderful  that  the  consequences  of  this  operation  have  been  so  long  dreaded ; 
since,  in  two  hundred  and  fifty  cases  collected  by  M.  Lacour,  in  the  commencement  of  1844, 
more  than  one-half  of  the  children  survived,  and  scarcely  one  woman  in  sixteen  died.  Let 
any  one  compare  these  results  with  those  furnished  either  by  symphyseotomy  or  by  the  Caesa- 
rean  operation. 


INDUCTION     OF    PREMATURE    LABOR.  833 

double  purpose  of  saving  the  child's  life,  and  of  preserving  the  mother  from  a 
danger  which  very  frequently  threatens  her  own  existence.  In  other  words,  it 
is  not  to  be  attempted  until  the  pregnancy  is  so  fiir  advanced  that  the  viability 
of  the  foetus  is  fully  established,  and  only  in  those  cases  where  the  contraction 
of  the  pelvis  is  such  that  a  delivery  at  term  is  wholly  impossible  without  perform- 
ing either  a  bloody  operation  on  the  patient  or  mutilating  her  child. 

The  French  law,  which  has  been  constructed  with  a  view  of  meeting  all  pos- 
sible anomalies,  has  decided  that  the  end  of  the  sixth  month  is  the  period  at 
which  a  foetus  might  be  considered  viable ;  but,  laying  aside  some  rare  excep- 
tions, which  ought  not  to  be  brought  in  question,  every  practitioner  well  knows 
that  the  foetus  seldom  lives  if  born  before  the  end  of  the  seventh  month.  Con- 
sequently, we  should  not  think  of  determining  its  premature  expulsion  before  the 
full  term  of  seven  months.  Although  this  point  is  easily  decided  so  far  as  the 
interests  of  the  new  being  are  concerned,  yet  with  regard  to  the  mother  such  is 
not  the  case;  for  the  mere  assertion  that  this  operation  is  to  be  performed  when- 
ever it  is  known  that  a  natural  delivery  at  term  will  be  impossible,  is  altogether 
too  vague  and  uncertain  for  a  question  of  such  importance ;  and  therefore  the  two 
following  points  are  to  be  established  with  the  gTcatest  possible  precision,  namely, 
1st,  the  degree  of  contraction  beyond  which  the  provoked  delivery  is  no  longer 
practicable;  and,  2d,  within  what  limits  its  employment  is  justifiable. 

As  the  operation  is  only  admissible  after  the  seventh  month  of  gestation,  we 
must  of  course  ascertain  what  is  the  length  of  the  various  diameters  of  the  head 
at  that  period ;  because  the  extent  of  the  biparietal  diameter,  which  in  most  in- 
stances corresponds  to  the  contracted  one  of  the  pelvis  (the  antero-posterior),  will 
evidently  show  to  what  ultimate  degree  of  pelvic  contraction  a  delivery  is  still 
possible.  Now,  it  appears  from  the  researches  of  Dubois,  of  Stoltz,  and  Madame 
Lachapelle,  that  the  biparietal  diameter  at  the  end  of  the  seventh  month  averages 
from  two  and  a  half  to  two  and  three-quarter  inches ;  in  addition  to  which,  we 
may  hope  for  a  further  reduction  of  one-fourth  of  an  inch,  on  account  of  the 
compressibility  of  the  head.  Therefore,  the  smallest  pelvic  diameter  must  be 
two  and  three-quarter  inches  at  the  least.  This,  then,  is  the  extreme  limit, 
beyond  which  the  induction  of  premature  delivery  is  no  longer  to  be  thought  of. 

But  practitioners  are  not  equally  unanimous  with  regard  to  the  highest  limit. 
From  the  fact  of  the  biparietal  diameter  being  three  and  a  half  inches  in  a  foetus 
at  term,  some  have  supposed  that  the  labor  ought  to  be  induced  whenever  the 
least  diameter  of  the  pelvis  does  not  equal  this  length  ;  and  making  allowance 
for  the  reducibility  of  the  head,  they  have  fixed  upon  three  and  a  quarter  inches 
as  the  highest  limit.  No  doubt,  when  the  woman  in  a  former  pregnancy  could 
only  be  delivered  by  a  resort  to  embryotomy,  the  practitioner  would  clearly  be 
warranted  in  bringing  on  labor,  even  though  the  sacro-pubic  diameter  was  not 
less  than  three  and  a  quarter  inches;  yet  in  primiparai  this  would  not  be  justi- 
fiable, for  a  spontaneous  delivery  is  generally  possible  under  such  conditions. 

On  the  whole,  therefore,  the  induction  of  premature  labor  is  admissible  only 
when  the  smallest  pelvic  diameter  measures  at  least  two  and  a  half  inches.  In 
multiparas,  where  former  experience  has  shown  the  necessity  of  a  resort  to  em- 

53 


834  DYSTOCIA. 

bryotomy,  it  may  be  practised  as  higb  as  three  and  one-quarter  inches,  but  in 
priuiiparrc  never  beyond  three  inches. 

As  regards  the  child,  it  is  the  more  likely  to  live  as  its  sojourn  in  the  uterine 
cavity  has  been  the  more  prolonged ;  and  this  proposition,  the  truth  of  which  is 
universally  acknowledged,  should  induce  the  operator  to  delay  the  induction  of 
premature  labor  as  long  as  possible.  The  degree  of  contraction,  therefore,  must 
guide  us  in  selecting  the  most  suitable  period  ;  but,  in  order  to  draw  any  positive 
conclusion  from  an  examination  of  the  pelvis,  it  is  absolutely  requisite  to  know 
the  child's  successive  growth  during  every  week  that  elapses  between  the  end  of 
the  seventh  month  and  the  close  of  pregnancy.  This  has  been  determined  ap- 
prosimatively  by  M.  Stoltz,  as  follows  : 

From  the  32d  to  the  33d  week,  the  biparietal  diameter  measures  2^  inches. 

From  the  34th  to  the  35th  week  it  measures  3?  inches. 

From  the  36th  to  the  37th  week  it  measures  3i  inches. 

Thus,  if  the  labor  were  to  be  induced  in  consequence  of  a  contraction  to  two 
and  a  half  inches,  it  would  be  necessary  to  operate  at  the  end  of  the  seventh 
month,  making  an  allowance  for  the  rcdueibility  of  the  head,  which  at  that 
period  is  quite  considerable.  But  where  it  is  clearly  ascertained  that  the  case 
under  care  is  a  twin  pregnancy,  the  operation  might  be  put  off  for  some  time,  or 
either  abandoned  altogether  to  nature,  if  the  pelvic  contraction  be  not  very 
great :  because,  on  the  one  hand,  twins  usually  attain  a  less  degree  of  develop- 
ment, and  on  the  other,  if  born  before  term,  their  organization  is  generally  too 
imperfect  to  admit  of  a  healthy  extra-uterine  existence. 

Perhaps  it  v^^ould  be  proper  here  to  give  our  opinion  with  regard  to  certain 
circumstances  that  have  been  stated  by  some  accoucheurs  as  contraindications  to 
the  induction  of  labor ;  we  allude  to  the  influence  of  first  labors,  of  twin  preg- 
nancies, and  of  malpresentations. 

Merriman  has  been  the  most  prominent  in  urging  circumspection  in  the 
cases  of  primiparous  females;  but  the  fears  on  this  head  arc  evidently  exagger- 
ated, as  numberless  observations,  among  others  the  successful  result  quite  re- 
cently obtained  by  M.  Nichet,  in  the  case  of  a  rachitic  patient  who  was  pregnant 
for  the  first  time,  clearly  prove.  For  myself,  I  would  not  hesitate  to  follow  the 
example  of  Stoltz  and  Velpeau,  and  bring  on  the  uterine  contractions  in  a  primi- 
para,  if  I  had  fully  ascertained  the  degree  of  contraction  of  the  pelvis;  in  flict, 
I  have  already  done  so.  The  obliteration  of  the  cervix,  which  we  all  know  re- 
mains closed  almost  till  term,  is  certainly  one  difficulty  the  more  to  overcome  in 
first  pregnancies,  but  still  this  is  not  insurmountable.  Busch's  dilator,  a  species 
of  three  bladed  forceps,  which  is  dilated  after  being  introduced  into  the  neck 
and  thus  distends  the  orifice,  will,  in  my  opinion,  rarely  be  found  useful. 

With  regard  to  a  malprcsentation  of  the  foetus,  were  we  to  pay  any  attention 
to  it,  we  should  often  lose  the  advantages  of  the  operation,  since  this  is  an 
obstacle  of  very  frequent  occurrence.  And  as  a  delay  of  a  few  days  only  may 
compromise  the  success  of  the  attempt,  it  would  be  better  to  change  the  pre- 
sentation by  external  manipulations,  as  performed  by  Stoltz.  When  this 
measure   proves  unsuccessful  in  modifying  the   presentation,  we   should   still 


INDUCTION     OP    PREMATURE     LABOR.  bdO 

endeavor  to  excite  the  uterine  contraction,  so  as  to  perform  version  as  soon  as 
the  OS  uteri  shall  be  sufficiently  dilatable. 

The  mere  detection  of  a  vertex  presentation,  is  not  a  sufficient  reason  for  feel- 
ing secure  as  respects  an  iinflivorable  position.  In  one  of  the  sis  operations 
which  I  have  had  occasion  to  perform,  although  the  contraction  affected  the 
antero-posterior  diameter,  the  head  presented  in  an  occipito-pubic  position  after 
the  membranes  were  ruptured  :  and  as  this  circumstance  required  the  application 
of  the  forceps  and  considerable  traction,  the  child  was  born  dead. 

B.  The  cases  in  which  there  is  a  contraction  of  the  pelvis  do  not  constitute 
the  only  ones  in  which  the  premature  labor  has  been  recommended.  For  the 
many  serious  diseases  to  which  females  are  subject  during  the  latter  months  of 
gestation  are  evidently  connected  with  that  condition ;  and  a  depletion  of  the 
womb  is  the  best  and  often  the  only  means  of  removing  them.  This  is  also 
advised  by  some  writers  in  certain  affections  that  endanger  the  patient's  life  ; 
among  others,  M.  Ferniot  has  endeavored  to  prove,  in  a  recent  thesis,  that  under 
such  circumstances  the  premature  labor  is  quite  as  justifiable  as  in  the  pelvic 
contraction.  The  forced  delivery  was  long  since  recommended  in  cases  of  pro- 
fuse flooding,  particularly  in  those  dependent  on  the  insertion  of  the  placenta 
over  the  os  uteri ;  and  the  artificial  rupture  of  the  membranes,  resorted  to  in  our 
day,  is  merely  another  method  of  bringing  on  the  uterine  contractions.  Further, 
many  skilful  physicians  have  not  hesitated  to  bring  on  labor  when  an  attack  of 
convulsions  has  resisted  the  ordinary  remedies,  or  which,  after  being  checked, 
returned  every  few  days  with  a  constantly  increasing  severity.  And  why  should 
not  the  same  course  be  pursued,  when  any  serious  disease,  that  existed  before 
pregnancy,  is  so  highly  aggravated  by  this  condition  as  to  threaten  an  early  tei*- 
mination  in  death,  if  its  course  be  not  speedily  arrested  by  emptying  the  womb  ? 
In  1827,  M.  Costa  submitted  the  question  to  the  Academie  de  MMecine, 
whether  or  not  it  is  proper  to  bring  on  labor  whenever  the  pregnancy  is  compli- 
cated by  any  disease  that  seriously  threatens  the  mother's  life,  supposing  the 
fcjetus  is  vi'able.  We  think  the  Academie  erred  in  treating  this  proposition  as 
inexpedient ;  for  although  Costa's  question  was  too  general,  and,  doubtless,  ought 
to  have  been  better  matured  before  making  a  final  decision,  yet  restricted  within 
certain  limits,  determined  by  observation,  it  already  has  received  and  will  still 
receive  numerous  applications  in  practice.  For  instance,  an  aggravated  disease 
of  the  heart,  general  serous  infiltration  of  the  tissues,  accompanied  by  effusions 
into  the  great  cavities,  a  threatened  suffocation,  and  the  existence  of  a  large 
aneurismal  tumor,  which  is  liable  to  be  ruptured  from  the  obstruction  to  the 
general  circulation  caused  by  the  developed  uterus,  are  certainly  quite  as  danger- 
ous as  flooding  or  an  attack  of  convulsions;  and  a  premature  delivery  appears 
to  me  advisable,  after  all  the  therapeutical  resources  usually  resorted  to  in  such 
cases  have  been  tried  without  benefit.  It  is  important,  however,  that  a  determi- 
nation of  this  kind  should  be  come  to  very  carefully,  and,  as  often  as  possible, 
after  consulting  with  enlightened  practitioners. 

In  describing  the  disorders  to  which  the  pregnant  condition  exposes  the 
female,  it  was  stated,  that  whenever  they  became  so  serious  as  to  threaten  the 


836  DYSTOCIA. 

life  of  the  patient,  we  thought  that  the  induction  of  premature  labor  was  thereby 
sufficiently  justified.  Thus,  vomiting  wliich  resists  all  therapeutic  measures,  ex- 
treme dropsy  of  the  amnios,  ascites  connected  with  amniotic  dropsy  and  threat- 
ening the  patient  with  suffocation,  and  the  recurrence  of  convulsions  at  short 
intervals  and  with  increasing  severity,  are  all  of  them,  we  have  said,  sufficient 
reasons  for  performing  the  operation. 

But  these  are  not  the  only  cases  in  which  the  operation  has  been  proposed, 
and  we  have  yet  some  other  indications  to  settle. 

1.  Abdominal  Tumors. — In  treating  of  the  various  tumors  that  so  often  com- 
plicate pregnancy  and  parturition,  Dr.  Ashwell  suggests  premature  delivery  as 
the  most  certain  method  of  preventing  those  serious  consequences,  to  which  the 
patient  is  then  exposed  during  the  labor,  or  lying-in.  But  this  opinion,  in  our 
estimation,  is  only  admissible  in  the  following  cases : 

1st.  When  any  voluminous  tumor  whatever  exists  in  the  belly  and  incommodes 
the  enlargement  of  the  womb;  or  is  itself  exposed  to  such  a  compression,  as 
almost  necessarily  to  lead  to  consecutive  inflammation. 

2d.  When  a  tumor  developed  in  the  excavation  is  so  fixed  and  adherent  to  the 
pelvic  walls  that  it  can  neither  be  pushed  above  the  superior  strait  nor  drawn 
down  beyond  the  vulva ;  provided  its  bulk  is  sufficient  to  prevent  the  expulsion 
of  a  fcetus  at  term. 

2.  StiiaUness  of  the  Ahdominal  Cavity. — The  capacity  of  the  abdominal 
cavity  in  some  individuals  of  very  small  stature,  is  so  inconsiderable  as  to  be  in- 
sufficient for  the  normal  development  of  the  uterus,  which  after  attaining  a  cer- 
tain bulk  might  render  the  regular  performance  of  the  great  functions  impossible. 
Thus,  M.  Depaul  mentions  a  case  of  asphyxia  occurring  in  a  rachitic  female  who 
was  aifected  with  a  deformity  of  this  kind.  Hence,  it  is  evident  that  under 
similar  circumstances,  a  premature  delivery  might  and  ought  to  be  thought  of. 
Still,  it  is  rarely  necessary  to  have  recourse  to  the  operation,  for  the  elasticity  of 
the  soft  walls  of  the  abdomen  of  these  individuals,  permits  the  development  of 
the  uterus  to  take  place  outside,  as  it  were,  of  the  abdominal  enclosure ;  and  if 
the  walls  should  prove  too  resisting,  it  is  infinitely  probable  that  in  consequence 
of  its  violent  compression,  the  uterus  would  enter  spontaneously  into  action. 

3.  Nervous  Disorders. — The  nervous  disorders  which  come  on  during  gesta- 
tion, may  sometimes  become  so  serious  as  to  suggest  the  question,  whether  it  be 
not  advisable  to  terminate  the  pregnancy  which  gave  rise  to  them.  M.  Dubois 
was  consulted  in  the  case  of  a  young  lady  in  the  third  month  of  gestation,  who 
had  been  affected  for  six  weeks  with  symptoms  resembling  chorea.  The  spasms 
were  first  limited  to  the  voluntary  muscles,  but  finally  invaded  those  of  organic 
life,  so  that  deglutition  and  speaking  had  become  difficult.  All  the  antispasmo- 
dics had  been  employed  without  success.  M.  Dubois  replied,  that  he  approved 
of  the  means  that  had  been  used,  but  that,  whenever  the  convulsions  invaded 
important  organs,  he  anticipated  the  necessity  of  inducing  premature  labor. 

We  have  in  charge  a  young  lady  who,  when  in  her  ordinary  health,  has,  very 
rarely,  some  short  paroxysms  of  asthma,  and  then  almost  always  in  consequence 
of  an  emotion  or  physical  pain,  but  which  become  much  more  frequent  and  dis- 


INDUCTION    OF    PREMATURE    LABOR.  8-37 

tressing  when  pregnant.  Having  reached  the  fourth  month  of  a  fifth  pregnancy, 
she  has  just  had  a  slight  attack  of  varicella,  preceded  by  sis  da^ys  of  intense 
fever.  During  these  six  days,  the  suffocative  paroxysms  became  so  serious,  that 
MM.  Andral  and  Dubois,  who  were  called  in  consultation,  delivered  the  most 
unfavorable  prognosis.  All  these  symptoms  vanished  upon  the  appearance  of  a 
dozen  very  small  pustules,  only  two  of  which  presented  the  umbilical  depression. 
The  idea  of  premature  delivery  might  certainly  present  itself,  should  such  acci- 
dents reappear  and  continue  at  a  later  period  of  the  gestation ;  but  it  should  not 
be  forgotten  that,  as  ]M.  Laborie  remarks,  too  much  haste  shoiild  not  be  made, 
inasmuch  as  these  nervous  phenomena  often  cease  instantaneously;  and  the 
operation  should  be  carried  into  eifect  only  when  the  condition  of  the  patient 
demands  it  imperiously. 

4.  Intercurrent  Acute  Diseases. — Most  of  the  acute  affections  which  occur 
during  pregnancy,  seem  to  be  affected  unfavorably  by  abortion  and  spontaneous 
delivery.  We  have  already  stated  that  in  cholera,  in  which  the  induction  of 
premature  labor  and  abortion  have  been  recommended  as  a  therapeutic  measure, 
there  was  nothing  to  prove  conclusively  that  the  expulsion  of  the  foetus  was  at- 
tended with  any  favorable  result.  We  think  therefore  that,  as  yet,  it  were  wisest 
to  abstain. 

5.  Death  of  the  Fcetus  in  prcccdinrf  Pregnancies. — There  are  certain  women 
who,  after  reaching  the  eighth  or  ninth  month  of  gestation  without  the  slightest 
disorder,  suddenly  find  the  active  motions  of  the  foetus  to  diminish,  and  the  child 
dies.  This  unfortunate  event  occurs  with  some  again  and  again,  for  several 
consecutive  pregnancies,  so  that  certain  females  have  been  known  to  be  delivered 
thus  prematurely,  and  always  of  a  dead  child,  five  and  six  times  in  succession. 
Denman,  and  several  others,  thought  that  by  bringing  on  labor  before  the  period 
at  which  the  foetus  had  perished  in  the  preceding  pregnancies,  there  would  be  a 
chance  of  obtaining  living  children.  In  two  cases  mentioned  by  the  English 
author,  the  operation  proved  successful.  The  indication  should  not,  therefore, 
be  entirely  rejected.  However,  it  is  well  to  observe  with  M.  P.  Dubois,  that, 
notwithstanding  the  fatal  termination  in  preceding  pregnancies,  there  is  always 
cause  to  hope  for  a  happier  issue  as  respects  the  one  in  charge,  so  that  it  is 
impossible  to  establish  a  general  rule  in  reference  to  the  matter.  It  is  one  of  the 
cases  in  which  the  responsibility  of  the  physician  is  deeply  implicated. 

6.  Finally,  the  induction  of  premature  labor  has  also  been  recommended  in 
cases  in  which  the  foetus  is  dead,  and  in  pregnancies  which  overrun  the  usual 
time.  At  present,  and  especially  in  France,  the  supposed  disorders  attributed  by 
Mai  and  Fodere  to  the  death  of  the  fcetus  in  the  womb,  are  no  longer  believed 
in.  Expectation  is  adopted,  because  it  is  well  known  that  the  mother  incurs  no 
danger,  and  that  nature  will  rid  herself  of  the  dead  foetus  without  requiring  the 
intervention  of  art.    Nor  are  the  dangers  of  the  delayed  pregnancies  less  illusory. 


838  DYSTOCIA. 

ARTICLE   II. 

OPERATIONS   FOR   THE   INDUCTION   OF   PREMATURE   LABOR. 

The  methods  proposed  for  effecting  the  premature  expulsion  of  the  child  are 
quite  numerous ;  though,  with  reference  to  their  mode  of  action,  we  may,  like 
Professor  Stoltz,  divide  them  into  two  classes :  including  in  the  first,  all  those 
which,  by  primarily  influencing  the  general  oi'ganization,  have  the  secondary 
effect  of  exciting  the  uterine  contractions;  and,  in  the  second,  all  those  that 
opeiate  directly  and  mechanically  upon  the  vromb,  for  the  purpose  of  arousing  its 
action. 

The  operation  of  the  means  appertaining  to  the  first  division  is  too  uncertain 
to  be  relied  upon  in  a  case  where  it  is  necessary  to  act  promptly  and  surely ;  and 
although  tepid  bathing,  venesection,  &c.,  have  occasionally  been  followed  by  a 
premature  delivery,  yet  no  one  would  ever  think  of  employing  them  with  this 
view.  Even  the  partisans  of  the  ergot  are  few  in  number;  for  though  its  influ- 
ence in  rendering  the  slow  and  feeble  contractions  of  the  organ  more  energetic  is 
undoubted,  there  is  no  positive  evidence  that  it  is  capable  of  arousing  them 
where  none  have  previously  existed. 

Wherefore,  the  accoucheur  can  only  expect  to  bring  on  the  uterine  contrac- 
tions with  certainty,  by  resorting  to  those  measures  that  act  directly  on  the  womb; 
these  are,  1st.  Frictions  made  over  the  fundus,  and  titillations  of  the  os  uteri; 
2d.  The  detachment  of  the  inferior  segment  of  the  ovum  from  the  uterine  wall; 
3d.  Perforation  of  the  membranes;  4th.  The  introduction  of  a  foreign  body  into 
the  cervix ;   5th.  Plugging  up  the  vagina ;  6th.  Uterine  douches. 

The  repeated  frictions  over  the  anterior  part  of  the  bell}',  and  the  fundus  of 
the  womb,  originally  recommended  by  Professor  D'Outrepont,  to  which  Ritgen 
added  direct  excitation  of  the  os  uteri  by  one  or  more  fingers  introduced  into 
the  vagina,  are  now  general]}-  rejected.  In  truth,  the  irritation  thereby  pro- 
duced is  too  feeble  and  transitory  to  bring  on  a  genuine  labor.  The  same  remark 
applies  to  the  plan  proposed  by  Dr.  Hamilton ;  which  was  to  introduce  the  finger, 
or  a  gum-elastic  catheter,  beyond  the  internal  orifice,  and  push  it  up  as  far  as 
possible  between  the  membranes  and  the  internal  surface  of  the  womb,  so  as  to 
destroy  their  feeble  adhesions.  But,  even  supposing  that  it  were  always  feasible 
to  enter  the  finger,  or  a  sound,  in  this  manner  above  the  internal  orifice,  it  is  not 
at  all  apparent  how  such  a  separation  of  the  lower  part  of  the  ovum  could  prove 
suflacient  to  determine  the  expulsive  pains;  and  it  is  highly  probable  that,  in 
those  cases  where  this  plan  appeared  to  answer,  the  success  was  rather  owing  to 
the  irritation  at  the  neck,  caused  by  the  introduction  of  a  foreign  body,  than  to 
the  detachment  itself. 

Ought  we  to  attribute  any  greater  value  to  the  uterine  injection,  recently  pro- 
posed by  Dr.  Cohen,  of  Hamburg,  for  the  artificial  induction  of  premature  labor? 
Experience  can  alone  determine  the  question.  His  process  is,  however,  .so 
simple,  and,  according  to  the  author,  is  attended  with  such  prompt  effects,  and  is 


INDUCTION     OF    PREMATURE    LABOR.  839 

SO  devoid  of  danger,  that  we  think  it  right  to  notice  it.  He  says,  "  I  perform  the 
injection  as  follows  :  I  use  a  small  syringe,  usually  of  pewter,  containing  from 
two  to  two  and  a  half  ounces  of  tar  water,  and  whose  canula,  from  eight  to  nine 
inches  in  length,  and  about  the  eighth  of  an  inch  in  diameter,  has  a  curvature 
similar  to  that  of  a  female  catheter.  I  lay  the  woman  flat  on  her  back  with  the 
hips  raised,  then,  inserting  two  fingers  up  to  the  posterior  lip  of  the  os  tincce,  I 
use  them  as  a  guide  to  the  canula,  which  I  pass  between  the  anterior  wall  of  the 
uterus  and  the  ovum  to  the  distance  of  two  inches  within  the  uterus.  It  is  then 
only  that  I  commence  the  injection.  I  force  it  gently  and  slowly,  taking  care  to 
raise  the  syringe  a  little  to  avoid  applying  the  opening  against  the  wall  of  the 
uterus,  and  changing  the  direction  of  the  instrument  whenever  any  obstacle  pre- 
sents to  the  passage  of  the  fluid.  The  syringe  is  withdrawn  very  gradually ; 
ten  minutes  afterward,  the  woman  may  rise  and  walk,  and  if  at  the  expiration  of 
six  hours  there  is  no  appearance  of  labor,  the  injection  is  renewed."  .... 
As  M.  Cohen  has  succeeded  once,  and  the  process  is  so  harmless,  it  is  very  desi- 
rable that  he  should  try  again. 

Perforation  of  the  membranes  would  naturally  suggest  itself  as  the  most  cer- 
tain method  of  accomplishing  the  object ;  and  this  was  the  mode  adopted  by 
Macaulay  in  1756,  when  he  first  put  the  recommendation  of  the  most  celebrated 
London  physicians  into  practice.  Most  of  the  accoucheurs  who  have  performed 
this  operation  since  his  day  have  likewise  punctured  the  ovum ;  the  various  modi- 
fications suggested  at  difi"erent  times  merely  refer  to  the  shape,  the  length,  or 
the  curve  of  the  instniment  used,  and  scarcely  merit  a  notice.  For  it  must  be 
evident  that  any  canula  whatever,  that  is  sufficiently  curved  to  correspond  with, 
the  line  of  the  pelvic  axis,  and  is  long  enough  to  reach  the  os  uteri  without  diffi- 
culty (that  is,  about  eight  to  eight  and  a  half  inches),  and  furnished  with  a  trocar, 
having  its  point  concealed  within,  or  only  projecting  a  few  lines  beyond  the  end 
of  the  canula,  will  be  all  that  is  requisite.  The  only  precautions  to  be  observed, 
consist  in  guiding  the  instrument  along  in  such  a  way  as  not  to  Injure  the 
mother's  parts,  and  so  as  not  to  wound  the  foetus  by  the  point  of  the  trocar. 

As  elsewhere  stated,  this  is  the  most  certain  plan,  because  a  discharge  of  the 
waters  necessarily  occasions  a  retraction  of  the  uterine  walls,  and  sooner  or  later 
a  manifestation  of  the  pains;  we  may  further  add,  that  it  is  quite  as  easily  accom- 
plished, and  is  less  painful  to  the  mother  than  those  about  to  be  described ;  but 
we  must  acknowledge  that  the  child's  existence  is  much  more  endangered,  because 
a  partial  or  even  a  total  escape  of  the  amniotic  liquid  is  not  always  followed  at 
once  by  the  occurrence  of  the  first  pains. 

Sometimes  forty  or  even  sixty  hours  elapse  before  the  uterus,  irritated  by  the 
prolonged  contact  of  the  foetal  inequalities,  begins  to  contract ;  and  even  when 
the  labor  has  actually  commenced,  the  dilatation  of  the  os  uteri  progresses  very 
slowly,  for  at  the  seventh  or  eighth  month  the  fibres  in  the  neck  have  not  as  yet 
undergone  those  modifications  which,  at  the  ordinary  term  of  gestation,  render 
the  dilatation  easy;  and  thus  a  further  period  of  twenty-four  or  thirty-six  hours 
often  passes  away  before  the  os  uteri  is  sufficiently  dilated.  Now,  during  all  this 
time,  the  foetus,  being  no  longer  protected  by  the  amniutic  liquid,  is  subjected  to 


840  DYSTOCIA. 

tlie  direct  pressure  of  tlio  contracted  uterine  walls;  the  umbilical  cord  miditvery 
easily  be  involved,  and,  from  its  compression,  an  interruption  of  the  circulatory 
relations,  which  are  indispensable  to  the  support  of  the  child's  life,  would  inevi- 
tably result ;  besides  which,  the  placenta  itself  might  be  partially  detached  in 
consequence  of  the  retraction  of  the  wouib. 

Many  accoucheurs,  influenced  by  these  palpable  dangers,  had  altogether  re- 
,jected  the  perforation  of  the  membranes,  when  a  modification  was  proposed  by 
Meissner,  of  Leipsic,  which,  fortunately,  prevents  the  accidents  just  indicated, 
and,  therefore,  merits  a  further  investigation  into  the  propriety  of  puncturing 
the  ovum.  Various  plans  were  suggested  for  moderating,  as  it  were,  the  dis- 
charge of  the  amniotic  liquid,  and  of  only  permitting  the  escape  of  a  sufficient 
quantity  of  it  to  secure  the  induction  of  the  pains;  but  no  one  had  hitherto  suc- 
ceeded in  accomplishing  what  Meissner  has  so  happily  effected.  His  process  is 
as  follows : 

Instead  of  puncturing  the  bag  of  waters  at  its  lowest  part,  he  perforates  it  high 
up  close  to  the  fundus  of  the  womb,  by  using  an  instrument  consisting  of  a  canula 
and  two  stilets.  The  canula,  which  is  made  of  silver,  is  nearly  thirteen  inches 
long,  and  about  two  lines  in  diameter;  and  it  is  curved  so  as  to  correspond  to  a 
segment  of  a  circle  which  has  a  radius  of  eight  inches.  A  ring  is  attached  to  it, 
near  the  lower  extremity  on  the  eoaves  side,  by  which  the  instrument  is  managed, 
and  which  serves  to  indicate  the  direction  of  the  curvature  after  the  introduction. 
The  two  stilets  (one  being  terminated  above  by  an  olive-shaped  button,  and  the 
other  by  a  trocar)  are  adapted  to  the  canula;  their  lower  end  is  flattened  out  so 
as  to  keep  them  from  slipping  in  too  far;  the  olive-shaped  extremity  of  the  first 
stilet  ought  not  to  project  more  than  two  or  three  lines  beyond  the  canula;  but 
the  trocar  point  of  the  second  should  advance  at  least  half  an  inch.  The  first 
stilet  is  intended  to  ftxcilitate  the  introduction  of  the  canula,  and  the  second  to 
make  the  puncture. 

M.  Meissner  performs  the  operation  in  the  following  manner :  The  patient  is 
placed  in  an  erect  posture,  and  the  operator,  stooping  down  on  one  knee  before 
her,  first  ascertains  the  exact  position  of  the  cervix ;  if  this  is  high  up,  and  at 
the  same  time  is  directed  so  far  backwards  as  scarcely  to  be  reached,  the  patient 
will  have  to  sit  down  on  the  edge  of  a  chair,  or  else  lie  on  a  settee.  The  accou- 
cheur then  introduces  the  canula  armed  with  the  blunt  stilet,  along  the  palmar 
surface  of  the  index  finger  into  the  cavity  of  the  cervix,  and  presses  it  on  until 
it  has  passed  the  internal  orifice;  of  course,  always  having  the  convexity  of  the 
instrument  directed  towards  the  hollow  of  the  sacrum.  When  the  point  of  the 
canula  has  once  got  beyond  the  internal  orifice,  it  is  easily  slipped  up  between 
the  membranes  and  the  uterine  walls,  to  the  extent  of  eight  or  ten  inches  above 
the  OS  uteri.  After  having  ascertained  that  the  point  of  the  instrument  does  not 
rest  on  any  portion  of  the  foetus,  the  accoucheur  withdraws  the  olive-shaped 
stilet,  and  substitutes  the  trocar,  with  which  he  then  punctures  the  membranes. 
The  trocar  is  next  withdrawn,  a  small  quantity  of  liquid  is  allowed  to  escape 
through  the  canula,  and  then  the  latter  itself  is  removed.  After  the  ope- 
ration is  over,  the  woman  may  be  permitted  to  sit  down  or  walk  about  at  plea- 


INDUCTION     OF    PREMATURE    LABOR.  841 

sure.  The  waters  gradually  escape,  thus  lubricating  and  preparing  the  passages, 
and  the  pains  make  their  appearance  in  the  course  of  twent3--four  or  forty-eight 
hours;  and,  in  most  cases,  the  dilatation  is  soon  effected,  the  contractions  are 
strong,  and  the  labor  is  completed  in  thirty-six  or  forty-eight  hours.  When  the 
labor  docs  not  advance  regularly,  and  the  resistance  from  the  contracted  pelvis  is 
very  considerable,  M.  Meissner  resorts  to  the  measures  usually  employed  under 
similar  circumstances  at  term. 

He  has  tried  this  mode  of  operating  fourteen  times,  and  he  avers  that  both 
mother  and  child  were  saved  in  every  instance ;  such  a  result,  as  compared  with 
those  obtained  by  other  plans,  certainly  demands  attention,  and  must  encourage 
other  practitioners  to  attempt  it.  Let  us  hope  that  the  principals  of  large  lying- 
in  hospitals  will  shortly  confirm,  by  fresh  success,  the  favorable  accounts  given 
by  Meissner. 

The  introduction  of  Meissner's  canula  is  liable  to  occasion  a  partial  sepai'ation 
of  the  placenta,  and  consequently  endangers  the  lesion  of  some  of  its  vessels. 
This,  indeed,  happened  in  a  case  observed  by  Kivisch,  of  Wurzbourg  :  the 
canula  would  ascend  no  higher  than  five  inches,  and  after  the  punctui'e,  nothing 
escaped  but  a  little  blood  and  serum.  Not  having  obtained  a  discharge  of  water, 
it  was  decided  two  hours  afterwards  to  puncture  the  ovum  in  the  usual  way.  .  . 
"Why  not  have  directed  the  canula  toward  another  point  ? 

Dismayed  by  the  dangers  to  which  the  child  is  exposed  by  the  old  plan  of 
tapping  the  membranes,  many  obstetricians  have  suggested  an  induction  of  the 
uterine  contractions,  by  introducing  a  foreign  body  into  the  neck  of  the  womb, 
which  is  designed  to  act  both  as  an  irritant  and  as  a  mechanical  dilator.  Kluge 
may  be  considered  as  the  author  of  this  method  of  dilatation,  and  his  process  is 
the  one  still  genei'ally  preferred.  xVs  well  known,  this  is  performed  by  intro- 
ducing a  conical  piece  of  prepared  sponge  into  the  cervix  uteri,  and  keeping  it 
there  by  plugging  up  the  vagina,  until  the  pains  are  fully  developed.  The  mode 
of  operating  is  as  follows  : 

After  having  obtained  the  patient's  consent,  and,  whenever  possible,  the  ad- 
vice of  some  professional  brethren,  the  accoucheur  has  the  woman  prepared,  by 
directing  her  to  use  warm  emollient  and  narcotic  injections  into  the  vagina,  for 
a  few  days  previous  to  the  operation ;  before  commencing,  the  bladder  and  rec- 
tum are  to  be  emptied,  and  a  fresh  examination  is  to  be  made  for  the  purpose  of 
ascertaining  the  degree  of  the  pelvic  contraction,  as  well  as  the  child's  position. 

The  female  being  placed  in  nearly  the  same  position  as  if  the  forceps  were  to 
be  applied,  the  operator  first  draws  the  cervix  towards  the  median  line,  whenever 
it  is  found  deviated ;  or,  he  might  endeavor  to  get  the  neck  within  its  uterine 
extremity,  by  introducing  the  speculum  (Dubois).  But  this  is  not  always  prac- 
ticable, especially  if  the  part  be  directed  a  little  forward  ;  in  general,  the  finger 
answers  every  purpose  as  a  conductor ;  then  a  conical  plug  of  prepared  sponge, 
about  two  inches  long,  and  half  an  inch  in  diameter  at  its  base,  and  having  a 
piece  of  tape  ten  inches  long  attached  to  it,  is  held  by  its  large  extremity,  in  a 
pair  of  long  curved  forceps,  and  is  carried  up  towards  the  uterine  orifice  where  it 
is  gradually  made  to  enter.     After  holding  it  there  for  five  or  six  minutes,  the 


842 


DYSTOCIA. 


forceps  and  speculum  (if  used)  are  withdrawn,  and  the  vagina  is  next  filled  up 
with  a  large  sponge,  or  bits  of  charpie,  so  as  to  keep  the  first  sponge  in  its  place ; 
the  whole  is  to  be  retained  by  a  proper  bandage,  and  the  patient  replaced  in  bed. 
The  mode  in  which  the  foreign  body  acts  here,  is  obvious ;  the  prepared  sjwnge, 

becoming  saturated  with  the 
^'3-  122.  fluids   from   the  neighboring 

parts,  swells  up,  and  irritates 
the  cervix  by  its  bulk;  this 
determines  a  dilatation  of  the 
latter  and  the  irritation  thus 
caused,  by  reacting  on  the 
fibres  of  the  uterus,  often 
brings  on  the  contractions  in 
five  or  six  hours.  Should  it 
happen  that  the  pains  are  not 
fully  established,  or  the  dila- 
tation of  the  OS  uteri  is  not 
completed  in  the  course  of 
twenty  four  hours,  the  opera- 
tion ought  to  be  performed 
again,  taking  care  this  time 
to  introduce  a  larger  piece  of 
sponge  (the  first  having  been 
extracted  by  the  tape) ;  this 
second  operation  is  nearly  always  successful.  If,  however,  the  labor  pains  be 
still  too  slow  and  feeble,  local  irritants,  such  as  frictions  over  the  abdomen,  and 
titillations  of  the  cervix,  or  still  better,  the  general  stimulants,  the  ergot  par- 
ticularly, might  be  resorted  to. 

This  process,  which  has  now  come  into  general  use,  has  the  great  advantage 
of  retaining  the  amniotic  liquid  nearly  as  long  as  in  natural  labor  at  term ;  its 
results,  however,  are  far  from  being  so  satisfactory  as  those  obtained  by  M.  Meiss- 
ner's  plan,  which  certainly  constitutes  a  sufiicient  reason  for  not  persisting  in  its 
employment,  in  all  cases,  and  for  giving. a  trial  to  the  modification  proposed  by 
the  Leipsic  accoucheur. 

The  necessity  of  plugging  the  vagina,  and  keeping  the  tampon  applied  for  two 
or  three  days,  and  sometimes  even  longer,  occasions  great  suffering  to  the  woman. 
From  having  witnessed  this  suffering,  I  had  an  instrument  constructed,  in  1845, 
by  means  of  which  the  prepared  sponge  is  kept  in  its  place  within  the  cervix. 
It  is  composed:  1.  Of  a  hypogastric  belt,  to  the  middle  and  front  part  of  which 
is  secured  a  metallic  stem  eight  inches  long,  and  curved  at  its  free  extremity, 
which  carries  a  canula  one  and  a  half  inches  in  length  :  2.  Of  a  stem  of  whale- 
bone, six  or  seven  inches  long,  and  about  a  quarter  of  an  inch  in  diameter,  bear- 
ing at  its  extremity  a  forceps  with  claws  capable  of  being  closed  at  will,  by  means 
of  a  sliding  ring,  like  those  of  a  porte-crayon.  The  prepared  sponge  is  first  fixed 
in  the  forceps,  and  then  introduced  as  usual  within  the  cervix  :  the  whalebone 
stem  is  next  introduced  into  the  canula  and  held  fast  by  the  pressure  of  a  screw. 


Kluge's  melliod  of  dilatini'  the  os  uteri. 


INDUCTION     OF    PREMATURE    LABOR.  843 

In  this  v^VLj,  the  use  of  the  tampon,  -svhich  is  always  painful,  is  ayoided ;  the 
sponge  cannot  be  displaced  and  escape  from  the  cervix,  as  often  happens  in 
Kluge's  process,  nor  are  the  functions  of  the  bladder  and  rectum  in  any  degree 
interfered  with.  The  patient  is  not  condemned  to  the  absolute  repose  usually 
directed,  but  can  move  in  bed  without  inconvenience.  I  therefore  regard  it  as 
a  plan  which  does  away  with  most  of  the  inconvcniencies  justly  complained  of  in 
the  performance  of  the  operation. 

Quite  recently.  Dr.  Schoellcr,  of  Berlin,  has  suggested  a  measure  which  is 
new  as  to  its  proposed  object,  though  one  of  long  standing  in  obstetrical  science. 
Every  practitioner  is  aware  of  the  principal  objection  to  the  use  of  the  tampon, 
so  highly  extolled  by  Leroux,  of  Dijon,  as  a  remedy  for  uterine  hemorrhage  ;  now 
jM.  Schoeller  has  conceived  the  idea  of  employing  the  irritation  it  produces  as  a 
means  for  the  induction  of  premature  delivery;  for  it  is  well  known  that  its 
application  is  most  generally  followed  by  uterine  contractions.  He  first  made 
use  of  it  in  1839,  and  was  entirely  successful ;  since  that  time  he  has  performed 
five  similar  operations,  and  the  child  was  born  living  in  four  of  them.  The  mode 
of  operating,  according  to  Stoltz's  translation,  is  as  follows  (^Gaz.  Med.  dc  Sfras- 
houiy,  Jan.  1843)  : 

Before  commencing,  the  bladder  and  rectum  are  to  be  emptied ;  then  sevei-al 
little  rolls  of  charpie,  steeped  in  oil,  or  smeared  with  cerate,  are  successively 
pushed  towards  the  upper  part  of  the  vagina,  the  first  of  them  having  a  piece  of 
tape  attached,  to  facilitate  its  subsequent  extraction.  Prepared  sponge  might 
be  used  for  the  same  purpose,  but  it  would  then  be  requisite  to  retain  it  in  sitd 
by  another  common  sponge.  It  is  not  necessary  to  fill  the  whole  vagina ;  in  fact, 
this  would  be  attended  with  some  inconvenience,  for  the  excretion  of  the  urine 
and  fecal  matters  would  be  thereby  impeded.  It  is  advisable  to  introduce  the 
tampon  in  the  evening,  when  the  patient  is  recumbent,  because  she  will  be  more 
likely  to  remain  quiet  during  the  early  periods  of  its  operation. 

The  efifects  of  this  measure  are  shortly  manifested  by  pains  in  the  abdomen 
and  loins,  and  by  a  feeling  of  tension  in  the  womb  itself;  repeated  frictions  are 
then  made  over  the  fundus  uteri,  with  a  view  of  aiding  its  operation.  As  the 
tampon  soon  becomes  saturated  with  the  mucus  from  the  vagina,  and  exhales  a 
disagreeable  odor,  it  ought  to  be  renewed  at  least  once  in  the  course  of  the  da}-, 
or  even  twice,  if  the  sensibility  of  the  parts  permits ;  but,  before  introducing  the 
second  one,  the  vagina  is  washed  out  by  an  injection.  As  soon  as  the  tampon 
has  roused  the  uterine  contractility,  and  the  orifice  dilates,  it  may  be  withdrawn  ; 
though,  should  the  labor  be  lingering,  and  the  contractions  become  slow  and 
feeble,  it  must  be  reapplied,  and  ten  grains  of  the  secale  cornutum  be  admi- 
nistered by  the  mouth  every  half  hour.  The  pains  may  also  be  restored  by 
dilating  the  orifice  with  the  index  finger,  carefully  avoiding  a  rupture  of  the 
membranes,  until  the  dilatation  is  nearly  completed. 

The  number  of  instances  in  which  Schoeller's  process  has  been  tried,  is  as  yet 
too  limited  to  warrant  us  in  recommending  it  for  general  adoption.  But  the 
perusal  of  his  cases  has  induced  us  to  believe  that  the  tampon  will  not  always 
succeed;  and  at  least,  has  convinced  us  of  the  slowness  of  its  operation.     For 


844:  DYSTOCIA. 

instance,  in  one  of  tlie  five  cases  reported,  it  was  first  applied  on  the  23d  of 
November,  and  the  delivery  did  not  take  place  until  the  '29th;  in  another,  it 
was  introduced  on  the  27th  of  January,  and  the  labor  was  accomplished  on  the 
6th  of  February.  The  process  must  be  a  very  painful  one,  besides  which,  as  M. 
Stoltz  observes,  the  abortive  action  of  the  tampon  has  only  been  noticed  in  those 
cases  where  the  labor  had  already  commenced,  or  where  some  marked  disorder 
in  the  functions  of  the  womb  had  occurred ;  but  there  is  a  vast  diflPcrence  be- 
tween these  latter  and  that  of  a  woman  in  whom  the  uterine  contractility  still  lies 
dormant. 

Lastly,  there  is  a  still  more  recent  process  possessing  undoubted  advantages 
over  all  the  others,  namely,  that  which  consists  in  directing  a  stream  of  warm 
water  upon  the  neck  of  the  uterus.  The  honor  of  introducing  it  into  obstetrical 
practice  is  due  to  Professor  Kiwiseh.  His  apparatus  was  a  simple  tin  box,  pro- 
vided with  a  long  tube  furnished  with  a  stopcock.  The  extremity  of  the  tube 
is  introduced  by  the  vagina  to  the  neck  of  the  uterus.  The  temperature  of  the 
water  should  be  about  7G°  or  78°  of  Fahrenheit,  and  the  jet  should  be  large 
and  powerful.  The  injections  should  last  from  10  to  15  minutes  without  inter- 
ruption. 

Instead  of  Kiwisch's  apparatus,  M.  P.  Dubois  uses  Dr.  Eguisier's  instrument 
for  irrigation  and  steady  injection.  The  latter  containing  six  quarts  of  fluid,  is 
sufficient  for  a  douche  of  a  quarter  of  an  hour  in  duration,  and  there  is  no  occa- 
sion to  renew  the  water  as  in  Kiwisch's  contrivance.  Besides,  thei'e  is  no  neces- 
sity for  its  being  very  elevated  like  the  other,  which  renders  it  much  more  con- 
venient to  manipulate.  I  made  use  of  Eguisier's  pump  in  the  three  cases  in 
which  I  employed  the  uterine  douches.  Unfortunately,  it  is  quite  expensive, 
and  not  readily  procured  out  of  the  city.  Therefore,  it  is  well  to  remember  that 
any  vessel,  capable  of  containing  eight  or  ten  quarts  of  water,  placed  at  an  eleva- 
tion of  seven  or  eight  feet,  and  provided  with  a  flexible  tube  of  sufficient  length, 
will  serve  the  same  purpose.  The  tube  is  furnished  with  a  stopcock  about  a  foot 
from  its  free  extremity.  To  this  extremity  is  adapted  a  gum-elastic  canula  with 
a  single  orifice  the  sixteenth  of  an  inch  in  diameter.  The  power  of  the  jet  may 
be  increased  or  diminished  at  will  by  varying  the  calibre  of  the  canula. 

The  woman's  seat  is  brought  to  the  edge  of  the  bed,  which  is  previously  covered 
with  oil  cloth,  so  that  the  water  may  fall  into  the  vessel  placed  between  the  legs 
without  wetting  the  clothes  or  the  bed.  The  forefinger  of  the  left  hand  is  in- 
troduced to  the  cervix  for  the  purpose  of  guiding  the  canula  which  the  accou- 
cheur holds  in  the  right  hand. 

In  ordinary  cases,  three  or  four  injections  a  day  are  sufficient,  though,  if  the 
case  were  urgent,  they  should  be  repeated  more  frequently. 

The  number  of  douches  required,  varies  greatly.  Sometimes,  the  contractions 
appear  upon  the  third  or  fourth  application ;  in  one  of  my  own  eases,  the  first 
pains  were  perceived  after  the  second  douche,  though  generally,  a  much  greater 
number  are  required.  In  the  ten  observations  of  Kiwiseh,  he  was  obliged  to 
repeat  them  four  times  at  the  least,  and  eighteen  times  at  the  most ;  the  mean 
for  the  ten  cases  beins;  ten  douches. 


INDUCTION    OF    PREMATURE    LABOR.  845 

The  mean  length  of  time  between  the  commencenient  of  the  operation  and  tlie 
moment  of  delivery,  was  about  three  days  and  a  half.  In  one  case,  but  twenty- 
four  hours  elapsed,  whilst  in  two  others,  it  was  delayed  seven  days. 

We  thus  see  that  in  this  respect,  the  cases  differ  greatly,  though  the  same 
variations  are  observed  in  all  the  other  processes.  Still,  as  that  of  Kiwisch  is 
not  painful  to  the  woman,  nor  of  itself  exposes  the  foetus  to  any  danger,  I  accord 
it  the  preference.  There  can  be  no  doubt  as  to  its  possessing  the  following 
advantages  claimed  for  it  by  its  author  : 

1.  The  uterine  douche,  prepares  the  way  for  the  act  of  premature  delivery  in 
the  best  manner  possible,  by  effecting  the  softening  and  necessary  dilatation  of 
the  inferior  segment  of  the  uterus. 

2.  It  requires  no  preparatory  treatment. 

3.  It  is  easily  employed,  and  is  not  disagreeable  to  the  patients,  inasmucli  as 
the  injection  of  warm  water  occasions  no  uncomfortable  sensations. 

4.  It  occupies  but  a  short  time. 

5.  Its  action  can  be  regulated  at  will  by  the  accoucheur,  who  may  increase  or 
diminish,  according  to  circumstances,  the  strength  of  the  jet  and  the  temperature 
of  the  water,  or  change  the  point  of  the  uterine  neck  or  inferior  segment  of  the 
womb  upon  which  it  is  directed. 

6.  It  can  never  injure  either  the  genital  organs,  the  membranes  of  the  ovum, 
or  the  foetus;  besides,  it  imitates  nature  chiefly  in  this,  that  it  hastens  the  prepa- 
ration of  the  genital  passages  by  occasioning  an  atllux  thither  of  a  greater  amount 
of  fluid. 

The  use  of  uterine  injections  was  not  restricted  by  Kiwisch  to  the  induction  of 
premature  labor.  He  also  recommends  them  as  a  means  of  increasing  the  energy 
of  the  contractions  in  cases  of  inertia  of  the  uterus,  and  of  making  them  regular 
when  spasmodic  or  irregular.  He  asserts  having  used  them  with  advantage  in 
a  case  of  spasmodic  contraction  of  the  cervix.  I  have  not  had  occasion  to  test 
the  value  of  tliese  last  assertions;  but  M.  Campbell  states  that  M.  Dubois 
restored  the  contractions  by  douches,  in  a  case  of  inertia,  or,  rather,  of  extreme 
sluggishness  of  the  womb.  It  is,  therefore,  a  means  which  should  not  be  ne- 
glected in  cases  of  the  kind,  especially  if  there  should  be  any  difiiculty  in  regard 
to  the  use  of  ergot. 

I  have  also  used  the  douches  with  the  object  of  procuring  the  expulsion  of  a 
placenta  which  was  retained  for  several  days  after  the  expulsion  of  the  foetus, 
and  whose  presence  within  the  uterus  kept  up  a  hemorrhage,  which  was  a  source 
of  uneasiness.  The  miscarriage  had  taken  place  at  the  end  of  the  fourth  month. 
Although  the  happy  effect  of  the  douche  was  not  rigorously  demonstrated,  I  am 
convinced  that  it  was  useful,  and  would  advise  it  to  be  used  in  a  similar  case. 

Until  of  latter  time,  I  had  practised  exclusively  the  method  of  Kluge;  giving 
preference  to  the  prepared  sponge,  kept  within  the  cervix  by  means  of  a  little 
instrument  hitherto  described,  whenever  I  had  occasion  to  bring  on  premature 
labor;  but  for  two  years  past  I  have  found  such  great  advantage  in  the  use  of 
Kiwisch's  injections,  that  I  do  not  hesitate  to  recommend  them  almost  exclu- 
sively, and  am  persuaded  that  ere  long  they  will  be  generally  adopted. 


846  DYSTOCIA. 


"Whatever  may  be  the  process  employed,  when  once  the  pains  become  quite 
regular,  the  remainder  of  the  labor  presents  nothing  peculiar.  Whatever  may 
be  said  to  the  contrary,  the  delivery  of  the  after-birth  is  not  more  difficult  than 
usual.  Children  born  before  term,  being  on  that  account  more  feeble,  require 
much  greater  care.  They  should  be  enveloped  in  warm  wadding,  and  for  the 
first  days  especially,  their  nourishment  should  be  less  substantial. 


CHAPTER  V. 

PllODUCTION    OF   ABORTION. 

The  premature  artificial  delivery,  requires,  as  just  seen,  certain  dimensions  in 
the  diameters  of  the  pelvis ;  but  when  the  contraction  is  so  great  that  the 
smallest  diameter  is  less  than  two  inches  and  a  half,  a  question  of  the  highest 
interest  presents  itself,  namely,  that  of  the  production  of  abortion. 

"When  a  woman,  three  to  four  months  pregnant,  has  so  contracted  a  pelvis  as 
to  preclude  all  hope  of  a  possible  expulsion  or  extraction  of  a  viable  foetus,  may 
we  think  of  inducing  abortion?  This  question,  put  to  Dr.  Hunter,  in  1768,  by 
W.  Cooper,  was  shortly  afterward  decided  in  the  affirmative  by  most  English 
practitioners.  The  propriety  of  the  operation  was  also  acknowledged  in  France 
by  Fodere  (1813),  Marc  (1821),  Velpeau  (1829),  and  by  ourselves  (in  1840), 
in  the  first  edition  of  this  work.  In  1843,  M.  P.  Dubois  published  an  article  in 
the  Gazette  Medicah, — an  article  which  foreshadowed  his  opinion,  although  it 
did  not  positively  express  it.  About  the  same  time,  M.  Simonard,  of  Brussels, 
published  a  dissertation,  in  which,  after  showing  the  morality  of  the  operation, 
lie  points  out  the  indications.  Finally,  MM.  Stoltz,  Jacquemier,  and  Chailly, 
have  adopted  the  views  of  the  English  accoucheurs. 

Too  many  imposing  authorities  have  pronounced  in  f;\vor  of  producing  abor- 
tion to  make  it  necessary  for  us  to  stop  in  order  to  discuss  the  moral,  religious, 
and  medico-legal  questions  which  this  operation  has  raised.'  Like  premature 
delivery,  it  is  now  received  as  an  obstetrical  operation,  and  it  only  remains  for  us 
to  determine  the  indications,  and  the  most  expeditious  and  least  dangerous 
means  of  accomplishing  the  object. 

1.  The  extreme  contractions  of  the  pelvis,  those  which  affi)rd  the  woman  at 
the  term  of  her  gestation  only  the  sad  choice  between  embryotomy  and  the  Caesa- 
rean  operation,  and  for  a  still  stronger  reason,  those  which,  by  affijrding  less  than 
two  inches  to  two  inches  and  a  half,  allow  of  the  extraction  of  a  dead  or  living 
foetus  only  by  incision  of  the  abdomen,  constitute  the  most  positive  indication  for 
producing  abortion.  If,  indeed,  as  we  shall  endeavor  to  prove  in  the  following 
chapters^  the  sacrifice  of  the  child  is  fully  justifiable  when  the  choice  only  lies 

"  For  further  details,  see  M.  Cazeaux's  report  to  the  Academy  of  Medicine,  and  the  dis- 
cussion which  followed  it.     [Bulletin  de  V Academic  et  I'Union  Medicale,  1852.) 


PRODUCTION    OF    ABORTION.  847 

between  hysterotomy  and  embryotomy,  tliis  sacrifice  would  be  still  more  rational 
at  a  period  of  gestation  in  which  the  operations  necessary  to  the  production  of 
aboi'tion  are  much  less  dangerous  than  those  whicli  the  mutilation  and  extrac- 
tion of  a  fostus  at  term  would  require.  For  our  own  part,  therefore,  we  think 
that  the  accoucheur  is  warranted  in  producing  abortion,  whenever  a  woman,  who 
is  five  or  six  months  pregnant  at  the  most,  shall  have  less  than  two  and  a  half 
inches  in  the  smallest  diameter  of  the  pelvis. 

2.  Contractions  of  the  pelvis  are  not  the  only  cases  in  which  it  has  been  pro- 
posed to  produce  abortion.  A  host  of  accidents  connected  with  the  pregnant 
condition,  and  a  multitude  of  coexisting  morbid  phenomena,  all  becoming  very 
dangerous  to  the  mother  in  consequence  of  this  coincidence,  have  appeared  to 
some  physicians  to  be  quite  as  rigorous  indications  as  the  pelvic  contractions. 
"We  cannot  partake  of  this  view,  at  least  as  respects  the  majority  of  cases.  The 
precepts  laid  down  by  us  in  treating  of  premature  deliver!/,  require  to  be  greatly 
modified  when  abortion  is  concerned.  In  a  grave  case,  indeed,  but  one  in  whicli 
tho  issue  is  on\y  j^roLuhl^  unfavorable,  we  may  conclude  to  induce  labor  after  the 
seventh  month  :  the  danger  to  which  the  mother  is  prohahJy  exposed  certainly 
legitimizes  an  operation  which,  afibrds  considerable  chance  of  saving  the  child's 
life.  The  same  is  by  no  means  the  case  as  respects  the  production  of  abortion ; 
here  it  is  no  longer  sufficient  that  the  mother's  life  is  prohalilij  compromised,  it 
should  be  almost  certain  that  death  is  imminent.  Under  this  head,  hemorrhages 
that  have  resisted  all  kinds  of  treatment,  irreducible  displacements  of  the  womb, 
extreme  dropsy  of  the  amnion,  tumors  of  the  soft  parts  which  cannot  be  dis- 
placed, punctured,  incised,  or  extirpated,  seem  to  me  to  be  the  only  admissible 
indications  for  the  production  of  abortion.  The  reasoning  by  which  we  endea- 
vored (page  265,  et  srq.)  to  oppose  the  provocation  of  abortion  in  cases  of  obsti- 
nate vomiting,  appear  to  me  to  be  entirely  sound  as  applied  to  serious  nervous 
disorders,  and  chronic  or  acute  diseases  complicating  gestation.  As  rocards 
eclampsia,  it  is  rare  in  the  first  half  of  pregnancy,  and  the  slowness  w^ith  which 
the  abortive  measures  act  at  a  very  early  period,  seem  to  me  to  be  a  formal  contra- 
indication. 

To  recapitulate,  extreme  contractions  of  the  pelvis,  voluminous,  immovable, 
and  non-operable  tumors  of  the  excavation,  extreme  dropsy  of  the  amnion,  irre- 
ducible displacements  of  the  womb,  and  hemorrhages  which  have  resisted  the 
employment  of  the  most  rational  measures,  we  consider  to  be  the  only  indications 
for  abortion.  Some  authors  have  admitted  a  greater  number,  but  only  for  want 
of  distinguishing  clearly  between  abortion  and  premature  labor. 

The  only  contraindication  is  the  formal  refusal  of  the  mother;  for  with  her 
alone,  after  all,  remains  the  right  to  decide  the  question. 

Whilst  respecting  the  scruples  of  certain  minds  as  respects  a  deformed  woman 
upon  whom  abortion  has  been  once  practised,  I  confess  that  it  would  not  deter 
me  for  an  instant  in  a  succeeding  pregnancy.  "We  have  no  right  to  constitute 
ourselves  judges  of  the  morality  and  of  the  antecedents  of  the  patient  who  de- 
mands our  assistance.  Even  supposing  that  we  have  to  do  with  one  of  those 
unfortunate  creatures  who  will  trample  under  foot  the  most  sacred  feelings,  and 


848  DYSTOCIA. 

give  way  all  the  more  to  their  passions,  because  they  think  they  can  find  impu- 
nity for  their  bad  conduct  in  the  humanity  of  the  surgeon,  we  owe  her  none  the 
less  our  care;  for  us,  the  only  question  to  resolve  in  the  second,  or  third,  as  in 
the  first  pregnancy,  is,  whether  the  conformation  of  that  woman  allows  us  to  hope 
for  the  extraction  of  a  viable  child. 

It,  therefore,  only  remains  for  us  to  determine  the  period  at  which  it  is  proper 
to  operate,  and  the  most  advantageous  methods. 

None  but  the  contractions  or  obstructions  of  the  pelvis,  permit  the  accoucheur 
to  choose  the  most  favorable  moment,  and  then,  the  only  precaution  to  be  ob- 
served, is  to  wait  until  the  pregnancy  can  be  certainly  determined,  that  is  to 
say,  between  the  fourth  and  fifth  months.  In  all  other  cases,  it  is  necessary  to 
act  as  soon  as  the  gravity  of  the  accidents  have  left  no  other  alternative. 

j\Jodes  of  Operating. — In  the  first  half  of  gestation,  the  womb  is  far  from 
having  acquired  the  muscular  properties  which  it  possesses  in  so  high  a  degree 
at  a  later  period;  its  contractility  is  very  feeble,  and  the  irritability  also  is  much 
less  acute  than  towards  the  ninth  month.  Therefore,  most  of  the  external  or 
internal  excitants,  by  whose  assistance  premature  labor  can  be  induced,  would 
probably  have  no  effect  within  the  first  four  or  five  months  of  gestation.  Even 
electricity,  which  several  physicians  have  employed  successfully  in  cases  of 
inertia  during  or  after  labor,  appears  to  have  been  ineffectual  whenever  it  was 
attempted  to  excite  contractions  which  had  no  previous  existence.'  I  therefore 
think,  that  whenever  it  is  desired  to  produce  abortion,  the  use  of  ergot,  frictions 
upon  the  abdomen,  frequent  excitation  of  the  cervix,  and  even  the  separation  of 
the  inferior  segment  of  the  membranes,-  should  be  set  aside,  and  that  the  choice 

'  Electricity,  proposed  by  several  physicians  as  a  means  of  producing  premature  labor, 
but  hitberto  without  success,  was  employed  by  M.  Dubois  in  the  case  of  a  rachitic  woman 
three  months  and  a  half  gone  in  her  second  pregnancy.  The  electric  shocks  were  not,  per- 
haps, continued  long  enough  on  account  of  the  indociliiy  of  the  patient,  still,  tlie  result  was, 
that  he  was  obliged  to  relinquish  the  attempt  after  two  trials,  without  having  obtained  a 
single  contraction. 

The  professor  made  use  of  the  ingenious  machine  of  the  Lebreton  brothers ;  the  two  con- 
ducting plates  were  applied  on  the  fundus  of  the  uterus,  depressing  at  the  same  time  the 
anterior  wall  of  the  abdomen,  and  then  the  machine  was  put  in  action.  The  patient  imme- 
diately experienced  violent  shocks  in  the  hypogastric  region,  and  the  pain  was  so  severe  that 
she  refused  to  submit  to  the  operation.  It  was  with  great  dilhculty  that  she  could  be  pre- 
vailed upon  to  make  another  trial  after  an  interval  of  a  few  days,  and  then  it  was  relin- 
quished. The  pregnancy  was  not  in  the  least  affected  by  these  attempts,  and  the  uterus 
continued  to  increase  in  size. 

The  uselessness  of  efTcrts  made  to  bring  on  premature  labor  by  means  of  electricity, 
rendered  its  efficiency  very  doubtful  as  applied  to  the  production  of  abortion;  for,  as  we 
have  already  said,  the  muscular  organization  of  the  womb  is  yet  too  imperfect  to  allow  us 
to  hope  for  its  having  the  same  action  upon  that  organ  as  upon  the  other  muscles  of  the 
economy.  Still,  the  process  is  so  simple,  and  so  innocent  as  respects  the  mother,  that  I  see 
no  impropriety  in  rej)eating  the  attempts.  Besides,  the  irritability  of  the  womb  dillers  so 
much  in  ditferent  individuals,  that  past  failures  ought  not  to  make  us  renounce  the  eflbrt  in 
another  case. 

^  The  separation  of  the  membranes,  now  generally  abandoned  as  a  means  of  inducing  pre- 
mature labor  on  account  of  its  uncertainty,  appears  to  me  to  be  liable  to  the  same  objection 


PRODUCTION    OF    ABORTION.  849 

lies  between  the  puncture  of  the  ovuni^  the  introduction  of  the  prepared  sponge, 
and  the  utsrine  douches. 

A.  The  pimcture  of  the  membranes,  is  a  sure  method  of  terminating  the  preg- 
nancy, but  when  performed  within  the  first  four  or  five  months,  it  appears  to  me 
to  expose  the  woman  to  too  much  danger.  We  have  ah-eady  pointed  out  in  the 
article  on  Abortion,  how  greatly  the  integrity  of  the  ovum  facilitated  the  dilata- 
tion of  the  cervix  and  the  action  of  the  expulsive  pains,  and  on  the  other  hand, 
how  difficult  the  expulsion  of  the  membranes  and  placenta  is,  after  the  waters 
are  discharged,  and  to  what  dangers  their  expulsion  exposes  the  woman.  There- 
fore, we  shall  not  insist  upon  them  further. 

B.  Kluge's  process,  we  regard  as  the  best  means  for  producing  abortion.  It 
is  the  one  which  I  used  to  effect  this  result  in  the  case  of  the  woman  on  whom 
M.  Dubois  the  next  year  performed  the  operation,  the  details  of  which  I  have 
given  in  the  two  preceding  notes. 

It  is  true  that,  as  the  length,  density,  and  resistance  of  the  neck  of  the  uterus 
at  the  fourth  month  of  gestation  would  have  led  us  to  suppose,  the  action  of  the 
prepared  sponge  was  much  slower  than  at  the  eighth  month ;  still,  by  the  expira- 
tion of  five  days,  it  had  produced  a  dilatation  and  softening,  which  greatly 
facilitated  the  puncture  which  was  afterwards  necessary,  and  the  expulsion  of 
the  ovum.  The  long  time  for  which  I  was  obliged  to  leave  the  sponge  applied, 
is  not  an  objection  to  the  employment  of  the  method;  for,  during  all  this  time 
the  apparatus  which  I  have  described,  enabled  the  woman  to  support  it  without 
pain  and  almost  without  inconvenience,  which  certainly  would  not  have  been 
the  case  had  I  introduced  the  tampon  as  is  usually  done. 

It  will  often  be  necessary  to  puncture  the  ovum  after  a  commencement  of  dila- 
tation and  softening  has  been  brought  about  by  the  use  of  the  sponge ;  but  in 
consequence  of  the  contractions  which  will  have  taken  place  on  the  preceding 
days,  the  detachment  of  the  ovum  will  have  taken  place  to  a  great  extent,  and 
its  expulsion  be  rendered  much  more  easy. 

as  applied  to  the  production  of  abortion.  Nevertheless,  it  was  practised  successfully  by  M 
Dubois,  in  the  case  of  tlie  woman  mentioned  in  the  preceding  note.  He  first  made  use  of 
a  gum-elastic  catheter  supported  by  a  stylet.  It  was  easily  introduced  into  the  neck  of  the 
uterus,  but  as  he  found  it  too  yielding',  he  substituted  for  it  a  large  silver  catheter,  which 
enabled  him  to  effect  the  separation  extensively.  The  instrument  encountered  the  placenta 
and  destroyed  its  attachments  to  a  certain  extent,  giving  rise  to  a  slight  eflusion  of  blood 
(Laborie).     The  membranes  were  not  ruptured. 

Some  abdominal  and  lumbar  pains  came  on  almost  immediately  after  the  operation. 
Until  three  o'clock  in  the  morning  of  the  next  day  they  were  quite  feeble;  but  from  that 
time  the  labor  went  on  regularly  and  was  accompanied  with  but  a  very  moderate  loss  of 
blood.  The  membranes  gave  way  spontaneously  at  four  and  a  half  p.m.,  and  at  five  o'clock 
the  expulsion  was  completed. 

We  would  remark,  1.  That  the  placenta  was  partially  detached,  which  is  very  different 
from  the  mere  separation  of  the  inferior  segment  of  the  membranes  ;  2.  That  this  detach- 
ment might  give  rise  to  fiooding;  ;3.  That  if,  as  the  nonexistence  of  previous  pains  and  the 
undilated  state  of  the  cervix  might  have  led  to  anticipate,  the  labor  had  continued  for  several 
days,  the  hemorrhage  might  have  become  serious  and  have  de])rived  the  operation  of  the 
innocency  which  is  the  principal  advantage  of  the  detachment  of  the  membranes. 

54 


850  DYSTOCIA. 

I  do  not  think  that  Kiwisch's  injections  have  ever  been  tried  for  the  purpose 
of  producing  abortion,  though  there  is  every  reason  for  supposing  that  they 
might  prove  efficient. 


CHAPTER    VI. 

OF    THE    EFFECT    OF    BLEEDING    AND    A    DEBILITATING    REGIMEN    UPON 
THE    DEVELOPMENT    OF    THE    CHILD. 

As  the  foetus,  during  its  intra-uterinc  existence,  necessarily  derives  from  its 
mother  the  means  of  nutrition,  it  was  natural  to  suppose  that  her  emaciation, 
brought  about  by  restricted  diet  and  frequent  evacuations  by  bloodletting  or  pur- 
gation, might  have  the  effect  to  retard  the  development  of  the  child.  This  sup- 
position has  not,  however,  always  been  confirmed  by  experience ;  for  women, 
exhausted  by  disease,  or  the  severest  diet,  have  been  known  to  have  very  large 
and  robust  children,  whilst  others  who  had  become  stout  and  strong  during  preg- 
nancy, and  who  had  gained  thirty  pounds  in  weight,  gave  birth  to  very  medium- 
sized  children  (Baudelocque). 

This  observation  of  Baudelocque's,  the  truth  of  which  has  been  many  times 
proved,  has  dispelled  the  idea  of  using  purgation,  bleeding,  and  diet,  as  an  ob- 
stetric means  in  cases  of  contracted  pelvis.  With  the  exception  of  M.  Moreau, 
no  one  in  France  thought  of  having  recourse  to  this  method,  when  M.  Depaul 
published,  quite  recently,  two  very  interesting  observations  tending  to  prove  its 
efficiency.  Fortunate  results  had  indeed  been  mentioned  by  others.  Thus 
Dewees,  who  states  that  he  had  often  seen  mothers  in  consumption  give  birth  to 
very  .robust  children,  and  who  was  not,  therefore,  a  priori,  flivorably  inclined 
towards  the  method,  nevertheless,  quotes  a  letter  addressed  to  him  by  Dr.  IIol- 
comb,  in  which  five  cases  are  reported.  Four  of  these  five  women,  had  never 
been  able  to  have  living  children,  and  one  of  the  four  had  lost  eleven.  These 
five  were  very  early  subjected  to  the  dally  use  of  purgatives,  and  were  all  deli- 
vered of  living  children.  Dr.  Rltter  relates  the  case  of  a  woman  with  a  contracted 
pelvis,  who  was  several  times  delivered  of  dead  children,  with  great  difficulty. 
From  the  fourth  month  of  her  fourth  and  fifth  pregnancies,  she  was  subjected  to 
repeated  bleedings,  to  the  use  of  a  slightly  purgative  mineral  water,  and  severe 
diet,  composed  chiefly  of  a  small  quantity  of  vegetables,  milk,  bread,  and  fruits, 
without  meat,  eggs,  or  dried  vegetables.  The  children,  which  were  much 
smaller  than  usual,  were  extracted  quite  easily,  but  were  still-born.  One,  which 
presented  by  the  feet,  died  whilst  the  head  was  retained  by  the  contraction,  and 
was  expelled  spontaneously.  The  other  presented  the  arm,  and  had  to  be  turned  : 
it  was  necessary  to  extract  the  head  by  the  forceps. 

These  cases,  though  certainly  encouraging,  are  not  sufficiently  numerous  to 
establish  the  value  of  this  method. 

Admitting,  for  an  instant,  that  a  severe  regimen,  assisted  by  bleeding  and 


EFFECTS     OF     BLEEDING.  851 

repeated  purgation,  would  always  have  the  effect,  upon  the  development  of  the 
child,  which  it  appears  to  have  had  in  the  preceding  observations,  should  this 
method  be  preferred  to  the  induction  of  premature  labor  ? 

The  latter  operation,  though  almost  always  innocent  as  regards  the  mother,  is 
frequently  fatal  to  the  child :  thus,  of  225  cases  mentioned  by  M.  Lacour,  37  of 
the  children  perished.  According  to  M.  Stoltz,  but  half  of  the  children  are 
saved  ;  and  judging  by  my  own  cases,  and  those  which  I  have  witnessed,  the  mor- 
tality of  the  children  is  even  greater. 

Unfortunately,  we  have  not  yet  enough  cases  in  which  the  regimen  has  been 
employed,  to  establish  a  comparison.  However,  out  of  the  ten  cases  mentioned, 
we  have  only  two  dead  children,  and  this  may  be  partly  accounted  for  by  the 
mode  of  presentation.  Therefore,  this  method  appears  to  afford  greater  chances 
to  the  children. 

It  is  greatly  to  be  feared  that  the  same  cannot  be  said  as  respects  the  mothers. 
It  is,  indeed,  very  difhcult  to  suppose  that  a  pregnant  woman,  who  often  has 
much  greater  appetite  during,  than  before  her  pregnancy,  can  be  deprived  for 
five  or  six  months  of  three-fourths  of  her  usual  allowance,  with  impunity,  besides 
being  subjected  to  more  or  less  frequent  bleeding  or  purgation.  Is  it  not  to  be 
feared  lest  debilit}-,  and  the  alteration  of  the  solids  and  fluids  resulting  from  such 
a  course,  so  long  continued,  should  predispose  strongly  to  post  puerperal  disor- 
ders, and  even  have  an  unftivorable  effect  upon  her  future  health?  I  am  well 
aware  that  nothing  of  the  kind  is  mentioned  in  the  cases  referred  to ;  but  these 
are  yet  very  few,  and  on  that  account  no  rule  for  the  future. 

In  giving  prefex-ence  to  any  method,  we  should  also  tahe  into  account  the 
suffering  to  which  it  subjects  the  patient.  That  occasioned  by  the  induction 
of  premature  labor  is  almost  nothing,  and  lasts  but  a  short  time.  That  such  is 
not  the  case  as  regards  the  prolonged  diet,  even  its  partisans  admit.  In  speak- 
ing of  his  first  patient,  M.  Depaul  saj's,  we  may  conceive  what  she  had  to  suffer, 
especially  at  the  outset.  For  the  tico  first  months,  he  sajs,  alluding  to  the 
second,  she  suffered  much  from  epigastric  pains,  and  a  feeling  of  extreme  hun- 
ger; her  strength  gave  way,  so  as  to  make  her  unable  to  walk  any  considerable 
distance,  or  use  any  violent  exercise. 

All  these  sufferings  would  be  readily  endured,  and,  as  M.  Depaul  remarks, 
the  woman  would  derive,  from  the  ardent  desire  of  maternity  which  controls  her, 
strength  sufficient  to  brave  everything,  could  we  only  assure  her  as  to  the  result. 
But,  as  most  authors  have  regarded  this  method  as  very  uncertain,  as  a  large  num- 
ber of  well-observed  f\icts,  though  under  other  circumstances,  tend  to  excite  doubts 
as  to  its  efficiency,  and  especially,  as  besides  it,  is  found  an  operation  which  in 
no  degree  endangers  the  life  and  health  of  the  mother,  and  saves  the  life  of  the 
children  in  nearly  half  of  the  cases,  I  acknowledge  that  had  I  to  decide  for  my 
wife  or  sister,  I  would  prefer  the  latter. 

Again,  to  what  cases  of  contracted  pelvis  is  this  method  particularly  adapted? 
I  have  no  doubt,  says  M.  Depaul,  that  it  would  be  entirely  successful  whenever 
the  diameters  were  shortened  to  the  extent  of  an  inch  and  a  quarter;  but  I  would 


Qi>Z  DYSTOCIA. 

not  venture  to  affirm  it,  if  the  antero-posterior  diameter  was  onlj  from  two  and 
three  quarters  to  three  and  a  quarter  inches  in  length. 

It  is,  therefore,  to  such  pelves  as  present  diameters  of  at  least  from  three  and 
a  quarter  to  three  and  a  half  inches  in  length,  that  M.  Depaul  restricts  the  use 
of  the  debilitating  regimen.  But,  when  placed  on  this  ground,  the  question 
changes  its  aspect,  and  the  results  of  the  method  are  no  longer  comparable  to 
those  of  the  premature  delivery ;  for  the  latter  operation  is  never  practised  but 
for  contractions  of  a  far  more  aggravated  character.  Accoucheurs  are  unani- 
.  mous  in  considering  the  spontaneous  delivery  or  extraction  of  a  child  as  possible 
when  the  sacro-pubic  diameter  is  at  least  three  and  a  half  inches  in  length ;  and 
even  though  embryotomy  had  been  required  in  previous  labors,  they  rely  upon 
the  frequent  variations  in  size  of  the  children  of  the  same  woman,  and  discard 
the  provocation  of  premature  labor. 

But  if,  alarmed  by  the  recollection  of  antecedent  deliveries,  you  fear  lest  the 
child  should  have  a  large  head  like  its  predecessurs,  and  conclude  to  interpose, 
do  not  subject  a  poor  mother  to  the  martyrdom  of  the  prolonged  regimen. 
Should  the  pelvis  present  three  and  a  half,  four,  or  four  and  a  quarter  inches, 
you  might  defer  much  longer  the  period  at  which  premature  delivery  is  eflected ; 
and  instead  of  bringing  on  pains  at  seven  months,  or  seven  months  and  a  half  of 
gestation,  you  might  wait  for  eight  months,  or  even  eight  months  and  one  or 
two  weeks.  The  operation  would  then  very  probably  afford  a  living  child ;  for 
it  is  likely  to  support  an  independent  existence  in  proportion  as  its  intra-utcrine 
life  has  been  prolonged. 

The  mortality  of  the  children,  which  has  been  justly  objected  to  the  induction 
of  premature  labor,  diminishes  greatly  as  we  approach  the  term  of  gestation.  By 
this  operation,  you  spare  the  mother  the  long  sufferings  of  the  regimen,  and  pro- 
pably  afford  equal  security  to  the  child. 

Below  from  two  and  three  quarters  to  three  and  a  quarter  inches,  there  is 
nothing  which  shows  any  advantage  in  the  J)lan  of  dieting,  &c.,  over  the  induc- 
tion of  premature  labor.  But  would  the  latter  operation  afford  more  favorable 
results  if  the  mother  were  subjected  to  a  severe  regimen  for  a  long  time  before 
practising  it  ?  It  is  enough  to  remember  that  the  extreme  weakness  of  children 
born  before  term  is  the  usual  cause  of  their  death,  in  order  to  set  aside  a  method 
the  effect  of  which  is  to  weaken  them  still  further.  I  think,  therefore,  that  in 
the  present  siate  of  our  science,  new  facts  are  required  before  adopting  the  die- 
tetic regimen  and  bleedings.  However,  in  order  to  enable  the  practitioner  to 
judge  this  question  for  himself,  I  think  it  proper  briefly  to  state  the  rules  laid 
down  by  31.  Depaul  for  carrying  out  the  plan. 

1.  The  greater  the  obstacle  the  more  necessary  is  it  to  diminish  the  amount  of 
food,  and  to  bleed  more  frequently.  Thus,  when  the  pelvis  is  contracted  by  from 
tky-ee  quarters  of  an  inch  to  an  inch  and  a  quarter,  the  method  should  be  put  m 
full  force.  (M.  Depaul's  first  patient  had  her  food  regulated  as  follows  :  Soups 
formed  its  basis;  vegetables  once  a  day;  meat  once  a  week,  and  in  very  small 
quantity;  half  a  pound  of  bread  daily,  including  that  in  the  soups.  The  first 
bleeding  at  three  months,  a  second  at  six,  a  third  at  eight,  and  the  last  one  at 


SYMPHYSEOTOMY.  853 

ciprht  and  a  half  months.  Fourteen  ounces  of  blood  to  be  taken  at  each  time,) 
2.  It  should  be  commenced  toward  the  third  or  fourth  month.  3.  It  would  be 
well  to  diminish  the  amount  of  food  progressivel}'.  4.  She  should  abstain  from 
dark  and  very  nutritious  meats.  5.  The  bleedinp;  must  be  rcfiulated  by  the  con- 
stitution and  state  of  the  circulation;  it  will  be  more  useful  in  proportion  as 
practised  in  the  latter  months. 

It  is  hardly  necessary  to  add,  that  if  the  obstacle  were  less  considerable,  it 
would  be  proper  to  act  with  less  rigor,  to  begin  the  treatment  later,  and  to  in- 
crease the  amount  of  food  in  proportion  to  the  object  to  be  attained. 

For  the  same  purpose,  M.  Delfraysse,  of  Cahors,  recommends  the  administra- 
tion of  iodine  during  the  two  last  months  of  gestation.  Beside  experiments 
made  upon  animals,  the  results  of  which  seem  favorable  to  his  proposition,  he 
mentions  the  cases  of  two  women.  One  of  them,  whose  pelvis  was  rather  less 
than  three  and  a  quarter  inches  in  extent,  had  been  delivered  three  times,  and 
very  painfully,  of  dead  children.  In  the  two  subsequent  pregnancies,  and  during 
the  two  last  months,  she  took,  every  morning,  six,  and  afterward  eight  drops,  of 
the  following  mixture  : 

Iodine,  pure,     .  .  .  .  .  .  ,  .15  grs. 

lotlide  of  potassium,  ......  30  grs. 

Distilled  water,  .......     f5j. 

She  was  delivered  spontaneously  of  living  children,  one  of  them  weighing 
twenty-two  ounces,  and  the  other  twenty-three  less  than  their  predecessors. 

Experience  only  can  decide  the  merits  of  this  new  method,  which  does  not 
appear  to  have  been  injurious  to  the  mothers. 


CHAPTER   VII. 

OF    SYMPHYSEOTOMY. 

The  relaxation  of  the  pelvic  symphyses,  and  the  consequent  separation  of  the 
articular  surfaces,  which  often  occur  during  pregnancy,  have  so  long  been  known 
to  the  profession,  that  it  is  somewhat  surprising  the  operation  in  question  was 
not  sooner  suggested.  It  should  be  stated,  however,  that  certain  reflections,  and 
even  some  facts  well  worthy  of  attention,  are  scattered  here  and  there  through- 
out the  annals  of  our  science.  For  instance,  Severin  Pineau,  when  treating  of 
the  relaxation  of  the  pelvic  ligaments,  quotes  the  text  of  Galen,  and  seems  to 
anticipate  the  Sigaultian  operation;  since,  in  speaking  of  the  pelvic  articulations, 
he  says,  Non  tantuni  dilatare,  aed  etiam  secari  into  j^ossxint.  In  a  work  pub- 
lished by  Delacourvee,  a  French  physician,  in  1655,  we  find  that,  being  sum- 
moned to  a  pregnant  woman,  who  died  near  full  term,  he  divided  the  pubic 
symphysis  with  a  razor,  in  order  to  extract  the  child  more  readily.     In  176G, 


854  DYSTOCIA. 

Plenck,  under  very  similar  circumstances,  first  performed  tbe  C£esarean  opera- 
tion ;  but,  being  unable  to  extract  the  bead,  ■which  was  low  down  in  the  excava- 
tion, he  divided  the  symphysis,  and  was  successful  in  delivering  the  child.  But 
this  early  attempt,  instead  of  leading  to  the  performance  of  this  operation  on  the 
living  female,  seemed  to  have  the  opposite  effect. 

In  fact,  it  was  only  towards  the  end  of  the  last  century  (in  1708),  that  Sigault, 
then  a  student  of  medicine,  suggested  it  to  the  Academy  of  Surgery,  by  whom  it 
was  rejected  as  a  rash  proposal.  Not  disconcerted  by  this  reception,  young 
Sigault  supported  his  invention  in  a  thesis  at  Angers  in  1773;  that  is,  five  years 
after  the  presentation  of  his  original  memoir;  and,  finally,  in  1777,  he  performed 
his  first  operation,  assisted  by  Alphonse  Leroy,  who  declared  himself  its  zealous 
partisan.  The  mother  and  child  were  both  saved;  and,  on  account  of  his  suc- 
cess, Sigault,  who  had  been  almost  reviled  by  the  Academy  of  Surgery,  was 
thenceforth  covered  with  honors,  and  regarded  as  a  benefactor  of  humanity. 
The  Faculty  of  Medicine  at  Paris  even  resolved  to  celebrate  this  wonderful  dis- 
covery by  having  a  medal  struck  in  honor  of  its  author.  But,  notwithstanding 
its  early  succe.ss  soon  gained  him  numerous  followers,  it  also  stirred  up  new  and 
bitter  adversaries;  and  the  medical  world  was  for  a  long  time  divided  into  two 
sets  of  enthusiasts,  the  Si/mphi/scans  and  the  Casareans ;  but,  after  their  first 
ardor  had  abated,  both  parties  finally  settled  down  in  a  common  opinion,  as  soon 
as  they  discovered  that  thei-e  had  been  exaggerations  on  each  side.  Since  that 
time,  the  Cajsarean  operation  and  symphyseotomy  have  been  alike  regarded  as 
useful  operations,  applicable  to  certain  particular  cases  ;  and,  so  far  from  attempt- 
ing to  exclude  cither,  the  more  modern  writers  have  rather  endeavored  to  desig- 
nate the  conditions  requiring  their  respective  employment;  which,  indeed, 
would  have  been  the  wiser  course  at  the  time  of  its  first  discovery. 

§  1.  Effects  of  Symphyseotomy. 

Supposing  the  propriety  of  the  section  of  the  symphysis  pubis  to  be  admitted 
for  the  moment,  let  us  ascertain  what  advantages  could  be  derived  from  it. 
From  the  best  works  published  on  this  subject,  it  would  appear  that  we  cannot 
hope  to  gain  more  than  four  to  six  lines  in  the  length  of  the  antero-posterior  dia- 
meters of  the  superior  strait  and  excavation.  After  a  division  of  the  inter-pubic 
cartilage,  the  bones  of  the  pubis  separate  spontaneously  from  four  lines  to  an 
inch ;  which  separation  is  proiluced  by  the  retraction  of  the  ligamentous  fibres, 
known  as  the  posterior  sacro-iliac  ligaments.  While  this  is  being  efi'ected,  the 
coxal  bone  may  be  considered  as  a  lever  of  the  first  kind,  having  its  long  anterior 
arm  bent  near  the  middle ;  the  centre  of  movement,  or  fulcrum,  is  found  at  the 
posterior  part  of  the  articular  surface  of  the  sacrum.  During  the  separation,  the 
ligaments  situated  on  the  front  part  of  the  sacro-iliac  articulation  become  tense 
and  stretched,  or  even  lacerated,  when  this  is  carried  to  a  high  degree;  conse- 
quently, the  amount  of  their  resistance  greatly  influences  the  degree  of  separa- 
tion. Again,  if  the  accoucheur,  by  taking  hold  of  the  iliac  crests,  attempts  to 
draw  them  asunder,  he  may  considerabl}'  increase  the  interval  already  existing  be- 
tween the  pubic  bones;  but  it  would  be  imprudent  to  carry  this  artificial  separation 


SYMPHYSEOTOMY.  855 

too  far;  because,  if  carried  beyond  two  inches,  the  anterior  sacro-iliac  ligaments 
would  probably  be  ruptured,  and  the  mother  be  subjected  to  very  serious  conse- 
cutive inflammations.  The  antero-posterior  diameter  of  the  strait  is  increased 
from  two  to  three  lines  for  every  inch  of  separation  between  the  pubes;  and,  since 
this  interval  may  amount  to  two  inches,  four  to  five  lines  are  therefore  added  to 
the  length  of  the  sacro-pubic  diameter.  In  addition  to  which,  the  anterior  pari- 
etal protuberance,  by  engaging  in  the  space  left  between  the  pubic  bones,  dimi- 
nishes the  biparietal  diameter  to  a  corresponding  extent;  and  it  has  been  calcu- 
lated that  two  to  three  lines  arc  gained  in  this  way;  which  would  give  a  sum 
total  in  the  increased  length  of  the  sacro-pubic  diameter  of  six  to  eight  lines. 

But  the  sacro-pubic  is  not  the  only  diameter  augmented  by  symphyseotomy ; 
for  the  oblique,  and  more  particularly  the  transverse,  ones  are  thereby  greatly 
enlarged.  In  fact,  the  researches  of  Desgranges  would  seem  to  prove  that  the 
increase  in  the  transverse  dii'ection,  throughout  the  whole  pelvis,  amounts  nearly 
to  one-half  of  the  separation  at  the  pubis;  and  that  the  transverse  enlargement 
of  the  pubic  arch  is  almost  equal  to  the  whole  of  this  interval.  Whence  it  fol- 
lows that  the  operation,  which  would  appear  to  be  applicable  to  those  cases  only 
in  which  the  contraction  affects  the  sacro-pubic  interval,  is  in  reality  especially 
advantageous  when  the  transverse  diameters  of  the  excavation,  or  of  the  inferior 
strait,  are  shortened. 

§  2.  Indioations  for  Symphyseotomy. 

The  results  furnished  by  experiments  made  on  the  dead  body,  naturally  lead 
to  the  conclusion  that  this  operation  is  practicable  whenever  five  to  eight  lines, 
added  to  the  contracted  diameters,  would  prove  sufficient  to  admit  of  a  sponta- 
neous delivery,  or,  at  least,  of  an  extraction  of  the  fcetvis  by  the  forceps.  Such 
is  the  view  adopted  by  most  practitioners  since  the  days  of  Sigault,  and  the  ex- 
tremes of  the  operation  have  been  limited  to  two  and  a  half  inches  for  the  lowest, 
and  three  and  a  quarter  inches  for  the  highest.  But,  at  the  present  day,  sym- 
physeotomy is  seldom  resorted  to,  and  it  will  be  even  less  so  hereafter,  when 
accoucheurs  generally  shall  hav^^rlearned  to  appreciate  the  advantages  derivable 
from  the  induction  of  premature  labor.  ^^ 

The  circumstances  that  have  led  to  the  performance  of  the  Sigaultian  op^'tation, 
are  equally  strong  in  flivor  of  the  induction  of  premature  labor;  and  the  results 
deduced  from  experience,  the  only  impartial  judge  in  such  cases,  have  already 
decided  in  behalf  of  the  latter  operation.  For,  whenever  a  patient  comes  under 
care  during  the  last  two  months  of  her  pregnancy,  whose  pelvis  ranges  from  two 
and  a  half  to  three  inches  in  its  smallest  diameter,  we  ought  to  bring  on  the  labor 
before  term ;  more  particularly  if  a  mutilation  of  the  foetvis  has  been  deemed 
necessary  in  a  former  confinement ;  and,  on  the  other  hand,  we  have  elsewhere 
shown  (page  586)  that,  whenever  there  is  reason  to  believe  that  the  child's  life 
is  more  or  less  compromised  by  the  previous  duration  of  the  labor,  and  the  un- 
successful attempts  resorted  to  for  its  extraction,  the  accoucheur  should  act  as  if 
it  were  really  dead.  Hence  symphyseotomy  should  only  be  performed,  even 
though  the  pelvis  measures  from  two  and  a  half  to  three  inches  in  its  smallest 


856  DYSTOCIA. 

dianitter,  when  tlic  operator  ascertains  the  existence  of  the  deformity  before  the 
men)brancs  are  ruptured. 

For,  even  admitting-  that  it  were  not  better  to  sacrifice  the  infant's  life  than  to 
perform  an  operation  Avhich  so  often  endangers  the  existence  and  commonly  the 
health  of  the  mother,  is  it  always  possible,  in  practice,  to  conform  strictly  with 
theoretical  principles?  The  cases  in  which  a  similar  degree  of  retraction  has 
permitted  the  spontaneous  expulsion  of  the  foetus  naturally  suggest  themselves  to 
the  mind;  and  although  these  exceptions  to  the  rule  are  certainly  rare,  yet  they 
may  reoccur.  Consequently,  is  it  not  prudent,  before  alarming  the  patient,  to 
ascertain,  by  a  proper  delay,  the  inefficiency  of  the  uterine  efforts  ?  Is  not  such 
a  delay  indispensable  for  proving  the  necessity  of  the  operation  ?  In  most  in- 
stances, would  it  not  require  several  hours  to  induce  the  patient  to  yield  to  the 
entreaties  of  her  family  ?  Would  the  relatives  themselves  consent,  before  the 
lapse  of  time  had  convinced  them  of  the  absolute  impossibility  of  a  natural  de- 
livery ?  iVnd  would  they  not  demand  a  trial  of  all  other  means,  before  a  resort 
to  such  an  extreme  measure?  Could  the  accoucheur  object  to  an  application  of 
the  forceps,  which  has  so  many  times,  under  like  circumstances,  been  followed 
with  success?  Or  could  he  refuse,  had  ho,  like  ourselves,  seen  a  living  fcetus 
expelled  at  term  through  a  pelvis  whose  antero-posterior  diameter  measured  but 
three  inches?  These  uncertainties,  hesitations,  and  forced  delays,  which  a  firm 
and  resolute  physician  having  charge  of  an  hospital  may  escape,  are  inevitable 
in  private  practice,  where  we  have  the  fears  of  the  fiimily,  the  resistance  on  the 
part  of  the  patient  herself,  and  oftentimes  the  anxiety  caused  by  the  jealousy  of 
some  of  our  own  brethren,  to  contend  with;  during  all  which,  time  runs  away, 
the  labor  is  progressing,  the  membranes  are  ruptured,  and  the  favorable  chances 
for  performing  the  operation  are  lost.  It  will  be  said,  perhaps  the  slowness  of 
the  labor  is  more  dependent  on  the  feeble  contractions  than  on  the  disproportion 
between  the  diameters  of  the  head  and  those  of  the  pelvis ;  or,  perhaps  a  little 
artificial  aid  joined  to  the  powers  of  nature  will  succeed  in  accomplishing  her 
work.  But  while  thus  wavering  from  hope  to  hope,  from  perhaps  to  perhaps, 
the  labor  reaches  that  stage  where  we  begin  to  doubt  the  viability  of  the  foetus; 
and,  when  such  a  doubt  arises,  can  we  any  longer  think  of  resorting  to  symphy- 
seotomy ? 

This  operation  has  been  proposed  in  other  cases,  besides  those  dependent  on  a 
contraction  of  the  pelvis ;  as,  for  instance,  for  tumors  in  the  excavation,  for  a 
very  large  head,  or  a  retroversion  of  the  womb,  occurring  during  the  early  months 
of  gestation.  Thus,  it  was  resorted  to  by  Duret,  in  order  to  overcome  an  ob- 
stacle to  the  engagement  of  the  head,  created  by  the  development  of  an  exostosis, 
about  the  size  of  a  nut,  on  the  first  false  vertebra ;  as  also  in  the  following  case, 
published  by  Dr.  Damman,  in  Casper's  journal:  A  woman  had  been  three  days 
in  labor,  but  the  head  was  so  voluminous  that  it  could  not  engage  in  the  excava- 
tion, notwithstanding  the  perfect  conformation  of  the  pelvis;  and,  having  become 
wedged  in  the  superior  strait,  an  application  of  the  forceps  was  impossible.  Al- 
thou^-h  the  long  duration  of  the  labor  ought  naturally  to  have  created  some  doubt 


S  Y  51  P  II  Y  S  E  0  T  0  M  Y.  857 

with  regard  to  the  cliild's  condition,  yet  >I.  Daninian  resorted  to  symphyseotomy; 
the  infant  was  born  dead,  but  he  was  fortunate  enough  to  save  the  mother. 

The  remarks  before  made  with  regard  to  this  operation  in  cases  of  deformed 
pelvis,  equally  apply  to  those  of  tumors  in  the  excavation,  and  to  those  in  which 
the  excessive  size  of  the  child's  head  constitutes  the  only  obstacle  to  a  sponta- 
neous delivery.  As  to  its  utility  or  disadvantages  when  resorted  to  for  the  pur- 
pose of  facilitating  the  reduction  and  correction  of  a  retroverted  uterus,  expe- 
rience is  still  wanting. 

In  our  estimate  of  the  indications  for  this  operation,  we  cannot  conform,  as  the 
reader  will  see,  to  the  rules  laid  down  by  its  partisans;  because,  so  far  from  being 
precise  and  positive,  as  they  suppose,  these  rules  only  leave  the  practitioner  in 
doubt  and  uncertainty.  Laying  aside  for  a  moment  all  theoretical  discussions, 
and  looking  at  the  rjuestion  only  in  its  practical  point  of  view,  we  are  led  ahuost 
irresistibly  to  the  conclusion  that,  in  the  present  state  of  our  science,  symphyse- 
otomy is  no  longer  practicable.  For,  independently  of  the  difficulties  in  deter- 
mining its  indications  preciseh',  it  must  not  be  supposed  that  the  operation  is 
attended  with  as  little  danger  as  Sigault  and  Alphonse  Leroy  endeavored  to 
prove ;  and  we  only  need  refer  to  the  numerous  accidents  thereby  produced  to 
sustain  the  justice  of  our  conclusions.  In  fact,  these  dangers  are  so  great  that, 
according  to  Baudelocque,  of  forty-one  females  operated  upon,  fourteen  died, 
and  thirteen  children  only  were  born  living  I  Not  to  allude  to  the  numberless 
infirmities  that  embittered  the  existence  of  nearly  all  the  patients  who  survived 
the  operation. 

Operation. — This  is  very  simple.  The  woman,  being  placed  in  the  same  posi- 
tion as  if  the  forceps  were  to  be  applied,  is  properly  supported  by  assistants ;  the 
bladder  is  emptied,  and  the  catheter  left  in  the  urethra  for  the  purpose  of  pro- 
tecting this  canal  from  the  edge  of  the  knife,  by  pressing  it  towards  the  right 
side.  The  operator  depresses  the  skin  covering  the  pubis,  so  as  to  find  the  pre- 
cise spot  for  cutting  down  on  the  symphysis.  This  being  done,  an  assistant 
stretches  the  skin  upward  as  much  as  possible,  and  the  surgeon  then  makes  an 
incision  through  the  soft  parts,  commencing  about  half  an  inch  above  the  sym- 
physis, and  prolonging  it  downwards  over  the  centre  of  the  articulation,  nearly 
to  the  clitoris,  and  terminating  a  little  to  the  left ;  the  inter-pubic  ligament  is 
then  carefully  incised,  and,  when  it  is  nearly  cut  through,  great  precaution  is 
requisite  not  to  wound  the  bladder.  As  soon  as  the  section  is  effected,  a  separa- 
tion of  the  pubes  follows  ;  when,  if  the  patient's  strength  is  not  exhausted,  and 
the  uterine  pains  are  still  strong  and  frequent,  the  further  delivery  is  abandoned 
to  nature ;  but  in  the  opposite  case  the  forceps  is  applied,  or  the  labor  termi- 
nated by  the  pelvic  version  and  by  tractions  on  the  lower  extremities.  After 
the  delivery  is  completed,  the  patient  is  cleansed,  and  the  vessels  tied,  if  any 
were  divided ;  the  pubic  bones  are  drawn  together,  and  the  lips  of  the  wound 
sustained  by  adhesive  strips,  charpie,  and  a  compress,  and  the  whole  retained  in 
nitd  by  a  bandage  around  the  body.  The  symptoms  subsequently  manifested  are 
to  be  carefully  combatted  as  they  arise.  The  perfect  consolidation  of  the  sym- 
physis is  seldom  completed  under  three  or  four  months,  even  in  the  most  favor- 


858  DYSTOCIA. 

able  cases,  anl  instances  have  been  known  where  this  never  occurred,  though 
the  patients  were  ultimately  enabled  to  walk,  by  the  formation  of  a  cellulo- 
fibrous  tissue  ;  which,  says  Alphonse  Leroy,  by  filling  up  the  space  in  the  sym- 
physis, restores  the  solidity  of  the  articulation. 

This  process  is  the  one  generally  followed  ;  but  numerous  modifications  of  it 
have  been  suggested,  most  of  which  arc  intended  for  the  better  protection  of  the 
urethra ;  though  none  of  them,  however,  are  of  much  value.  Attributing  the 
consequences  that  follow  in  the  train  of  symphyseotomy  to  the  exposure  of  the 
articular  surfaces  and  the  lips  of  the  womb  to  the  external  air,  M.  Irabert,  of 
Lyons,  has  proposed  the  division  of  the  interpubic  cartilage,  without  involving 
the  skin.  This  procedure  is  feasible  enough;  but,  in  our  estimation,  it  can 
only  obviate  the  smallest  part  of  the  consecutive  accidents ;  for  the  various 
dangers  to  which  the  patient  is  then  exposed,  are  far  less  dependent  on  an  in- 
flammation of  the  pubic  symphysis  than  on  the  disorders  created  by  the  separa- 
tion of  the  sacro-iliac  articulations. 

These  remarks  apply  with  equnl  force  to  the  division  of  the  pubis,  which  Pro- 
fessor Stoltz  advises  to  be  performed  by  the  subcutaneous  method.  But,  after 
the  opinion  I  have  advanced  with  regard  to  the  operation  itself,  it  seems  un- 
necessary to  dilate  on  the  different  ways  of  performing  it ;  I  must,  however, 
describe  that  of  the  Strasbourg  professor,  for,  although  experience  has  not 
decided  on  its  relative  merits,  yet  it  seems  to  offer  the  most  favorable  chances. 

It  consists  in  the  division  of  one  of  the  pubic  bones  near  the  symphysis,  by 
means  of  a  chain-saw,  without  incising  the  integuments.  The  .'^kin  having  been 
previously  shaved,  a  small  opening  is  made  on  the  mons  veneris  at  the  point 
corresponding  with  the  crest  of  the  pubis,  either  on  the  right  or  left  side  of  the 
symphysis;  a  long  and  slightly  curved  needle,  having  the  saw  attached,  is  then 
entered  at  this  opening,  and  slipped  along  the  inner  fiice  of  the  pubis,  grazing 
the  bone,  and  its  point  is  brought  out  at  the  side  of  the  clitoris,  between  the 
cavernous  body  and  the  descending  branch  of  the  pubis  from  which  the  latter 
arises.  The  handle  is  next  fitted  on,  and,  taking  the  saw  by  both  extremities, 
it  is  moderately  stretched  between  the  two  hands,  and  the  pubis  is  cut  through 
by  a  few  strokes.  The  divided  portions  of  the  bone  immediately  separate,  and 
this  separation  can  be  increased  almost  at  will,  or  it  may  be  effected  by  the 
direct  pressure  of  the  child's  head  or  trunk.  The  pubis  being  divided,  one  of 
the  handles  is  removed,  the  instrument  is  withdrawn,  and  the  small  opening 
which  is  left  behind  heals  up  without  difficulty. 

But  I  repeat,  that  the  modifications  suggested  by  Stoltz  and  Imbert,  still  re- 
quire the  sanction  of  a  more  extended  experience. 


CiESAREAN    OPERATION.  859 


CHAPTER  VIII. 

OF   THE    CESAREAN    OPERATIOX. 

Hysterotomy,  or  the  Caisarean  operation,  consists  of  an  incision  through  the 
abdominal  and  uterine  walls,  for  the  purpose  of  extracting  the  child. 

This  section  had  been  recommended  in  cases  where  a  pregnant  woman  died 
tindelivei'ed,  long  before  it  was  resorted  to  on  the  living  female ;  and  it  can 
readily  be  traced  back  to  remote  sources  worthy  of  credit,  without  confounding 
it  with  the  mysteries  of  the  poets,  or  with  the  marvels  of  antiquity.  Thus, 
Valerius  Maximus  speaks  of  the  posthumous  birth  of  the  philosopher  Gorgias  j 
and  Pliny  states  that  the  celebrated  Scipio  Africanus  and  Manilius  were  saved 
under  Xuma's  law,  which  interdicted  the  interment  of  a  woman,  big  with  child, 
until  her  belly  was  opened.  This  wise  and  prudent  law  was  received  and 
adopted  throughout  Christendom,  and  it  still  flourishes  vigorously  in  the  Roman 
Church. 

The  precise  period  at  which  the  operation  was  first  performed  on  the  living 
patient  remains  undetermined.  3Iansfield,  of  Brunswick,  endeavored  to  discover 
indubitable  traces  of  it  in  the  Talmud;  but  one  of  his  coteniporaries  has  wholly 
refuted  such  an  opinion.  According  to  M.  C.  Lage,  the  first  authentic  case  was 
reported  by  Nicolas  de  Falcon,  in  1491;  J.  Xufer  performed  it  in  1500,  as  de- 
tailed by  Gaspard  Bauhin ;  and  F.  Eousset  published  a  work  in  1581,  which 
has  since  acquired  considei'able  celebrity  from  the  great  number  of  cases  it  con- 
tains, all  of  which  were  successful. 

The  surgeons  were  so  emboldened  by  Rousset's  monograph,  that  the  Cajsarean 
operation  was  often  resorted  to  without  any  indication  whatever,  and  its  popu- 
larity became  so  great  at  one  time,  that  a  cotemporary  Dominican  friar,  Scipio 
Merunia,  afiirms  that  it  was  as  common  in  France  as  bloodletting  in  Italy. 
However,  a  reaction  soon  took  place ;  for  Guillemeau,  Pare,  Viard,  and  some 
other  prominent  surgeons  having  failed  in  their  attempts,  Marchant  succeeded 
in  stirring  up  his  countrymen  against  Rousset,  by  founding  some  virulent  attacks 
on  these  reverses;  and  the  C^esarean  section  Avould  have  fallen  into  oblivion, 
if  Gaspard  Bauhin  had  not  come  to  its  aid  with  fresh  proofs  in  its  favor. 

The  interesting  and  delicate  question  of  hysterotomy  was  again  contested 
during  the  whole  of  the  seventeenth  century,  and  then,  as  in  the  preceding  one, 
its  advantages  and  disadvantages  were  grossly  exaggerated;  so  that  the  following 
century  arrived  without  any  clear  idea  having  been  formed  respecting  the  opera- 
tion or  its  value,  owing  to  the  total  want  of  probity  and  justice  in  the  examina- 
tion of  the  facts  of  the  case.  In  1749,  Sfmon  read  a  remarkable  memoir  on  this 
subject  before  the  Royal  Academy  of  Surgery ;  but  it  is  characterized  by  credu- 
lity rather  than  accuracy.  Since  that  period,  most  of  the  works  on  the  Caesarean 
operation  have  merely  discussed  the  indications  for  its  performance;  but  not  one 
of  them,  unless  it  is  Sacombe's  passionate  and  scandalous  dissertation,  has  at- 
tempted to  prove  the  impossibility  of  its  proving  successful.     Although  the 


860  DYSTOCIA. 

favorable  cases  are  not  very  numerous,  yet  there  arc  a  few  that  may  clearly  be 
considered  as  incontestable.  In  our  day,  the  field  for  the  Ciesarean,  as  well  as 
for  all  other  obstetrical  operations,  has  been  limited ;  but  this  is  rather  to  be 
attributed  to  the  advance  of  science,  and  to  the  eminently  practical  spirit  of  the 
present  age. 

This  operation  may  be  practised  on  the  living  female  whenever  the  natural 
passages  through  which  the  child  has  to  pass  are  so  narrow,  or  so  obstructed, 
that  a  delivery  by  the  application  of  the  forceps,  or  by  syniphysootoniy,  is  wholly 
impossible;  and  when  the  mutilation  of  the  child  itself  would  not  permit  its  ex- 
traction without  exposing  the  mother  to  the  greatest  dangers.  It  may  likewise 
be  resorted  to  for  the  purpose  of  saving  the  infant  when  the  patient  dies  in  the 
advanced  stages  of  gestation. 

"Whenever  a  physician  is  summoned  to  a  pregnant  woman  soon  after  her  death, 
he  ought  to  perform  it,  after  having  carefully  ascertained  that  the  death  is  real ; 
because,  the  child's  decease  does  not  always  precede  that  of  the  mother,  and 
numerous  instances  are  recorded  where  living  children  have  been  extracted  ten 
or  fifteen  minutes,  and  even  half  an  hour,  after  the  woman  died.  Although  the 
operation  will  generally  prove  ineifectual  after  the  lapse  of  a  longer  period,  still 
it  ought  to  be  tried;  since  some  few  cases,  whose  authenticity  I  do  not  vouch 
for,  would  seem  to  prove  that  the  foetus  has  continued  to  live  in  the  womb  during 
ten.  fifteen,  and  even  twenty-four  hours  ! 

"We  can  only  expect  to  extract  a  living  infant  after  the  seventh  month ;  never- 
theless, the  desire  of  the  relatives  in  Catholic  families  to  have  the  child  baptized, 
often  constrains  the  medical  attendant  to  open  the  patient,  even  where  death 
occurs  before  the  sixth  month  of  gestation.  The  incision  through  the  abdominal 
and  uterine  walls,  under  such  circumstances,  should  be  made  with  the  same  pre- 
cautions as  during  life ;  because,  the  necessity  of  acting  as  promptly  as  possible, 
may  not  afford  the  operator  a  sufficient  length  of  time  to  ascertain  that  the  death 
is  real.  Should  the  female  die  during  the  parturition,  he  ought  to  examine  the 
condition  of  the  genital  organs  immediately ;  for,  notwithstanding  the  fact  that 
the  labor  may  have  but  recently  commenced,  these  parts,  from  their  diminished 
resistance  after  death,  have  occasionally  permitted  the  delivery  of  the  foetus  to 
be  eflPected  by  the  version  or  the  forceps.  In  fact,  this  latter  operation  would  be 
positively  indicated  if  the  child's  head  were  low  down  in  the  excavation ;  be- 
cause, in  such  cases,  its  extraction  by  the  Coesarean  section  would  be  rendered 
extremely  difficult,  if  not  impossible ;  for  numerous  recorded  instances  have  fully 
tested  the  inefiSeiency  of  tractions  made  on  the  foetal  trunk  through  the  abdomi- 
nal incision. 

"VVhen  practised  on  the  living  female,  the  Ca^sarean  section  constitutes  one  of 
the  most  serious  operations  in  surgery ;  for  three-fourths  of  its  unfortunate  vic- 
tims have  perished.  This  result,  which  would  probably  be  still  more  unfavorable 
if  the  same  pains  had  been  taken  to  bring  before  the  public  the  unsuccessful,  as 
have  been  used  to  circulate  the  more  fortunate  cases,  is  indeed  calculated  to 
alarm  the  surgeon  who  is  obliged  to  contemplate  performing  such  an  operation. 

All  accoucheurs  agree  in  the  opinion  that,  when  the  smallest  diameter  of  the 


CESAREAN     OPERATION.  861 

pelvis  docs  not  amount  to  two  and  a  half  inches,  a  delivery  by  the  natural  pas- 
sages is  absolutely  impossible;  and  that  we  have  then  only  to  choose  between 
hysterotomy  and  a  mutilation  of  the  fu?tus.  Now,  with  a  view  of  explaining 
more  clearly  the  indications  presented  by  this  degree  of  contraction,  we  shall 
adopt  the  subdivision  made  by  M.  Paul  Dubois;  that  is,  into  pelves  presenting 
at  least  two  and  one-eighth  inches  in  the  smallest  diameter,  and  into  those  below 
that  point. 

Supposing  the  smallest  diameter  measures  two  and  one-eighth  inches,  and  it 
has  been  positively  determined  that  the  child  is  still  alive  (for  the  question  is  no 
longer  doubtful  when  there  is  the  least  uncertuinty  on  this  point),  two  different 
measures  ai'e  presented  for  our  serious  consideration,  namely,  embryotomy  and 
the  Caesarean  operation.  All  the  French  accoucheurs,  including  Dubois  himself, 
are  in  favor  of  the  latter,  for  he  says,  "  the  Caesarean  operation  is  our  only  re- 
source, and,  therefore,  it  must  be  resorted  to."    (^These,  p.  71.) 

"We  are  not  ignorant  of  the  importance  of  this  question;  and  it  requires  a  set- 
tled and  positive  conviction,  on  our  part,  to  warrant  us  in  deciding  it  differently 
from  other  French  authors;  but  we  are  sustained  by  the  almost  unanimous  opinion 
of  the  English  practitioners,  who  believe  that  the  child  ought  to  be  sacrificed 
whenever  the  delivery  can  be  effected  by  embryotomy.  Four  years  ago,  we 
strongly  expressed  a  desii'e  (in  the  first  edition  of  this  work,  page  7GG)  to  see  the 
views  of  our  neighbors  more  generally  disseminated  in  France,  in  the  following 
words :  "  And,  as  to  ourselves,  our  voice  will  be  against  the  Caesarean  operation 
in  all  cases  where  it  is  not  absolutely  indispensible  to  the  mother's  safety."  And 
we  do  not  hesitate  now  to  advance  the  same  doctrine.  In  fact,  it  cannot  be  for- 
gotten that  this  operation  is  nearly  always  fotal  to  the  female,  even  admitting  that 
the  statistical  tables  exhibit  the  exact  truth.  For  instance,  laying  aside  the  de- 
tails contributed  by  the  surgeons  of  Great  Britain,  who  are  charged  with  the 
non-performance  of  the  operation  at  the  opportune  moment,  and  supposing  that 
the  unsuccessful  cases  have  been  as  honestly  reported  as  the  successful  ones,  an 
impartial  examination  of  all  the  fiicts  leads  to  the  melancholy  conclusion,  that 
nearly  four-fifths  of  the  mothers  have  perished  (according  to  Keyser,  the  precise 
ratio  of  mortality  is  seventy-nine  per  cent.).  The  question  then  recurs,  does  this 
frightful  operation  save  the  child?  Oris  it  at  all  certain  that  we  can  present  to 
the  mother,  as  a  compensation  for  all  her  sufferings,  something  more  than  a  life- 
less corpse  ?  Unfortunately,  this  is  not  the  case,  and  the  partisans  of  the  Caesa- 
rean section  are  constrained  to  acknowledge  that  they  are  not  always  fortunate 
enough  to  extract  a  living  child,  even  when  the  operation  is  performed  at  the 
most  favorable  moment.  But  admitting  for  an  instant  that,  if  resorted  to  imme- 
diately after  the  membranes  are  ruptured,  the  section  will  always  save  the  child, 
still  this,  in  my  opinion,  does  not  compensate  for  the  dangers  to  the  mother. 

You  confess  that  more  than  one-half  of  the  females  die,  but  can  you  aver  that 
more  than  a  moiety  of  the  children  you  save  by  gastrotomy  will  live  long  enough 
to  dry  the  tears  shed  over  their  birth  ?  Read  the  tables  hitherto  published  on 
the  average  of  human  life,  and  then  tell  me  whether  fifty,  out  of  a  hundred  living 


862  DYSTOCIA. 

infants,  attain  their  thirtieth  year.*  "Wherefore,  it  is  not  only  the  ininiec'iite 
effect  of  crastrotomy,  but  also  its  remote  consequences  that  are  to  be  taken  into 
consideration.  This  at  least  is  certain,  that  you  sacrifice  more  than  half  of  the 
women  immediately;  and,  even  supposing  that  every  child  was  alive  at  the  time 
of  its  birth,  the  experience  of  ages  has  proved,  that  you  will  not  find  one-half  of 
them  attain  the  age  at  which  their  mothers  died. 

The  advantage  is,  therefore,  in  favor  of  embryotomy,  when  considered  with 
recjard  to  the  mere  question  of  figures.  But  the  feeble  and  uncertain  life  of  an 
infant,  who  is  connected  with  the  external  world  only  through  its  mother,  who  as 
yet  has  neither  thought  nor  affection,  hope  nor  fear,  can  it  be  compared  to  that 
of  a  young  woman  associated  with  those  around  her  by  a  thousand  social  and 
relicjious  ties  ?  Or  will  the  survival  of  this  poor  child  fill  up  the  void  left  by  the 
death  of  its  mother?  And,  lastly,  can  society  at  large  ever  hope  to  receive  from 
a  new-born  infant  the  duties  it  had  a  right  to  expect  from  the  adult  woman  ? 
Hence,  family  ties  and  social  interests  all  militate  in  favor  of  the  mother. 

In  a  political,  if  not  in  a  moral  point  of  view,  we  are  clearly  justified,  says 
Ramsbotham,  in  preferring  the  strong  to  the  feeble,  the  sound  man  to  a  diseased 
one,  and,  consequently,  the  mother  of  a  family  to  the  still  unborn  infant,  when- 
ever we  are  placed  under  the  cruel  necessity  of  sacrificing  the  one  or  the  other. 
One  more  argument  yet  remains  in  favor  of  the  view  I  adopt — the  most  ancient 
of  all  the  principles  of  morality,  the  foundation  of  all  medical  law — is,  that  we 
should  treat  our  patients  as  we  would  treat  ourselves  or -our  dearest  relatives ; 
now,  where  is  the  physician  who,  if  forced  to  decide  under  such  circumstances 
between  the  life  of  his  wife  and  that  of  the  child  she  still  bears  in  her  womb, 
would  hesitate  to  authorize  the  sacrifice  of  the  latter  ? 

We  are  therefore  justified  in  the  conclusion  that,  whenever  the  pelvis  exhibits 
but  two  inches  and  one-eighth  in  its  smallest  diameter,  embrj-otomy  ought  to  be 
resorted  to. 

But,  unhappily,  the  Crcsarean  operation  is  the  only  practicable  resource  when 
the  smallest  diameter  of  the  pelvis  does  not  exceed  two  inches;  for  the  extrac- 
tion of  a  mutilated  foetus  is  then  so  slow,  difficult,  and  painful,  that,  while 
necessarily  killing  the  child,  the  danger  to  the  mother  is  as  great  as  from  the 
performance  of  hysterotomy. 

The  almost  constant  failure  of  the  operation  in  large  cities,  such  as  London  and 
Paris,  as  compared  with  the  successes  obtained  in  smaller  localities,  has  suggested 
to  some  individuals  the  propriety  of  erecting  a  hospital  in  the  country,  or  at  least 
of  sending  out  of  town  such  patients  as  it  is  supposed  will  require  the  Cacsarean 

'  From  the  investigations  of  Villermd,  it  appears  that  in  France  20-100  of  tlie  inliabitants 
in  the  wealthy  departments,  die  at  one  year  of  age,  and  22-100  in  the  poor  ones;  31-lUO  in 
the  wealthy  departments  and  33-100  in  the  poor  ones  die  at  four  years  of  age;  38-100  in  the 
former  and  42-100  in  the  latter  die  at  ten  years;  and,  finally,  at  twenty  years,  rather  more 
than  42-100  die  in  the  wealthy  departments,  and  49-100,  that  is  to  say  nearly  one-half,  in 
the  poor  ones.  Yet  these  figures  do  not  include  children  abandoned  by  their  parents,  of 
whom,  notwithstanding  the  zeal  of  public  charity,  at  least  60  out  of  every  100  die  in  Paris 
within  the  year. 

M.  Villerm6"s  researches  are  confirmed  by  those  of  M.  Benoiston,  of  Chateauneuf. 


I 


CESAREAN     OPERATION.  863 

operation.  This  precaution  is  especially  insisted  upon  by  M.  Guisard,  who  has 
just  published  three  new  cases  of  success.  The  idea  could  not  be  carried  into 
execution  very  easily,  yet  I  think  it  deserves  to  be  considered,  and  sujrgested  to 
the  proper  authorities.  All  who  have  had  long  experience  of  the  diseases  of 
lying-in  women,  are  convinced  that  most  of  them  originate  in  the  assemblage  of 
a  large  number  of  newly-delivered  patients  in  the  same  place;  and  this  is  espe- 
cially true  as  regards  those  whose  labors  were  difficult,  and  required  a  bloody 
operation.  To  increase  the  number  of  lying-iu  institutions,  and  to  .separate  the 
patients  as  much  as  possible,  I  regard  as  the  surest  means  of  obtaining  an  early 
convalescence. 

Supposing  the  necessity  for  the  operation  has  been  fully  determined,  numer- 
ous important  questions  arise  for  consideration,  namely,  what  is  the  most  favor- 
able stage  of  the  labor  for  its  performance  ?  lias  the  previous  duration  of  the 
labor  any  positive  influence  over  the  result  ?  And  is  it  better  to  operate  before 
or  after  the  membranes  are  ruptured?  An  answer  to  all  these  questions  will  be 
found  in  the  careful  examination  of  the  published  cases. 

A.  Duration  of  Lahor. — The  whole  duration  of  the  labor  has  been  noted  in 
one  hundred  and  sixty-four  cases ;  in  sixty-two  of  which  the  woman  recovered, 
and  in  one  hundred  and  two  she  was  lost.  "With  a  view  of  showing  the  influence 
of  duration  as  regards  the  mother,  we  divide  these  cases  into  three  classes, 
namely : 

Where  the  operation  was  performed  after  tlie  labor  liad  lasted  twenty-four  honrs, 
there  were     .....         20  successful,  and  40  unsuccessful  cases. 
From  2.'3  to  72  hours,  there  were        .34  "  41  "  " 

More  than  72       "  "  .8  "  21  "  " 

62  102 

From  this  table,  which  is  taken  from  Keyser's  excellent  work,  we  may  con- 
clude that  the  duration  of  the  labor  would  appear  to  have  an  unfavorable  influ- 
ence only  when  it  has  continued  beyond  seventy-two  hours. 

But  the  same  remark  docs  not  apply  to  the  child;  for,  taking  the  same  one 
hundred  and  sixty-four  cases,  in  a  hundred  and  fifty-eight  of  which  the  infant's 
condition  is  reported,  we  find  that  fifty-seven  wore  stillborn,  and  a  hundred  and 
one  survived;  and,  adopting  the  same  division,  we  have  : 

After  a  duration  of  24  hours,      .         .         42  successful  and  IC  unsuccessful  cases. 
From  25  to  72     "  .         .         48  "  24  "  " 

More  than  72     "  ,         .         11  "  17  "  " 

101  57 

Whence  it  follows  that  the  chances  are  less  for  a  living  child  as  the  labor  is 
the  more  prolonged. 

B.  Rupture  of  the  3Iemhranes. — The  time  that  elapsed  after  the  membranes 
were  ruptured  has  been  stated  in  one  hundred  and  twelve  cases.  We  shall  like- 
wise classify  these  under  three  heads,  according  to  whether  the  operation  was 
performed : 


As  reirards  the  Mother. 


Successlul. 

U 

iisuccessl'ul. 

20 

19 

14 

21 

13 

25 

Cases. 

Successful. 

Slillliorn. 

=      37 

34 

3 

=      32 

25 

7 

=      37 

19 

18 

106 

78 

28 

864  DYSTOCIA. 


Cases. 
1st.  Before  nr  within  G  hours  after  the  membranes 

were  ruptured,     .  .  .  .  .  .    =     39 

2cl.  From  7  to  24  hours  after  the  rupture,      .         .    =      35 

3tl.  More  than  24  hours  after  the  rupture,     .  .    =     38 

112  47  G5 

From  which  it  appears  that  the  operation  is  so  much  the  more  unfavorable  for 
the  mother  as  a  greater  time  has  elapsed  after  the  rupture  of  the  membranes. 

The  fjxte  of  the  child  is  known  in  only  one  hundred  and  six  cases;  still  using 
the  same  classification,  we  have  : 

1st.   Before  or  within  6  hours  after  the  rupture, 
2d.  From  7  to  24  hours  after  tlie  rupture, 
3d.   ^lore  than  24  hours  after  the  rupture, 


C.  It  is  unnecessary  to  add  that,  with  regard  to  the  foetus,  the  prognosis  is 
much  more  unfavorable  when  an  artificial  extraction  has  been  attempted  before 
I'esorting  to  the  Cesarean  section.  Indeed,  it  must  be  evident,  from  the  fore- 
going facts,  that  the  most  favorable  time  for  operating  is  either  before  or  imme- 
diately after  the  rupture  of  the  membranes. 

Whenever  we  have  an  opportunity  of  attending  the  patient  during  the  last 
few  days  of  her  pregnancy,  it  is  advisable  to  prepare  her  for  the  operation  by  a 
suitable  regimen,  such  as  tepid  bathing,  moderate  bloodletting,  &c.  But  when 
the  labor  has  actually  commenced,  the  operation  is  to  be  proceeded  with  as  soon 
as  the  OS  uteri  is  sufficiently  dilated  to  permit  the  subsequent  discharge  of  the 
lochia.  It  has  been  recommended  to  puncture  the  membranes,  lest  the  waters 
be  effused  into  the  peritoneal  cavity ;  but  as  this  accident  can  very  easily  be  pre- 
vented, and  as  the  distension  of  the  womb  is  favorable  to  the  retraction  of  the 
organ  after  the  operation,  this  ought  not  to  be  done.  Just  before  commencing, 
the  bladder  and  rectum  are  to  be  emptied.  Two  bistouries,  the  one  convex,  the 
other  having  a  straight  probe-pointed  blade,  forceps,  ligatures,  cold  and  tepid 
water,  a  little  vinegar,  sponges,  needles  armed  with  thread,  quill-barrels,  strips  of 
adhesive  plaster,  some  charpie,  and  compresses,  and  a  bandage  for  the  body,  con- 
stitute the  necessary  apparatus. 

The  patient  is  then  laid  on  a  bed  of  the  proper  height,  and  is  held  quiet  by 
the  attendants;  an  intelligent  assistant  is  charged  with  the  duty  of  keeping  the 
womb  on  the  median  line  by  placing  his  hands  over  it;  and  another  presses  one 
hand  over  the  fundus  uteri  with  a  view  of  keeping  up  the  intestines,  which  are 
apt  to  become  insinuated  between  the  uterine  and  the  abdominal  walls.  The 
surgeon  then  makes  an  incision  along  the  median  line,  through  the  skin  and  sub- 
cutaneous fatty  tissue,  extending  from  a  little  below  the  umbilicus,  downwards  to 
within  an  inch  and  a  half  or  two  inches  of  the  pubis ;  this  incision  ought  to  be 
at  least  five  or  six  inches  long,  and  provided  this  extent  is  not  obtained  within 


C  CESAREAN     OPERATION.  8G5 

the  indicated  points,  in  consefjucncc  of  the  woman's  low  stature,  it  should  be 
prolonged  a  little  upwards  and  to  the  left  of  the  umbilicus.  The  operator  next 
divides  the  aponeurotic  fibres  of  the  linea  alba,  layer  b}'  layer,  and  thus  gets  to 
the  peritoneum,  into  which  he  then  makes  a  small  opening;  having  inserted  the 
index  finger  of  the  left  hand  into  this,  he  directs  the  prube-pointed  bistoury 
along  its  palmar  face  and  enlarges  the  incision.  The  tissue  of  the  uterus  is  now 
carefully  incised,  layer  by  layer,  until  the  surface  of  the  membranes  or  the  pla- 
centa is  brought  into  view;  the  bag  of  waters  is  then  opened  by  a  simple  punc- 
ture, and  the  probe-pointed  bistoury  is  entered  at  this  orifice,  and  the  incision 
enlarged  to  the  extent  of  five  or  six  inches,  directing  it  rather  toward  the  supe- 
rior than  the  inferior  angle  of  the  external  wound.  The  assistant,  who  is  charged 
with  the  duty  of  keeping  the  lips  of  the  wound  apart,  must  be  very  careful  to 
hold  the  abdominal  and  uterine  walls  in  contact  with  each  other  at  the  time 
when  the  membranes  are  ruptured.  The  extraction  of  the  foetus  is  afterwards 
accomplished  by  seizing  hold  of  the  first  extremity  that  presents.  The  uterus 
retracts  immediately  and  effects  the  detachment  of  the  placenta,  which  is  pushed 
towards  the  wound :  it  is  then  extracted  together  with  the  membraises,  which 
have  been  carefully  twisted  into  a  cord.  If  any  blood  has  escaped  into  the 
uterine  cavity,  it  is  removed,  as  well  as  any  other  foreign  body  that  may  obstruct 
the  cervix. 

The  wound  in  the  uterus  requires  no  other  attention  than  that  of  being  well 
cleansed.  The  lips  of  the  one  made  through  the  abdominal  walls  are  brought 
together  at  two  or  three  points  by  the  twisted  suture,  taking  care  to  leave  a  free 
space  towards  its  inferior  part  for  the  discharge  of  the  fluids  that  escape  from  the 
abdomen ;  strips  of  adhesive  plaster  are  used  between  the  points  of  the  suture, 
over  which  the  uniting  bandage  is  then  applied ;  the  wound  is  next  covered  with 
charpie  smeared  with  cerate,  and  common  compresses,  and  the  whole  retained  in 
situ  by  a  moderately  drawn  body-bandage.  The  subsequent  treatment  is  re- 
stricted to  combating  the  inflammatory  and  other  symptoms  as  they  may  arise, 

Vayinal  Cctsarean  Operation. — This  name  is  applied  to  the  incisions  which 
are  sometimes  made  on  the  neck  or  other  portion  of  the  uterus  that  projects  into 
the  vagina.  It  may  be  resorted  to  in  cases  of  partial  obliteration  of  the  cervix, 
where  a  scirrhous,  or  carcinomatous  degeneration  of  the  lips  prevents  its  dilata- 
tion ;  or  when  any  accident  occurs  necessitating  a  prompt  delivery  and  the  os 
uteri  is  not  sufficiently  dilated.  This  therefore  is  a  mere  division  of  the  neck, 
having  no  resemblance  whatever  to  the  CiBsarcan  operation  properly  so  called. 

But  in  some  instances  no  opening  at  all  is  to  be  found,  and  then  the  uterine 
wall  has  to  be  divided  for  the  purpose  of  creating  an  artificial  passage  for  the 
child.  This  latter  operation  has  been  practised  a  number  of  times  by  different 
persons,  among  others  by  my  friend.  Dr.  Caffe,  in  1833,  with  entire  success. 
The  mode  of  performing  it  is  very  simple  :  a  sharp-pointed  bistoury  is  carefully 
guided  up  along  the  left  forefinger  directly  upon  the  anterior  inferior  portion  of 
the  uterine  wall,  which  it  incises ;  but  the  instrument  must  not  be  pushed  in  too 
deep,  lest  the  presenting  part  of  the  child  be  wounded;  and  equal  care  is  requi- 
site to  avoid  prolonging  the  incision  too  far,  either  forwards  or  backwards,  for  fear 

55 


866 


DYSTOCIA. 


of  injuring  the  bladder  or  rectum.  Of  course,  the  lateral  incisions  are  the  least 
dangerous.  A  crucial  form  is  the  best  one  for  the  opening,  and,  the  latter  being 
effected,  the  delivery  is  generally  abandoned  to  nature. 


CHAPTER  IX. 


OF    EMBKYOTOMY. 


123. 


124. 


This  name  is  applied  to  the  operation  by  -which  the  parts  of  the  child  are 
divided  so  as  to  admit  of  their  successive  extraction,  when  it  is  impossible  to  ter- 
minate the  delivery  in  any  other  way.  In  some  cases,  it  consists  of  simple  punc- 
tures or  incisions  made  on  the  head,  chest,  or  abdomen,  ■with  a  view  of  diminish- 
ing its  size,  while  in  others  the  body  of  the  child  is  divided  into  several  parts. 

It  was  elsewhere  stated  that,  whenever  a  considerable  quantity  of  water  had. 
accumulated  in  the  head,  chest,  or  bell}-,  the  fluid  could  easily  be  evacuated  by  a 
simple  puncture  with  a  straight  bistoury,  or  still  better  by  a  trocar;  and,  there- 
fore, we  need  not  recur  to  the  subject.    (See  Hydrocephalus.) 

Embryotomy  is  indicated  whenever  there  is  any  insurmountable  obstacle  to  the 
spontaneous  expulsion  of  the  child,  and  where  an  application  of  the  forceps  proves 
insufficient  to  effect  the  delivery;  always  supposing  that  the  foetus  is  dead,  or 
there  are  good  reasons  for  believing  that  its  viability  is  destroyed  by  the  length 

of  the  labor.  This  operation  is  resorted  to  in 
England  much  oftener  than  in  France ;  for 
most  of  the  accoucheurs  of  that  country  pro- 
scribe the  Cesarean  section  and  symphyse- 
otomy, except  in  cases  of  absolute  necessity, 
but  they  do  not  hesitate  to  mutilate  the  infant, 
even  when  it  is  still  living ;  and  the  reader  will 
have  seen,  from  the  foregoing  chapters,  that  we 
fully  embrace  the  same  opinion. 

Of  course,  when  the  pelvis  is  thus  contracted, 
the  child  may  present  either  by  its  pelvic  or  its 
cephalic  extremity,  or  by  some  intermediate 
portion  of  the  body,  at  the  superior  strait ;  and 
therefore,  we  have  to  describe  the  operation  re- 
sorted to  in  these  different  cases. 
A.  Presentation  of  the  Head. — Embryotomy  having  been  decided  upon,  the 
surgeon  should  proceed  to  the  operation  as  early  as  possible,  with  a  view  of 
sparing  the  patient  useless  and  often  dangerous  exertions.  The  artificial  dimi- 
nution of  the  head  is  compounded  of  several  successive  operations,  the  whole  of 
which  constitute  craniotomy,  ov  ceplialotomij ;  these  are,  the  perforation  of  the 
cranium,  the  removal  of  the  cerebral  matters,  and  the  crushing  of  the  base  of 


Fig.  123.   Smellie's  scis.<ors  closed. 
Fiff.  124.  The  same  opened. 


EMBRYOTOMY. 


867 


Fig.  125. 


the  skull.  Numerous  instruments  have  been  devised  for  each  of  these  purposes, 
but  we  shall  only  enumerate  those  which  appear  preferable. 

Craniotomy. — The  perforation  of  the  cranium  can  be  accomplished  by  a 
straight,  sharp-pointed  bis- 
toury ;  but  the  best  instru- 
ment by  far  for  this  purpose 
is  Smellie's  scissors,  which  is 
very  strong,  and  has  its  cut- 
ting edges  externally;  and, 
being  terminated  by  a  sharp 
point,  is  admirably  calculated 
for  penetrating  through  the 
osseous  vault ;  when,  by  open- 
ing the  handles,  the  original 
orifice  is  easily  enlarged.  The 
patient  being  placed  in  a  pro- 
per position,  the  instrument 
is  held  in  the  right  hand,  and 
its  point,  covered  by  a  little 
pellet  of  wax,  is  carefully 
guided  along  the  palmar  sur- 
face of  the  left  one,  previously 
introduced  into  the  vagina 
(see  Fig.  125)  directly  upon 

the  head,  on  a  fontanelle,  or  suture,  if  possible;  but  if,  as  generally  happens, 
this  is  not  feasible,  the  point  of  the  scissors  is  applied  against  one  of  the  cranial 
bones,  being  careful  to  place  it  perpendicularly  on  the  part,  to  prevent  its  slip- 
ping. It  penetrates  easily  through  the  scalp  which  is  often  quite  thick,  and  as 
soon  as  it  is  felt  to  have  reached  the  bone,  the  instrument  is  rotated  in  opposite 
directions,  until  the  want  of  resistance  shows  that  it  has  entered  the  cranium. 
The  opening  is  next  enlarged,  either  by  pressing  the  handles  of  the  scissors  apart, 
or,  if  deemed  more  advisable,  by  making  a  second  incision  at  right  angles  to  the 
first.  The  instrument  is  now  pushed  deeper,  and  moved  about,  so  as  to  break  up 
the  cerebral  mass. 

M.  Ilippolyte  Blot,  has  latterly  had  a  perforator  constructed  by  M.  Charricre, 
which,  I  think,  is  destined  to  supersede  S7neUic's  scissors,  generally  made  use 
of  hitherto.  It  possesses  all  the  advantages  of  the  latter  without  its  incon- 
veniences. 

This  craniotome  is  composed  of  two  blades,  which  cover  each  other,  so  that 
when  the  instrument  is  closed,  the  blunt  edge  of  one  extends  slightly  beyond 
the  cutting  edge  of  the  other,  and  reciprocally. 

Each  free  surface  bears  at  its  extremity  A,  a  projection,  which  gives  to  the 
point  of  the  instrument  a  quadrangular  form  (these  projections  are  borrowed 
from  the  perforator  of  i\I.  Marehand,  of  Charenton) ;  a  screw  fixed  on  the  inter- 
nal surface  of  the  movable  branch  d,  enters  a  notch  in  the  opposite  branch,  and 


Mode  of  introducing  and  using  Smellie's  scissors. 


868 


DYSTOCIA. 


limits  its  motion  in  one  direction,  whilst  the  spring  c,  limits  it  in  the  opposite 
one. 

The  two  branches  are  articulated  in  a  manner  peculiar  to  M.  Charriere  ((2 
town),  which  admits  of  thc-ir  being  readily  dismounted. 

The  patient  being  placed  in  a  suitable  position,  the  operator  grasps  the  instru- 
ment by  its  handle,  with  his  right  hand,  and  introduces  it  to  the  head  of  the 
foetus  by  passing  it  along  the  palmar  surface  of  the  fore  and  middle  fingers  of  the 
left  hand,  which  also  serve  to  keep  it  in  its  place  ;  it  is  then  rotated  on  its  axis  like 
a  punch,  until  it  penetrates  the  cranium,  which  is  indicated  by  the  cessation  of 
resistance.  Then,  and  not  before,  the  instrument  is  opened  for  the  purpose  of 
enlarging  the  aperture.  To  effect  this,  the  left  hand  retains  its  position,  and 
holds  the  instrument,  whilst  the  extremities  of  the  four  fingers  of  the  right  hand 
press  upon  the  lever  D,  the  handle  resting  upon  the  thenar  eminence. 


Fics.  12G  and  127. 


Fig.  128. 


Fig.  126.  Cephalotome  closed. 
Fig.  127.  Cephalotome  opeued. 


Fig.  12S.  Cephalotome  incising  the  cranium. 


The  brain  is  afterwards  broken  up  by  inserting  the  instrument  still  deeper, 
and  moving  it  in  all  directions. 

Before  withdrawing  the  craniotonic,  it  is  allowed  to  close  itself,  after  which 


EMBRYOTOMY.  869 

its  extraction  from  the  genital  parts  is  unattended  witli   danger  either  to  the 
vaginal  mucous  membrane,  or  to  the  fingers  of  the  operator. 

The  principal  advantages  of  this  instrument  may  be  summed  up  as  follows  : 

1.  Great  solidity  and  simplicity. 

2.  Introduction  and  withdrawal  entirely  safe,  rendering  it  capable  of  being 
used  by  the  least  experienced  operators. 

3.  Capability  of  acting  by  pressure,  and  that  with  a  single  Jiand,  the  other 
remaining  at  liberty  to  guide  the  instrument,  keep  it  in  its  place,  and  know  what 
becomes  of  it  during  the  operation. 

4.  Power  of  perforating  the  bones  with  the  least  effort,  and,  consequently, 
with  the  least  chance  of  slipping. 

5.  It  is  easily  dismounted  and  cleaned. 

6.  Finally,  simplicit}-  of  structure,  rendering  it  a  cheaper  instrument  than 
Smellie's  scissors,  provided  with  their  sheath. 

\Yhatever  instrument  is  used  for  perforating  the  cranium,  the  second  stage  of 
the  operation,  or  evacuation  of  the  cerebral  substance,  should  be  immediately 
performed.  This  is  done  by  injections  through  the  opening  which  has  been 
made,  by  means  of  a  syringe,  provided  with  a  long  canula.  But  such  injections 
are  generally  superfluous  when  the  embryotomy  forceps  is  to  be  used,  for  the 
pressure  made  by  it  is  quite  sufficient  to  produce  the  evacuation. 

If  the  woman  is  not  much  exhausted,  and  the  pelvic  contraction  is  not  such  as 
to  preclude  the  passage  of  the  base  of  the  skull,  the  operation  might  be  sus- 
pended for  a  time,  and  the  subsequent  delivery  be  left  to  the  powers  of  nature ; 
but,  under  other  circumstances,  the  common  forceps,  or  even  the  embryotomy 
forceps,  where  the  narrowed  pelvis  is  less  than  three  inches,  ought  to  be  ap- 
plied. 

This  latter  instrument  is  advantageously  substituted  for  the  serrated  pincers, 
the  sharp  crotchets,  and  all  the  other  murderous  implements  that  were  formerly 
used  in  these  difficult  cases.  The  honor  of  its  invention,  notwithstanding  several 
rival  claims,  is  due  to  M.  A.  Baudelocque,  nephew  of  the  celebrated  accoucheur 
of  that  name.  It  is  composed  of  two  long  branches,  the  blades  of  which  are  de- 
void of  fenestra,  and,  besides,  are  far  less  curved  than  those  of  the  ordinary 
forceps,  so  that,  when  closed,  they  can  pass  through  a  diameter  not  exceeding 
two  inches.  The  two  branches  articulate  with  each  other  near  the  middle,  and 
when  they  are  joined,  the  blades  can  be  tightened  at  pleasure,  by  means  of  a 
screw  passing  through  the  ends  of  the  handles,  and  worked  by  a  powerful 
lever. 

Even  as  it  is  now  constructed,  Baudelocque's  embryotomy  forceps  is  certainly 
a  very  useful  instrument;  but  as  I  have  elsewhere  proved  {Revue  Medicale, 
May,  1843),  it  presents  some  disadvantages  which  render  Its  application  difficult 
and  often  even  dangerous.  For  Instance  :  1.  It  is  too  straight  to  accommodate 
itself  to  the  curvature  of  the  pelvis,  and  it  is  therefore  applied  with  difficulty  to 
the  sides  of  the  head ;  2.  As  the  clams  are  nearly  plane  they  open  like  a  pair  of 
scissors,  and  do  not  encase  the  head,  as  the  concave  blades  of  the  ordinary  for- 
ceps do;  consequently,  they  are  liable  to  slip,  and  thus  give  rise  to  serious  acci- 


870 


DYSTOCIA. 


(lonts;  3.  Tractions  made  by  it  are  very  often  ineffectual,  even  when  well 
applied  to  the  head ;  because  it  necessarily  draws  in  a  direction  different  from 
the  axis  of  the  superior  strait,  owing  to  the  absence  of  curvature  in  the  edges  of 
its  blades. 

As  the  difficulties  and  dangers  attending  its  use  are  not  imaginary,  I  have 
endeavored  to  prevent  them,  by  suggesting  a  modification  in  the  embryotomy 
forceps  generally  employed,  although  well  convinced  that  the  failure  of  an  opera- 
tion is  very  frequently  more  dependent  on  the  operator  himself  than  on  his  in- 
strument. With  this  view,  I  had  an  instrument  made  by  M.  Charrit^re,  which 
differs  in  two  important  particulars  from  those  hitherto  constructed,  and  which 
seems  to  obviate  the  various  disadvantages  I  have  just  enumerated. 

We  stated  above  that  the  absence  of  curvature  in  the  edges  interfered  very 
seriously,  with  the  seizure  of  the  head,  which  is  found  more  anteriorly  than  in 
well-formed  pelves,  both  in  consequence  of  the  pelvic  contraction  and  its  own 
elevation ;  hence,  we  have  given  a  curvature  to  our  forceps  slightly  exceeding 
that  of  Levret's.  This,  however,  did  not  require  a  great  effort  of  the  imagination, 
for  we  have  only  impressed  the  same  modification  of  the  embryotomy  forceps 
that  Smellieand  Levret  long  since  gave  to  the  one  invented  by  the  Chamberlens. 
This  curvature  is  intended  to  fulfil  the  indication  of  accommodating  the  shape  of 
the  instrument  to  that  of  the  curved  canal  it  has  to  traverse. 

The  slipping  of  the  head  during  the  tractions  is  principally  owing  to  the  fact, 
as  averred  above,  that  the  blades,  from  being  nearly  plane  on  their  internal  sur- 


Fi-;.  129. 


Fig.  130. 


The  embryotomy  or  cephalotribe  forceps. 

A  comparison  of  ihese  two  figures  will  furnish  an  idea  of  the  amount  of  separation  obtained  at  the  base 
of  the  blades  (Fig.  130),  by  means  of  the  regulating  screw. 

face,  do  not  properly  embrace  this  part,  and  that,  opening  like  a  pair  of  scissors, 
their  widest  separation  is  found  at  the  points.  Here  the  difficulty  was  consider- 
ably greater,  because  the  internal  surface  of  the  clams  could  not  be  hollowed  out 


E  M  B  R  Y  0  T  0  JI  Y. 


871 


■without  greatly  increasing  the  interval  at  their  middle  part,  and,  consequently, 
without  rendering  the  instrument  inapplicable  to  a  host  of  cases  where  Baude- 
locque's  might  be  successfully  used.  After  mature  reflection,  we  propose  the 
following  as  its  second  and  most  important  modification  :  namely,  to  make  a  much 
wider  entablature  at  the  joint;  v/hile,  in  other  respects,  the  length  and  width  of 
our  forceps  correspond  with  Baudelocque's.  This  increased  vridth  at  the  articular 
part  permits  the  base  of  the  blades  to  be  removed  from  each  other  laterally  by 
means  of  a  regulating  screw,  that  can  be  turned  at  will;  the  point  of  which,  by 
working  on  the  pivot,  will  permit  a  greater  separation  at  the  base  than  at  the 
points  of  the  blades.  Hence,  it  is  evident  that  when  the  head  is  once  embraced 
by  the  instrument  it  cannot  slip  from  the  extremity  of  the  clams  during  the 
tractions,  because  the  interval  is  much  less  here  than  at  the  base  or  even  than 
at  their  middle  part.  In  a  word,  the  embryotomy  forceps  hitherto  employed 
resembles  a  cone  when  half  opened,  the  base  of  which  is  at  the  points  of  the 
blades,  and  the  apes  at  the  articulation ;  but  ours,  on  the  contrary,  may,  under 
the  same  conditions,  be  compared  to  a  cone  having  its  base  at  the  articular  part, 
and  its  summit  at  the  extremity  of  the  blades.  M.  Baudelocque  has  erred  in 
endeavoring  to  extend  the  employment  of  the  embryotomy  or  cephalotribe  forceps 
beyond  its  sphere.  But  when  restricted  within  proper  limits,  it  certainly  con- 
stitutes one  of  the  most  useful  instruments  in  obstetric  surgery ;  for  experience 
has  already  shown  that  it  may  render  invaluable  service  whenever  the  smallest 
diameter  of  the  strait  amounts  to  two  inches;  but,  less  than  that,  it  cannot  re- 
duce the  size  of  the  head  sufficiently  to  enable  it  to  pass  through  the  contracted 
part.  Hence  (as  already  stated,  when  treating  of  the  indications  presented  by 
the  pelvic  deformities),  the  Csesarean  operation  is  our  only  resource  where  the 
contracted  strait  does  not  afford  two  inches  of  space. 

The  application  of  the  cephalotribe  is  regulated  by  the  same  rules  as  that  of 
the  ordinary  forceps,  being  always  introduced  on   the  sides  of  the  pelvis.     The 

Fig.  131. 


The  emliryotomy  forceps  applied  and  locked. 


greatest  precaution  is  requisite  to  ascertain  po.sitively  that  the  instrument  has 
really  entered  the  uterine  cavity,  and  that  none  of  the  mother's  parts  are  pinched 
by  its  clams. 

After  the  blades  are  articulated,  a  strong  pressure  is  made  on  the  head  by 
means  of  the  winch  attached  to  the  end  of  the  handles ;  and,  when  the  reduction 


S72  DYSTOCIA. 

is  supposed  to  be  sufficient,  tlie  operator  takes  hold  of  the  instrument  witli  both 
hands,  and  endeavors  to  make  the  head  engage,  by  resorting  to  tractions  in  the 
proper  direction.  Of  course,  as  this  descends,  he  must  accommodate  tlie  line  of 
traction  to  the  axis  of  the  part  through  which  it  is  passing. 

In  case  of  necessity,  and  if  there  was  no  embryotomy  forceps  at  hand,  the 
practitioner  should  resort  to  the  crotchet,  and  carefully  fix  it  on  one  of  the  most 
solid  parts  of  the  cranium.  But  the  greatest  possible  care  must  be  taken  to  pre- 
vent its  slipping,  and  to  protect  the  soft  parts  of  the  mother  from  its  point. 
Ilowever,  it  is  out  of  the  question  to  lay  down  positive  rules  for  the  regulation  of 
its  use  in  all  cases ;  the  operator  must  be  governed  by  circumstances. 

It  would  certainly  be  much  better  to  use  strong-toothed  or  hooked  pincers, 
articulated  in  the  usual  style  or  like  the  forceps.  One  of  the  jaws  should  be  in- 
troduced in  the  opening  made  in  the  cranium,  while  the  other  is  applied  to  some 
part  of  the  external  surface.  These  instruments  are  far  less  likely  to  wound  the 
mother's  parts  than  the  sharp  crotchet. 

There  are  pelves  so  exceedingly  contracted,  that  it  is  impossble  to  extract  the 
head  even  when  crushed  by  the  embryotomy  forceps,  and  by  too  long-continued 
efforts,  the  patient's  risks  maybe  greatly  enhanced.  M.  Van  Huevel  has  devised 
a  very  inirenious  instrument  which  he  called  the  saio  forceps,  which  enables 
him,  after  seizing  the  head,  to  divide  it  transversely  from  above  downward,  be- 
tween the  blades  of  the  instrument.  The  portions'  can  then  be  extracted 
separately,  and  as  they  flatten  of  themselves,  and  yield  to  the  slightest  traction, 
they  neither  wound  nor  bruise  the  patient. 

I  borrow  the  description  and  mode  of  operation  from  the  Belgian  edition  of 
this  work,  to  which  they  are  added  in  a  note  by  M.  Van  Huevel  himself.' 

.  '  It  is  composed  ; 

1.  Of  an  ordinary  forceps,  each  blade  of  which  bears  internally  two  tubes  flattened  in 
opposite  directions,  and  soldered  together,  the  side  of  one  against  the  surface  of  the  other,  so 
that  their  horizontal  section  represents  an  overturned  H.  They  are  bent  from  without  in- 
ward, like  the  forceps  itself,  but  are  set  in  a  straight  line  from  below  upwards,  and  from 
behind  forward  in  one,  or  curved  on  the  anterior  edge  in  the  other.  The  inUrnal  of  the 
tubes  encloses  a  steel  blade  which  conducts  the  saw;  the  extenuil,  which  is  directed  across 
the  instrument,  lodges  the  prolongation  of  the  chain.  They  communicate  by  a  large  slit, 
which  divides  the  internal  and  external  walls  of  the  former  throughout  its  length,  and  the 
internal  side  only  of  the  latter.  The  forceps  articulates  by  entablature,  with  a  movable 
pivot;  upon  the  base  of  the  latter  turns  a  support  perforated  with  a  hole,  in  which  is  inserted 
a  grooved  key. 

2.  Of  a  clock  chain,  toothed  as  a  saw  in  the  middle  of  its  length  for  the  space  of  eight  and 
a  half  inches,  and  provided  with  transverse  handles,  one  of  which  can  be  unhooked.  Tliis 
chain  passes  by  the  upper  opening  of  two  steel  blades,  which  are  flexible  above,  and  thicker 
and  toothed  below,  and  which,  by  entering  the  internal  tubes,  conduct  the  saw  between  the 
blades  of  the  forceps. 

3.  Of  a  long  key,  with  grooves  and  collar,  like  that  of  Heurteloup's  instrument  for  crushing 
calculi,  entering  into  the  hole  of  the  support  upon  the  base  of  the  articular  pivot,  and  fitting 
into  the  teeth  of  the  conducting  blades.  The  extremity  of  the  handle  is  split,  and  serves  to 
turn  the  pivot  of  the  forceps,  as  also  for  drawing  out  separately,  with  one  of  the  t\\o  points, 
the  blades  from  their  sheaths. 


EMBRYOTOMY.  873 

Further  trials  are  evidently  required  to  confirm  the  advantages  claimed  by  M. 
Yan  ITuevel  for  his  instrument.  We  know  that  it  has  been  used  but  a  few 
times  in  France,  and  that  it  has  failed  in  skilful  hands.  Still,  this  is  no  reason 
for  passing  over  the  successes  attributed  to  it  by  the  Brussels  accoucheur,  and 
we  recommend  that  it  be  afforded  a  fair  trial. 

The  instrument  should  only  be  applied  when  the  woman  cannot  be  delivered  eitlier  natu- 
rally, or  with  the  assistance  of  the  vectis,  forceps,  or  by  turning;  the  neck  of  the  womb 
should  also  be  dilated,  and  the  membranes  ruptured.  Before  operatin;^,  a  bed  should  be 
prepared  with  a  straw  mattress,  and  a  mattress  folded  double;  bolsters,  pillows,  napkins, 
and  bedcloths,  make  up  this  part  of  the  provision.  The  woman  lies  upon  her  back,  with  the 
hips  brought  down  to  the  etlge  of  the  mattress;  the  legs  and  thighs  are  flexed,  and  held 
apart  by  two  aiils,  one  on  either  side.  The  forceps  are  warmed  slightly,  and  greased  exter- 
na My. 

Suppose  the  head  presents,  no  matter  in  what  position.  The  operator  takes  his  place 
before  the  woman,  and  inserts  first  on  the  left  side  of  the  pelvis,  the  male  branch,  if  he  uses 
the  straigiitest  forceps,  or  the  female  branch,  if  he  uses  the  one  with  the  greatest  curvature. 
He  introduces  it  as  far  as  possible  into  the  uterus,  and  one  of  the  assistants  holds  it,  whilst 
the  other  is  passed  in  on  the  right  side.  When  the  forceps  is  articulated,  a  few  tractions  are 
made,  in  order  to  be  certain  that  the  head  is  well  seized.  The  surgeon  gives  the  handle  of 
the  instrument  to  the  assistant  on  his  right,  whilst  he  surrounds  it  with  a  ligature.  Then, 
immersing  the  ends  of  the  conducting  blades,  armed  with  the  saw,  in  oil,  he  introduces  both 
of  them  into  their  respective  sheaths  until  they  touch  the  head  of  the  foetus.  He  next  passes 
the  key  beneath  the  left  thigh  of  the  patient,  and  engages  the  grooved"  end  in  the  opening  of 
the  support;  the  assistant  takes  its  handle  in  his  right  hand,  and  turns  the  key  slowly  on  its 
axis,  whilst  the  operator  puts  the  saw  in  motion.  Care  should  be  taken  to  prevent  the  chain 
from  twisting,  and,  as  far  as  possible,  to  make  the  tractions  in  the  direction  of  the  guiding 
tubes.  Unless  the  key  is  turned  very  slowly,  the  saw  will  be  arrested  by  pressing  too 
strongly  upon  the  bones  of  the  head.  Should  this  occur,  the  assistant  must  reverse  the 
motion  of  the  key  slightly,  and  afterward  continue  the  manoeuvre  until  the  operation  is  com- 
pleted. 

When  the  section  is  finished,  the  key  is  taken  out,  and  the  handle  of  the  chain  unhooked 
thai  it  may  be  witlidrawn  ;  the  conducting  blades  are  also  removed,  and,  finally,  the  branches 
of  the  instrument  itself,  after  their  disarticulation. 

At  this  stage  of  tlie  operation,  if  the  woman  is  not  exhausted,  and  expulsive  pains  make 
their  appearance,  the  rest  is  left  to  nature,  being  careful  to  ascertain  the  disposition  of  the 
segments  by  the  touch.  A  jiart  of  the  brain  escapes,  the  sawn  edges  override  each  other, 
the  two  portions  of  the  craniimi,  especially  the  posterior  one,  become  flattened,  in  conse- 
quence of  their  being  traversed  by  flexible  sutures,  and  the  foetus  is  eventually  expelled. 
When,  on  the  contrary,  the  woman's  strength  is  exhausted,  the  detached  portion  of  the  head 
is  seized  with  the  abortion  forceps  or  a  pair  of  pincers,  and  therewith  extracted.  Should 
it  happen,  that  in  consequence  of  the  blades  of  the  forceps  not  liaving  been  introduced  far 
enough  into  the  pelvis,  the  division  was  not  thoroughly  effected,  the  adhesions  should  be 
broken  up  by  means  of  twisting  and  other  motions  communicated  by  the  pincers  :  as  soon 
as  the  segment  is  detached,  both  it  and  the  reinaining  parts  will  pass  without  difilculty. 

However,  should  any  trouble  be  experienced  in  extracting  the  fragments,  there  is  no 
reason  why  another  section,  difierent  from  the  first,  should  not  be  made,  by  giving  another 
direction  to  the  forceps.  The  already  divided  cranium  can  be  depressed  without  difficulty 
and  therefore  cannot  prevent  the  diagonal  application  of  the  branches.  This  second  opera- 
lion  leaves  tlie  skull  divided  into  four  tmequai  portions  capable  of  being  compressed  in  any 
direction,  and  extracted  without  difllculty. 


874  DYSTOCIA. 

B.  Presentation  of  the  Pdilc  Extremity. — Should  tlie  head  be  arrested  by  a 
contraction  of  the  pelvis,  after  the  delivery  of  the  breech,  and  the  attempts  made 
for  its  removal  prove  ineffectual,  a  resort  to  craniotomy  appears  to  us  the  only 
resource,  whether  the  child  be  living  or  dead.  But  in  these  cases  the  base  of 
the  cranium  presents,  a  perforation  of  which  is  attended  with  much  more  diffi- 
culty than  any  other  part;  and,  therefore,  the  point  of  the  perforating  instru- 
ment ought  to  be  entered  at  the  posterior  part  of  the  occipital  bone.  The 
application  of  the  embryotomy  forceps  will  also  require  greater  precaution,  and 
will  be  attended  with  more  difficulty,  from  the  presence  of  the  trunk  in  the 
excavation ;  and,  should  this  obstacle  prove  insurmountable,  the  child  may  be 
decapitated,  and  the  head  alone  be  left  in  the  parts. 

But  this  is  not  the  only  case  in  which  the  separated  head  is  left  behind  in  the 
uterus,  for  it  will  presently  appear  that  a  similar  course  is  adopted  in  certain 
trunk  presentations;  or,  the  same  thing  may  happen  from  ignorance  or  stupidity. 
In  all  cases  the  head  has  to  be  delivered,  and  its  extraction  is  exceedingly  pain- 
ful when  the  pelvis  is  much  deformed;  for  it  then  presents  by  its  base,  thereby 
rendering  a  perforation  more  difficult.  Under  such  circumstances,  it  has  been 
recommended  to  attempt  to  turn  the  head,  so  as  to  bring  some  portion  of  the 
cranial  vault  to  the  superior  strait,  which  of  course  should  be  done  whenever 
possible.  The  excessive  mobility  of  the  head  singularly  favors  the  slipping  of 
the  perforator,  and  exposes  the  mother's  parts  to  laceration.  The  best  way  of 
preventing  this  accident,  is  to  direct  an  assistant  to  place  both  hands  over  the 
hypogastric  region,  and  fix  the  head  there  by  making  considerable  pressure  at 
that  point. 

But  the  difficulty  is  not  brought  to  an  end  by  the  perforation  of  the  cranium, 
for  even  then  the  embryotomy  forceps  will  often  become  necessary  if  the  con- 
traction is  excessive ;  and,  owing  to  the  mobility  of  the  part,  its  application  is 
very  imperfect,  and  it  is  likely  to  slip  at  the  first  tractive  effijrt.  The  trouble  in 
getting  hold  of  the  head  is  not  merely  dependent  on  its  mobility,  because,  when 
the  inclination  of  the  superior  strait  is  very  great,  it  is  situated  above  the  pubis, 
and  therefore  cannot  be  reached  by  the  instrument,  which  is  necessarily  directed 
posteriorly,  in  consequenee  of  its  moderate  curvature. 

It  was  to  this,  that  I  attributed  the  failure  of  the  attempts  made  on  one  occa- 
sion by  M.  Paul  Dubois,  at  la  Maternite.  The  Professor,  being  worn  out  by 
several  hours  of  fruitless  manipulations,  had  the  kindness  to  permit  my  assistance. 
I  introduced  the  right  hand,  and  got  hold  of  the  lower  jaw,  which  I  attempted 
to  draw  down,  but  without  any  better  success,  as  the  base  of  the  cranium  was 
arrested  by  the  symphysis;  I  found  that  the  failure  of  my  tractions  was  owing 
to  the  fact  of  their  being  directed  too  far  downwards  and  forwards;  I  then  sub- 
stituted a  blunt  hook  for  the  finger,  and  fixed  it  on  the  lower  jaw,  when,  by 
depressing  the  handle  of  the  instrument  posteriorly,  so  as  to  make  it  operate 
downwards  and  backwards,  I  was  soon  fortunate  enough  to  get  the  head  into  the 
excavation,  from  which  it  was  readily  delivered  afterwards. 

Most  of  the  difficulties  met  with  in  this  case  might  certainly  have  been  pre- 
vented, by  using  the  instrument  just  described,  invented  by  myself.  (For 
further  details,  see  the  before-mentioned  article  in  the  Revue  Aledicale.) 


EMBRYOTOMY. 


875 


Fi^.  132. 


C.  Presentation  of  the  Trunk. — Version  is  not  always  practicable  in  the  trunk 
presentations ;  for  instance,  where  the  membranes  have  been  ruptured,  and  the 
waters  discharged  for  some  time,  and  the  shoulder  is  low  down  in  the  excava- 
tion, the  forcible  contraction  of  the  uterus  may  render  an  introduction  of  the 
hand  and  version  of  the  foetus  absolutely  impossible.  In  such  a  case,  we  have 
nothing  to  do  but  to  wait  for  spontaneous  evolution,  if  the  child  is  living ;  but, 
as  soon  as  it  is  dead,  we  must  promptly  relieve  the  mother  from  the  dangerous 
consequences  of  a  prolonged  labor. 

To  amputate  the  arm  under  such  circumstances  is  altogether  useless,  because 
its  presence  cannot  incommode  the  operator;  and,  besides,  it  may  afterwards 
prove  very  serviceable  by  favoring  the  tractions ;  it  is  on  the  body  we  have  to 
act.  Various  plans  have  been  suggested  for 
this  purpose,  but  those  described  by  Celsus 
and  Dr.  Lee  are  the  only  ones  that  appear 
practicable.  In  cases  of  this  kind,  Celsus 
had  recourse  to  decapitation ;  and  I  have 
known  this  plan  to  be  employed  by  M. 
Dubois  on  several  dilFerent  occasions.  lie 
acts  in  the  following  manner :  Having 
ascertained  the  exact  situation  of  the  child's 
neck,  he  introduces  the  whole  hand  into 
the  uterus  (the  left  one  when  the  head  is 
at  the  right  side,  and  the  right  one  when  it 
is  at  the  left),  and,  hooking  the  index 
finger  over  the  cervical  region,  he  endeavors 
to  draw  it  downwards,  so  as  to  make  tliis 
part  more  accessible;  should  the  finger  not 
prove  sufficient,  the  blunt  hook  is  advan- 
tageously substituted  for  the  same  purpose 
(see  Fig.  132).  A  pair  of  long  scissors, 
having  thick  and  very  sharp  blades,  and 
moderately  curved  on  the  side,  so  as  to 
correspond  with  the  axis  of  the  pelvis,  is  then  guided  up  to  the  infant's  neck 
along  the  palmar  surface  of  the  hand  previously  introduced;  then  the  blades  are 
opened  a  little,  and  a  small  portion  of  the  neck  is  cut,  then  a  second,  and  thus, 
by  repeated  small  incisions,  its  whole  extent  is  gradually  divided.  When  the 
decapitation  is  completed,  he  draws  on  the  arm  which  is  usually  found  in  the 
vagina,  in  this  way  extracting  the  trunk  without  much  difficulty ;  and  after- 
wards he  delivers  the  head  in  the  manner  above  stated. 

Kamsbotham,  Sr.,  devised  an  instrument  resembling  the  blunt  hook,  and 
having  a  cutting  blade  concealed  within  its  curved  part;  when  the  neck  is  pro- 
perly secured,  this  blade  is  detached  from  the  principal  stem,  so  as  to  operate 
like  the  guillotine  on  the  child's  neck.  M.  Van  der  Ecken,  has  recently  pro- 
posed for  the  same  purpose,  to  embrace  the  child's  neck  with  a  blunt  hook  con- 
taining a  chain  saw. 


Mode  of  using  the  blunt  hook  in  ihe  trunk 
presentations,  to  bring  down  the  neck. 


87G  DYSTOCIA. 

The  decapitation  is  not  always  feasible,  at  least  we  could  not  succeed  in 
effecting  the  section,  in  a  case  to  which  we  Avere  called  by  Doctor  Lcveille.  The 
head  and  neck  were  so  high,  and  the  uterus  so  strongly  contracted,  that  it  was 
not  possible  to  get  the  hand  and  scissors  far  enough  up  to  embrace  the  neck 
properly ;  after  several  fruitless  attempts,  we  determined  to  perform  the  opera- 
tion recommended  by  Doctor  Lee,  but,  before  doing  so,  concluded  to  try  the 
pelvic  version.  The  right  hand  was  passed  in  as  far  as  the  breech,  but  it  could 
not  reach  the  feet ;  the  forefinger,  curved  like  a  hook,  grasped  the  buttocks, 
and  whilst  this  hand  was  pulling  on  the  breech,  the  side  of  the  foetus,  which 
had  already  engaged  in  the  excavation,  was  pushed  upwards  and  to  the  right  by 
the  fingers  of  the  other  hand.  By  operating  in  this  manner  for  five  or  six 
minutes  we  were  fortunate  enough  to  bring  down  the  pelvic  extremit}',  and  thus 
terminate  the  labor  favorably  as  regards  the  mother.  The  lying-in  presented 
nothing  unusual. 

Doctor  Lee's  method  consists  in  separating  the  arm  from  the  body,  as  also 
in  perforating  the  thorax  and  abdomen ;  then,  by  fixing  the  blunt  hook  on  the 
pelvis  or  lower  part  of  the  spine,  he  makes  use  of  sufiicient  force  to  bring  the 
child  down  double,  and  thus  effects  its  delivery  by  a  mechanism  very  similar  to 
the  spontaneous  evolution.  Perhaps  it  would  be  better  to  follow  Davis's  plan, 
and  divide  the  trunk  in  two,  and  afterwards  extract  the  parts  separately.'  This 
method  should  never  be  resorted  to  except  when  the  section  of  the  neck  is  im- 
possible. 

In  a  case  in  which  version  could  not  be  effected,  M.  Pamart  resorted  to  a  pro- 
cess somewhat  resembling  that  of  Dr.  Lee's,  except  that  he  did  not  first  amputate 
the  arm,  this  very  properly  seeming  to  him  an  altogether  useless  preliminary. 
Making  use  of  the  blunt  hook  which  terminates  the  handle  of  the  forceps,  he 
passed  it  beyond  the  false  ribs,  and  then  turning  it  forcibly,  so  as  to  bring  its 
extremity  in  contact  with  the  integuments  of  the  foetus,  he  perforated  with  it 
the  walls  of  the  abdomen,  if  unable  to  reach  the  ribs,  so  that  in  withdrawing  it, 
it  hooked  into  the  lower  border  of  the  thoracic  parietes. 

Then,  by  means  of  tractions  with  the  branch  of  the  forceps,  he  succeeded  in 
communicating  to  the  trunk  a  motion  similar  to  that  which  it  performs  in  spon- 
taneous evolution.  The  head  and  shoulder  ascended  gradual!}^,  whilst  the  pelvis 
approached  the  vulva  and  was  finally  delivered. 

This  quite  simple  method  is  certainly  preferable  to  Dr.  Lee's,  and  in  many 
cases  might  be  substituted  for  the  decapitation  of  the  foetus. 

■  M.  Payan,  of  Aix,  resorted  to  Davis's  operation  in  one  instance,  where  the  trunk  was  low 
down  in  the  excavation:  but  the  plan  certainly  did  not  originate  with  him.  {Gaz.  Med. 
521,  1840.) 


PAET    Y. 

OF  THE  DELIVERY  OF  THE  AFTER-BIRTH. 


This  comprises  the  natural  or  artificial  expulsion  of  the  foetal  appendages  from 
the  mother's  womb,  and  is  the  complement  of  the  labor.  Like  the  latter,  it  is 
generally  accomplished  by  the  unaided  powers  of  nature,  though  in  certain  cases, 
which  are  fortunately  very  rare  (about  one  in  two  hundred),  it  is  attended  by 
difficulties  or  complicated  by  accidents  that  may  require  the  intervention  of  art. 
We  shall,  therefore,  have  to  treat  of  the  natural  and  the  artificial  delivery  of  the 
after-birth. 

ARTICLE    L 

OF   THE    NATURAL    DELIVERY   OF    THE   AFTER-BIRTH. 

Whilst  the  expulsion  of  the  foetus  is  being  completed  by  the  spontaneous  exit 
of  the  breech  and  lower  extremities,  or  immediately  after  the  expulsion,  the 
■walls  of  the  uterus  retract  in  virtue  of  their  inherent  contractility  of  tissue,  and 
its  cavity  diminishes;  but  the  placenta,  being  a  spongy  and  non-contractile  mass, 
docs  not  follow  this  action  of  the  organ.  Consequently,  it  becomes  puckered  up, 
and  the  cellular  and  vascular  tissues,  that  connect  it  to  the  internal  uterine  sur- 
face, are  rendered  tense  and  then  torn,  as  the  difference  in  the  respective  size  of 
the  two  bodies  becomes  greater  under  the  force  of  the  repeated  contractions.  A 
rupture  of  all  these  bonds  of  union  is  soon  effected,  the  placenta  is  completely 
detached,  and  descends  by  its  own  weight  to  the  os  uteri ;  the  latter,  being  irri- 
tated by  its  presence,  reacts  on  the  body  of  the  organ  which  is  immediately 
thrown  into  contraction ;  the  internal  orifice,  which  was  closed  after  the  delivery 
of  the  child,  again  dilates,  and  the  placenta,  being  driven  from  the  uterine  cavity, 
passes  into  the  vagina,  whence  it  is  forced  outwards  by  the  contraction  of  the 
vaginal  walls  aided  by  the  abdominal  muscles. 

Hence  there  are  three  distinct  stages  in  the  delivery  of  the  after-birth ;  whicli 
we  may  divide,  like  Desormeaux,  into  the  detachment  of  the  placenta,  its  expul- 
sion from  the  uterus,  and  its  expulsion  from  the  vagina. 

The  detachment  of  the  placenta  is  not  always  accomplished  in  the  same  way; 
the  process  varying  with  the  part  of  the  uterus  to  which  it  is  united.     For  in- 


878  DELIVERY    OF    THE    AFTER-BIRTE. 

stance,  when  attached  to  the  fundus,  the  separation  first  begins  near  the  centre 
of  the  mass,  because  this  is  the  thickest  part,  and  can  least  acconnnodate  itself 
to  the  retraction  of  the  uterine  walls;  -whilst  its  thinner  margins,  being  more 
easily  wrinkled,  are  less  liable  to  rupture  the  tissue  connecting  them  with  the 
womb ;  a  lenticular  cavity  is  thereby  created,  which  is  bounded  externally  by 
the  still  adherent  borders  of  the  placenta.  A  quantity  of  blood  is  gradually 
effused  into  this  cavity,  which  contributes,  with  the  uterine  contractions,  to  effect 
the  separation ;  thus,  in  this  case,  the  detachment  is  effected  from  the  centre 
towards  the  circumference.  The  placenta,  being  wholly  detached,  then  descends 
to  the  orifice,  its  foetal  surface  corresponding  to  the  latter,  and  becoming  the  ex- 
ternal face,  whilst  the  uterine  surface  is  the  internal  face,  which,  together  with 
the  inverted  membranes,  constitutes  a  pouch,  wherein  such  a  quantity  of  fluid 
or  coagulated  blood  is  occasionally  collected,  as  to  seriously  impede  its  delivery. 

When  it  is  attached  to  the  anterior,  the  posterior,  or  the  lateral  portion  of  the 
womb,  the  separation  commences  at  one  of  the  margins;  or,  if  at  the  centre,  it  is 
soon  propagated  towards  one  border,  generally  the  superior,  though,  in  some 
instances,  the  inferior  one.  In  the  former  case,  the  process  advances  in  the  way 
just  described,  and  the  placenta  again  presents,  by  its  foetal  surface,  at  the 
cervix  uteri ;  but,  in  the  latter,  being  suspended  on  the  uterine  wall  until  the 
detachment  is  completed,  it  presents  at  the  neck  by  its  inferior  margin.  It  is 
then  generally  folded  upon  itself,  and  engages  in  the  orifice  rolled  up  in  a  conical 
form. 

When  the  placenta  presents  its  fo?tal  surfiice  at  the  os  uteri,  it  plugs  up  the 
orifice  by  its  bulk,  and  prevents  the  blood  from  escaping ;  wherefore,  its  delivery 
in  such  cases  is  usually  followed  by  the  expulsion  of  numerous  large  coagula. 
But  where  only  one  border  engages,  there  is  no  obstacle  to  the  issue  of  the 
blood,  and  hence  the  discharge  of  this  fluid  commences  with  the  detachment 
of  the  after-birth,  is  increased  at  every  pain,  and  persists  throughout  the  whole 
process. 

From  the  description  just  given,  the  reader  would  naturally  suppose  that  the 
detachment  of  the  placenta  only  begins  after  the  child  is  born ;  this,  however,  is 
not  always  the  case.  In  fact,  the  following  phenomena  are  more  usually  ob- 
served to  take  place  :  as  soon  as  the  labor  pains  are  developed  and  the  dilatation 
of  the  OS  uteri  has  commenced,  the  separation  of  the  ovum  begins  in  the  neigh- 
borhood of  the  uterine  orifice,  and  then  gradually  progresses  over  all  parts  of  its 
surface,  although  not  in  a  perfect  and  complete  manner.  After  the  membranes 
are  ruptured,  and  the  waters  are  partially  discharged,  the  uterine  cavity  dimi- 
nishes ;  the  ovum  becomes  wrinkled,  and  its  detachment  is  carried  to  a  still 
greater  extent;  even  involving  the  after-birth,  as  proved  by  the  fact  that  the 
fluid  or  coagulated  blood  is  frequently  expelled  simultaneously  with  the  foetus, 
in  cases  of  protracted  labor;  which  blood  must  evidently  come  from  that  portion 
of  the  uterine  surface  in  contact  with  the  placenta.  A  separation  of  the  greater 
part  of  the  placental  mass  is  particularly  apt  to  occur  in  the  breech  presentations, 
in  consequence  of  the  gradual  contraction  of  the  womb,  as  the  lower  parts  of  the 
foetus  are  delivered. 


NATURAL    DELIVERY.  879 

The  interval  between  the  child's  birth  and  the  delivery  of  the  secundines  is 
very  variable.  Dr.  Clarke,  I'roni  a  great  number  of  observations,  established  its 
mean  duration  at  twenty-five  minutes;  but  if  by  this  a  perfectly  spontaneous 
delivery  is  to  be  understood,  one  in  which  no  traction  is  made  on  the  cord,  we 
believe  he  is  in  error,  for  this  interval  is  generally  much  longer.  At  the  in- 
stance of  M.  P.  Dubois,  we  made  some  experiments,  in  1836,  with  a  view  of 
determining  this  question ;  and  those  researches  proved  that,  when  the  delivery 
was  left  entirely  to  nature,  the  final  expulsion  of  the  placenta  did  not  usually 
occur  under  an  hour  or  an  hour  and  a  half  after  the  birth  of  the  child.  It  is 
true,  the  detachment  of  the  after-birth,  and  its  removal  from  the  uterine  cavity, 
is  eifected,  as  Clarke  states,  in  the  course  of  fifteen,  twenty,  or  twenty-five 
minutes;  but,  having  passed  into  the  vagina,  it  sometimes  remains  there  for 
sevei-al  hours  without  causing  the  least  irritation  by  its  presence,  the  least  tenes- 
mus,- or  bearing-down  effort.  This  circumstance  is  easily  explained  by  the  fact 
,that  the  sensibility  of  the  vaginal  walls  is  blunted,  as  it  were,  by  the  long  pres- 
sure they  were  subjected  to  from  the  head  and  other  parts  of  the  child.  Besides 
which,  as  Levret  long  since  remarked,  the  after-birth  will  be  the  sooner  expelled 
in  proportion  as  the  patient  is  stronger,  and  the  contractions  more  energetic;  as 
the  quantity  of  water  in  the  womb  was  smaller,  and  as  tlie  period  between  the 
rupture  of  the  membranes  and  the  delivery  of  the  child  was  the  longer. 

Although  its  delivery  may  generally  be  left  to  the  powers  of  nature  without 
any  serious  inconvenience,  yet  it  is  equally  true  that  it  will  be  delayed  a  long 
time  in  a  large  number  of  cases.  Xow,  such  a  delay  would  force  the  patient  to 
remain  on  a  bed,  which  is  poorly  adapted  for  repose  after  all  the  fatigues  of 
labor;  and  besides,  so  long  as  the  delivery  is  not  completed,  she  still  considers 
herself  exposed  to  numerous  dangers,  and  her  fears  may  have  an  unfavorable 
influence  over  her  condition.  On  this  account,  most  of  the  accoucheurs  of  the 
present  day  believe  it  advisable  to  accelerate  the  extraction  a  little,  for  the  pur- 
pose of  relieving  the  woman  from  her  anxiety,  and  of  sparing  her  unnecessary 
pain ;  without,  however,  attempting  to  deliver  the  secundines  immecUateli/  after 
the  child's  birth.  But,  before  making  any  traction  on  the  umbilical  cord,  it  is 
necessary  to  ascertain  the  situation  of  the  placenta,  and  especially  the  condition 
of  the  uterus.  If  the  latter  is  small,  hard,  and  contracted,  and  situated  in  the 
lowest  part  of  the  abdomen,  it  is  infinitely  probable  that  the  placenta  is  in  great 
part  at  least,  expelled  from  the  cavity  of  the  womb  into  the  vagina.  This,  how- 
ever may  be  easily  ascertained,  for  the  finger  introduced  into  the  vagina  readily 
detects  the  mas.s,  and  even  distinguishes  the  insertions  of  the  cord.  There  is 
then,  generally,  nothing  to  prevent  its  being  extracted  at  once,  and  simple 
tractions  upon  the  external  end  of  the  cord  are  all  that  are  required  for  this 
purpose. 

"When,  on  the  contrary,  the  uterine  tumor  continues  on  a  level  with,  or  even 
above  the  umbilicus,  and  has  a  soft  doughy  feel,  due  to  its  imperfect  contraction, 
the  placenta  is  very  probably  still  within  the  womb,  and  the  first  object  should 
be  to  ascertain  whether  or  not  it  is  detached.  Now  we  know  that  the  separation 
is  usually  accomplished  by  the  fresh  contractions  that  reappear  after  the  apathy 


880 


DELIVERY     OP    THE     AFTER-BIRTH. 


which  follows  the  expulsion  of  the  clukl ;  and  hence,  tliere  is  every  reason  to 
suppose  it  is  completed  when  these  contractions  have  repeatedly  occurred.  A 
little  hlood  usually  escapes  from  the  vulva  durint;  the  process.  Finally,  if  one  or 
several  fingers  be  passed  up  to  the  uterine  orilice,  the  after-birth  is  found  present- 
ing there,  and,  if  it  should  not  be  met  with,  the  accoucheur  may  rest  satisfied  that 
the  separation  is  not  yet  completed,  and  therefore  he  ought  to  wait.  Should  the 
detachment  be  delayed  too  long,  frictions  over  the  fundus  uteri  are  resorted  to, 
for  the  purpose  of  rousing  the  pains,  or  the  same  object  is  produced  by  titillating 
the  cervix  uteri  with  one  or  two  fingers.  Great  care  should  be  taken  not  to 
make  frequent  tractions  upon  the  cord,  for  unpleasant  consequences  might  result. 
Thus,  if  the  placenta  is  completely  adherent,  the  tractions  are  liable  to  detach  a 
part,  and  give  rise  to  hemorrhage,  or  they  might  tear  away  a  portion  of  the 
after-birth  and  leave  the  remainder  in  the  womb ;  again,  the  organ  might  be  in- 
verted or  the  cord  ruptured  thereby. 

Certain  writers  recommend  a  ligature  on  the  placental  extremity  of  the  cord , 
after  the  child's  birth,  for  the  sole  purpose  of  facilitating  the  detachment  of  the 
after-birth.  The  easy  separation  when  this  has  been  done,  says  JM.  Stoltz,  is 
caused  by  the  weight  and  turgescence  of  this  organ,  which,  when  expelled,  is 
found  to  be  engorged  with  blood;  this  practice  is  attended  with  no  inconve- 
nience, and  is  at  least  beneficial  by  preventing  the  patient's  bed  from  being  soiled 
with  the  blood  that  ordinarily  escapes  from  the  cord. 

After  its  entire  separation,  the  after-birth  constitutes  a  foreign  body  in  the 
uterine  cavity,  which  the  organ  endeavors  to  dislodge  by  contracting.  These 
contractions,  which  are  recognizable  by  the  hardness  of  the  uterine  globe,  and 
which  are  usually  perceptible  to  the  patient,  indicate  the  time  for  operating;  the 
accoucheur  then  takes  hold  of  the  umbilical  cord,  after  having  enveloped  it  with 
a  cloth  so  as  to  prevent  it  from  slipping,  and  winds  its  end  around  one  or  two 
fingers;  he  next  makes  a  moderate  traction  with  a  view  of  extracting  it,  but,  as 


Fiff.  133. 


Tlie  mode  of  extracting;  ihe  plnceiila. 


soon  as  any  resistance  is  felt,  he  ought  to  slip  up  two  or  even  three  fingers  of  the 
other  hand  along  the  upper  surface  of  the  cord  as  far  as  the  os  uteri;  the  points 
of  these  fingers,  which  are  intended  to  press  the  cord  backwards,  are  brought 
together  so  as  to  receive  the  latter  in  the  entering  angle  thereby  formed,  around 


NATURAL     DELIVERY.  881 

which  it  phiys  like  a  pulley.  To  understand  the  advantage  of  this  manoeuvre,  it 
is  only  necessary  to  bear  in  mind  that  the  tractions  made  by  one  hand  alone 
would  correspond  to  the  axis  of  the  vagina,  which  forms  an  angle  with  that  of 
the  uterus ;  whence  it  happens  that  the  placenta,  instead  of  being  drawn  towards 
the  centre  of  the  orifice  it  has  to  traverse,  would  abut  against  its  anterior  border, 
and  the  corresponding  parts  of  the  cervix,  upon  which  all  the  tractive  efforts  are 
spent.  The  patient  should  be  directed  to  boar  down  while  the  tractions  are  made. 
As  the  placenta  clears  the  orifice,  and  gets  into  the  excavation,  the  operator 
changes  the  line  of  action,  and  gradually  carries  the  cord  forward,  so  as  to  make 
it  always  correspond  with  the  axis  of  the  pelvic  canal.  Under  the  joint  influence 
of  the  tractions  and  the  patient's  bearing-down  efforts,  the  placenta  soon  reaches 
the  vulva,  where  it  is  seized  by  the  thumb  and  fingers  and  twisted  round  several 
times,  so  as  to  complete  the  detachment  of  the  membranes  and  form  them  into  a 
solid  cord,  for  the  double  purpose  of  preventing  their  laceration  and  of  securing 
their  entire  removal.' 

It  is  impossible  to  state  precisely  the  amount  of  force  which  mny  be  used  in 
these  tractions  upon  the  cord,  and  it  must  be  left  to  the  intelligence  of  the  prac- 
titioner to  discover  what  is  proper  to  be  done.  When,  however,  the  tractions 
have  no  effect,  and  the  placenta  seems  to  rise  up  and  draw  the  cord  after  it,  as 
soon  as  they  have  ceased,  all  efforts  should  be  suspended  for  the  time  being. 

^'  When  the  placenta  is  partially  engaged  in  the  orifice  by  a  portion  of  its 
periphery,  this  plan,"  snys  M.  Gruillemot,  "ought  to  be  somewhat  modified;  for, 
in  this  presentation,  the  root  of  the  umbilical  cord,  instead  of  corresponding  to 
the  cervix,  is  higher  up  in  the  uterine  cavity;  and  hence,  if  the  operator  resorts 
to  traction,  the  centre  of  the  placenta  will  have  a  tendency  to  enter  the  orifice, 
and  thus  add  its  bulk  to  the  disk  already  engaged  there.  Such  a  disposition 
sometimes  constitutes  an  ob.stacle  to  the  further  delivery  of  this  mass ;  but  it  is 
surmounted  by  making  some  moderate  tractions,  not  on  the  cord  itself,  but  rather 
upon  the  part  previously  engaged,  by  applying  two  fingers  on  its  surfaces."  We 
have  had  numerous  opportunities  of  testing  the  practical  utility  of  M.  Guille- 
mot's advice. 

"This  seems,"  says  Merriman,  "all  that  it  is  right  to  do,  for  a  full  hour  after 
the  child  is  born ;  but  that  time  being  elapsed,  and  there  being  no  reason  to 
expect  that  uterine  contractions  will  spontaneously  arise,  the  accoucheur  is  to 
consider  whether  it  is  prudent  to  wait  longer,  before  he  proceeds  to  extract  the 
placenta,  by  introducing  his  harid  into  the  uterus. 

'  Tlieie  certainly  would  be  no  very  great  danger  in  leaving  a  portion  of  the  membranes 
in  the  uterine  cavity;  although,  in  addition  to  the  accidents  that  may  arise  from  the  presence 
of  a  foreign  body  there,  the  following  phenomenon  might  possibly  occur.  The  membranes 
may  inclose  some  coagula,  and  thus  form  a  mass  whose  expulsion  is  often  difficult.  In  the 
course  of  a  few  days,  the  uterus,  being  irritated  by  the  presence  of  this  inconvenient  lodger, 
begins  to  contract,  and  the  woman  experiences  some  colicky  pains,  varying  in  intensity  with 
the  strength  of  the  contractions ;  a  little  blood  escapes  from  the  vulva,  and,  after  the  pains 
have  lasted  for  a  longer  or  shorter  period,  the  patient  is  finally  delivered  of  the  foreign  body, 
or,  according  to  her  expression,  of  a  large  piece  of  flesh,  the  appearance  of  which  causes  great 
alarm. 

56 


882  DELIVERY     OF    THE    AFTER-BIRTH. 

''  If  no  bad  syiuptonis  are  present,  there  can  be  no  danger  in  allowing  more 
time  to  elapse  before  we  proceed  to  this  operation ;  especially,  if  there  be  reason 
to  think  that  the  retention  arises  principally  from  the  exhausted  state  of  the 
patient;  because  it  is  possible  that  a  little  more  delay  will  recruit  her  strength, 
and  that  afterwards  sufficient  power  may  be  imparted  to  the  uterus  to  expel  the 
placenta. 

''Yet,  generally  speaking,  we  can  have  but  little  expectation  that  the  pla- 
centa will  be  expelled  by  the  natural  powers,  after  it  has  been  retained  much 
more  than  an  hour ;  we  may,  therefore,  consider  ourselves  justified  in  interfering 
to  extract  it,  at  the  end  of  an  hour  or  two  after  the  child  is  born. 

''It  appears,  then,  to  be  a  question  of  prudence  or  discretion,  which  every 
accoucheur  must  judge  of,  in  the  individual  ease  he  is  attending,  whether  to  pro- 
ceed to  delivery  at  the  end  of  the  hour,  or  to  wait  another  hour  or  two  before 
he  undertakes  this  operation.  But,  of  course,  this  only  applies  to  cases  where 
there  is  no  apparent  danger."     (^S/jnopsis,  page  153.) 

"  The  time  for  interference  of  the  accoucheur  for  the  delivery  of  the  placenta, 
should  always  be  regulated  by  the  condition  of  the  uterus  itself,"  says  Dewees, 
"and  that  condition  is  whenever  it  is  firmly  contracted.  Time,  simply  consi- 
dered, can  never  form  a  safe  rule  for  the  delivery  of  the  placenta ;  the  degree  of 
contraction  of  the  uterus  alone  can  point  out  the  proper  moment  to  operate,  or 
teach  us  when  it  would  be  improper  to  attempt  it.  This  rule,  I  believe,  will 
never  deceive,  or  at  least,  I  have  uniformly  acted  upon  this  principle;  and,  so 
far,  I  think  I  am  safe  in  saying,  I  have  not  had  cause  to  believe  it  wrong," 
(^Sjystem  of  Midwifery,  page  447.) 

As  soon  as  the  placenta  is  delivered,  we  must  ascertain  whether  any  portion  of 
it,  or  of  the  membranes,  has  been  left  behind  in  the  womb ;  but  this  is  easily 
done  by  carefully  examining  the  secundines.  Should  it  happen  that  the  mem- 
branes or  after-birth  are  not  extracted  entire,  it  would  be  proper  to  pass  the  hand 
into  the  uterus,  for  the  purpose  of  removing  the  remnants. 

If  a  large  quantity  of  the  coagula  that  usually  accompany  the  placenta  remains 
in  the  womb,  they  may  subsequently  become  a  source  of  the  after-pains  before 
described.  Consequently,  if  there  is  reason  to  suspect  the  presence  of  large  clots 
in  the  womb,  the  latter  ought  to  be  stimulated  to  contraction  by  repeated  fric- 
tions over  the  hypogastrium.  Some  authors  have  even  recommended  the  intro- 
duction of  the  hand  into  the  uterine  cavity,  so  as  to  rid  it  completely  of  all 
foreign  bodies ;  but  this  advice  ought  not  to  be  followed,  because,  on  the  one 
part,  the  uterus  would  be  unnecessarily  irritated,  and,  on  the  other,  it  would  not 
prevent  the  subsequent  formation  of  fresh  coagula. 

We  stated  above,  that  usually  in  the  course  of  fifteen,  twenty,  or  twenty-five 
minutes  after  the  birth  of  the  child,  the  uterus,  by  contracting,  notifies  the 
accoucheur,  as  it  were,  of  the  proper  moment  for  his  intervention.  It  should 
always  be  remembered,  however,  that  moderate  tractions  are  all-sufficient  for  the 
delivery  of  the  after-birth;  and,  if  much  resistance  is  met  with,  it  would  be  for 
better  to  wait,  and  not  make  any  new  attempts,  until  the  contractions  shall  have 
partly  or  completely  overcome  the  obstacle. 


ARTIFICIAL    DELIVERY.  883 

Where  there  is  the  least  reason  to  suspect  the  existence  of  a  second  child, 
after  the  birth  of  the  first,  the  physician  ought  to  satisfy  himself  on  that  point, 
both  by  an  external  and  an  internal  exploration,  before  attempting  to  remove  the 
placenta  ;  and  should  a  twin  pregnancy  be  recognized  by  the  great  size  of  the 
womb,  and  more  particularly  by  the  vaginal  examination,  a  ligature  is  to  be  ap- 
plied immediately  on  the  placental  extremity  of  the  cord  belonging  to  the  first 
infant )  and  the  secundines  are  only  to  be  extracted  after  the  expulsion  of  both 
children.  If,  however,  the  placenta  were  detached,  and  presented  at  the  orifice, 
he  should  attempt  to  extract  it,  more  especially  when  it  seems  to  obstruct  the 
passage  of  the  second  foetus.  Nevertheless,  such  tractions  ought  to  be  exceed- 
ingly'^ reserved;  because,  in  compound  pregnancies,  there  are  frequent  adhesions 
between  the  two  placentas;  and,  if  this  were  the  case,  it  is  evident  that  any 
forcible  traction  might  detach  the  after-birth  of  the  second  child  long  before  its 
expulsion;  and  this  premature  separation  would  render  the  mother  liable  to 
severe  hemorrhage,  and  the  child  to  fatal  asphyxia. 

After  the  birth  of  both  children,  so  far  from  pulling  on  the  two  cords  simul- 
taneously, and  moderately  twisting  them  into  one,  it  is  more  prudent  to  bring 
down  the  placentas,  one  after  the  ether,  giving  the  priority  to  the  one  which 
offers  the  least  resistance.  The  mass  of  these  conjoined  bodies  is  made  to  en- 
gage in  this  way  by  one  extremity;  and  it  is  thus  enabled  to  clear  the  uterine 
orifice  more  readily. 

In  most  cases  of  compound  pregnancy  the  womb  is  excessively  distended,  and 
this  distension,  as  we  are  all  aware,  is  one  of  the  circumstances  that  is  most 
likely  to  enfeeble  the  contractility  of  its  tissue ;  therefore,  the  removal  of  the 
after-birth,  after  the  labor  is  over,  should  not  be  accelerated  too  much,  and  the 
womb  must  be  allowed  a  longer  time  than  usual  for  its  retraction ;  while  mode- 
rate frictions  are  to  be  made  over  the  fundus  of  the  organ  for  the  purpose  of 
stimulating  its  action. 

As  regards  the  removal  of  the  secundines  after  a  miscarriage,  we  have  no- 
thing to  add  further  than  what  was  stated  in  the  article  on  Abortion.  (See  p. 
347.) 

ARTICLE   II. 

OF   THE   ARTIFICIAL   DELIVERY   OF   THE   AFTER-BIRTH. 

The  diflBculties  that  may  require  an  artificial  delivery  of  the  after-birth,  are 
caused  either  by  inertia  of  the  womb,  excessive  volume  of  the  placenta,  weakness 
of  the  umbilical  cord,  irregular  contraction  of  the  uterus,  or  by  intimate  adhe- 
sions of  the  placenta  itself. 

Whenever  repeated  attempts  to  effect  its  delivery,  made  in  the  usual  way, 
prove  ineffectual,  the  attendant  ought  to  search  for  the  cause  of  the  delay,  both 
by  abdominal  palpation  and  by  a  vaginal  exploration.  One  of  two  things  will 
then  occur :  either  the  placenta  will  be  found  lying  over  the  internal  orifice,  or 
it  will  be  so  high  up  that  the  finger  cannot  reach  it.  Supposing  the  previous 
tractions  had  been  made  in  the   proper  direction,  an  obstacle  to  the  delivery  in 


884  DELIVERY    OF    THE    AFTER-BIRTH. 

the  foimer  case  could  only  depend  on  the  unusual  size  of  the  after-birth,  on  the 
fragility  of  the  umbilical  cord,  or  on  a  contraction  of  the  uterine  orifice;  in  the 
latter,  the  placenta  must  evidently  be  retained  at  the  fundus,  either  by  abnormal 
adhesions,  or  by  their  regular  contraction  of  some  part  of  the  uterine  walls.  This 
first  diagnosis  being  once  established,  the  operator  only  has  to  decide  upon  which 
of  those  circumstances  the  delay  is  dependent. 

§  1.  Inertia  or  the  "Womb. 

We  have  hitherto  stated  that  the  contracted  uterus  forms  a  large,  hard,  and 
resistant  tumor  in  the  subumbilical  region  after  the  child  is  born.  Now,  it  may 
happen,  either  from  the  general  debility  of  the  patient,  or  from  the  feebleness  or 
atony  of  the  womb  itself,  that  its  organic  contractility  is  not  aroused,  and  the 
organ  still  remains  after  the  birth  of  the  child  in  a  state  of  partial  or  complete 
inertia. 

This  inertia  of  the  womb  (which  will  claim  our  special  attention  when  treat- 
ing of  the  hemorrhage  that  so  frequently  accompanies  it  after  the  delivery)  may 
be  simple,  or  complicated  with  flooding ;  but  we  have  only  to  speak  of  the  first 
variety  at  the  present  time. 

This  condition  is  indicated  by  the  large,  soft,  and  insensible  tumor,  which  is 
detected  by  applying  the  hand  upon  the  abdomen. 

If  the  inertia  of  the  womb  is  not  attended  with  flooding,  it  is  probable  that 
the  placenta  still  remains  undetached;  and  therefore  no  imprudent  tractions 
should  be  made  on  the  cord,  lest  a  separation  occur  before  the  inertia  is  remedied. 
This  would  inevitably  produce  a  frightful  hemorrhage,  which  might  cost  the 
patient  her  life  in  a  few  minutes;  or,  should  the  placental  adhesions  resist  the 
tractive  eff'orts,  the  womb  would  be  drawn  down  along  with  the  after-birth,  thus 
producing  a  partial  or  complete  inversion  of  the  organ.  It  is,  therefore,  a  truly 
fortunate  circumstance  when  the  inertia  is  manifested  before  the  separation  of 
the  after-birth  has  commenced.  A  further  source  of  hemorrhage  is  found  in  the 
umbilical  vessels ;  but  this  accident  is  exceedingly  rare,  and  besides  it  can  easily 
be  ramedied  by  applying  a  ligature  on  the  cord. 

The  best  course  to  be  pursued  in  cases  of  simple  inertia,  is  to  wait  until  the 
uterus  regains  its  powers  :  the  return  of  the  contractions  might  be  accelerated, 
however,  by  moderate  frictions  over  the  lower  part  of  the  belly,  or  by  titillating 
the  OS  uteri  with  one  or  two  fingers  in  the  vagina,  and  by  the  application  of  cold 
compresses  over  the  hypogastric  region,  and  on  the  upper  part  of  the  thighs.  In 
cases  of  partial  inertia,  some  English  practitioners.  Dr.  Murphy  in  particular 
(^London  Med.  Gaz.),  have  recommended  a  tight  bandage  around  the  abdomen ; 
or,  preferably,  a  resort  to  immediate  pressure  over  the  uterus,  by  applying  both 
hands  on  the  sides  of  the  organ.  M.  Guillemot  asserts  that  he  has  often  suc- 
ceeded in  arousing  and  keeping  up  the  contractions  by  plunging  the  end  of  the 
cord  in  a  glass  of  cold  water;  but  we  can  scarcely  comprehend  how  this  singular 
result  can  occur.  The  patient's  strength  is  to  be  kept  up  at  the  same  time,  by 
some  broth,  or  possibly,  by  a  little  good  wine ;  but  the  use  of  this  latter  article, 
as  well  as  of  the  cordial  stimulants  recommended  by  the  older  accoucheurs,  which 


ARTIFICIAL     DELIVERY.  885 

frequently  gave  rise  to  the  most  dangerous  hemorrhages,  re<|ulres  the  exercise  of 
a  sound  discretion. 

§  2.  Excessive  Volume  of  the  Placenta. 

This  may  be  either  real,  or  due  to  the  collection  of  large  coagula  in  the  pouch 
of  the  membranes,  created  by  the  inversion  of  the  placenta  in  f:\lling  upon  the 
OS  uteri,  after  its  detachment.  This  source  of  diiSculty  is  easily  recognized  by 
observing  the  unusual  volume  of  the  uterus  above  the  pubis,  and  by  detecting 
the  detached  mass  at  the  os  uteri  by  the  finger. 

In  most  instances,  the  natural  contractions  of  the  womb,  assisted  by  a  mode- 
rate traction  upon  the  cord,  are  all-.sufficient  for  the  delivery  of  the  after-birth; 
though  it  is  occasionally  necessary  to  pass  the  hand  into  the  vagina  and  to  cany 
one  or  two  fingers  up  into  the  uterine  cavity  for  the  purpose  of  hooking  it  down. 
When  the  increased  size  is  owing  to  the  accumulation  of  coagula  in  the  pouch, 
the  membranes,  if  within  reach  of  the  finger,  or  the  placenta  itself,  should  be 
perforated  so  as  to  afford  an  outlet  to  the  fluid  part  of  the  blood,  whereby  the 
total  mass  is  diminished,  and  its  subsequent  expulsion  or  extraction  facilitated. 

§  3.  Weakness  of  the  Cord. 

This  weakness,  whether  owing  to  deficient  development  of  the  cord  itself, 
as  happens  in  cases  of  premature  labor,  or  to  the  particular  mode  of  distribution 
of  the  umbilical  vessels,  so  well  described  by  Benckiser  in  his  inaugural  thesis 
(see  Umbilical  Cord),  may  facilitate  its  rupture ;  and  hence  the  operator  ought 
to  be  very  careful  in  pulling  on  this  part.  Again,  a  rupture  of  the  cord  during 
the  delivery,  may  be  dependent  on  its  oblique  attachment  to  the  placenta. 
Therefore,  as  a  general  rule,  whenever  the  hand  feels  it  giving  way  during  the 
traction  (for  it  produces  a  peculiar  yielding  sensation),  the  attempt  should  be 
discontinued;  and,  unless  there  are  some  special  reasons  to  the  contrary,  the 
further  delivery  must  be  left  to  the  powers  of  nature,  or  else  the  placenta  itself 
should  be  laid  hold  of,  if  it  be  deemed  proper  to  extract  it  immediately. 

In  conclusion,  if,  notwithstanding  all  proper  precautions,  the  cord  does  become 
ruptured,  the  accoucheur  has  only  to  introduce  the  hand  into  the  vagina,  and 
pass  up  two  or  three  fingers  into  the  uterine  cavity,  so  as  to  seize  and  extract  the 
placenta. 

It  is  then  sometimes  difficult  to  distinguish  the  placenta  from  the  wall  of  the 
uterus  itself,  thus  exposing  the  operator  to  make  dangerous  tractions  upon  the 
latter.  The  following  signs  may  enable  us  to  avoid  committing  an  error  of  this 
kind :  1.  The  fingers  applied  to  the  foetal  surface  of  the  placenta  can  distinguish 
the  projections  formed  by  the  vessels  which  are  distributed  upon  it.  2.  Pressure 
upon  the  placenta  would  hardly  be  perceived  by  the  patient,  whilst  it  would  be 
painful  if  applied  to  the  wall  of  the  uterus.  3.  Lastly,  the  other  hand  applied 
upon  the  hypogastric  region,  is  sensible  of  a  greater  thickness  of  parts  intervening 
between  it  and  the  hand  within  the  organ  than  could  be  due  simply  to  the 
united  thickness  of  the  walls  of  the  abdomen  and  of  the  uterus. 


886  delivery   op   the   after-birth. 

§  4.  Irregular  or  Spasmodic  Contraction  of  the  Uterus. 

The  causes  of  uterine  spasm  are  very  obscure;  though,  accordinp;  to  Stoltz,  the 
predisposition  exists  in  the  organ  itself.  If  any  exterior  causes  can  contribute 
to  its  production,  they  certainly  must  be  those  which  have  a  special  action  on  the 
womb :  such  as  improper  frictions  or  manipulations,  pulling  on  the  cord,  and  the 
abuse  of  stimulating  remedies,  the  ergot,  particularly.  Again,  the  irregular 
contractions  of  the  uterus  are  more  frequently  remarked  after  a  twin  labor  than 
others.  The  modern  authors,  who  have  made  this  a  subject  of  special  study,  do 
not  fully  agree  with  each  other,  in  regard  to  the  sequelse  of  these  irregular  con- 
tractions. The  different  forms  exhibited  by  the  uterus  in  such  cases  have  been 
reduced,  by  M.  Guillemot,  to  two  principal  varieties :  the  one  depending  on  the 
conformation  of  the  womb  ;  and  the  other  developed  as  a  consequence  of  the 
presence  of  some  foreign  body  in  this  viscus.  The  former  is  designated  by  him 
as  the  hour-glass,  or  spasmodic  contraction  of  the  neck  at  its  internal  orifice; 
the  latter  by  the  term  encystment,  or  the  irregular  contraction  of  the  body  of  the 
womb. 

"Wc  shall  follow  the  example  of  M.  Stoltz,  by  admitting  four  distinct  varieties 
of  uterine  spasm,  namely:  1st,  a  spasmodic  contraction  of  the  external  orifice  of 
the  neck  ;  2d,  that  of  its  internal  orifice;  od,  that  of  one  or  more  portions  of  the 
body  of  the  uterus ;  and,  4th,  a  spasmodic  contraction  of  the  whole  womb. 

A.  Spasmodic  Contraction  of  the  External  Orifice. — A  person  who  has  had 
many  opportunities  of  observing  the  softness  and  flaccidity  of  the  cervix  uteri  at 
its  lovv-er  part  after  the  child  is  born,  can  scarcely  comprehend  the  possibility  of 
spasm  at  its  outer  orifice ;  and  hence  many  authors  have  altogether  denied  its 
existence.  Besides,  it  must  be  evident  that,  even  if  such  a  condition  were  to 
occur,  it  would  constitute  but  a  momentary  obstacle  to  the  delivery  of  the  after- 
birth ;  and  therefore  we  would  only  have  to  wait  until  the  spasm  of  the  orifice 
had  yielded  to  the  force  of  the  contractions.  Or,  if  any  accident  should  occur 
requiring  a  prompt  delivery,  the  resistance  might  be  surmounted  without  diffi- 
culty. 

B.  Spasmodic  Contraction  nf  the  Internal  Orifice. — This  is  what  M.  Guille- 
mot understands  by  the  term  hour-glass  contraction  of  the  womb;  and  we  quote 
a  considerable  part  of  his  excellent  description  of  it.  When  the  hand  is  intro- 
duced, the  cervix  is  found  projecting  into  the  vagina,  and  so  disfigured  that  it 
resembles  a  section  of  the  large  inte.'^tine;  but  about  five  or  six  inches  above  thi.s, 
the  finder  is  arrested  by  a  kind  of  stricture,  which  is  the  wrinkled  and  contracted 
internal  orifice.  According  to  Madame  Boivin,  the  uterine  neck  sometimes  mea- 
sures five  or  six  inches  in  length  and  four  to  five  in  diameter,  in  this  state  of 
flaccidity ;  the  cavity  of  the  womb  containing  the  placenta  is  found  above  the 
retracted  part.  In  some  instances,  the  uterine  walls  are  firmly  contracted  around 
this  mass,  whilst  at  others  they  are  in  a  state  of  partial  or  complete  inertia.  The 
cavity  of  the  womb  is  thus  divided  into  two  portions.  When  the  upper  one  is 
contracted  on  the  placenta,  as  most  generally  happens,  its  volume  does  not  ex- 
ceed the  moiety  of  the  whole  organ ;  and  hence  the  retraction,  although  seated 


ARTIFICIAL     DELIVERY.  837 

at  tlie  internal  orifice,  sccins  to  exist  very  near  tlie  middle  of  the  uterus;  which 
circumstance  has  induced  many  practitioners  to  suppose  that  they  had  encoun- 
tered an  irregular  contraction  of  the  body  of  the  womb. 

In  most  cases,  the  after-birth  is  retained  entirely  within  the  superior  cavity; 
but  this  is  not  always  the  case,  for,  in  some  instances,  this  vascular  mass  has 
been  found  strangulated,  to  a  certain  extent,  by  the  stricture  of  the  neck,  one 
part  being  retained  in  the  upper  portion  and  one  in  the  lower.  Yv  hence  it  may 
happen:  1st,  that  a  ver}'  small  portion  of  the  placenta  projects  into  the  vagina; 
or,  2d,  that  it  is  strangulated  near  its  central  part;  or,  od,  that  more  than  one- 
half  of  the  placenta  hangs  down  below  the  strictured  orifice;  which  different  cir- 
cumstances, as  we  shall  have  occasion  to  show,  modify  the  treatment. 

The  hour-glass  contraction  is  recognizable  by  the  shape  of  the  uterus,  and  by 
the  resistance  presented  at  the  internal  orifice,  both  to  the  placenta,  and  to  the 
accoucheur's  finger.  The  organ  is  found  hard  and  contracted,  when  felt  through 
the  abdominal  walls,  and  all  tractions  on  the  cord  prove  ineffectual ;  besides,  the 
operator,  by  resorting  to  the  touch,  will  find  the  placenta  above  the  internal 
orifice,  which  is  contracted,  whilst  the  walls  of  the  neck  below  are  soft,  flabby, 
and  pendent  in  the  vagina;  and,  lastly,  there  is  no  discharge  of  coagula,  and 
sometimes  even  no  blood  of  any  consequence  escapes. 

When  the  stricture  is  not  accompanied  by  any  pressing  symptoms,  we  should 
wait,  for  the  spasm  generally  gives  way  in  the  coui'se  of  a  few  hours ;  the  uterus 
then  regains  its  normal  form,  and  the  after-birth  is  expelled.  Should  it  persist 
longer  than  four  or  five  hours,  the  opiate  preparations  might  first  be  resorted  to, 
followed  by  venesection,  if  indicated  by  the  general  phenomena  of  plethora; 
bathing  might,  like  (vise,  prove  very  useful.  But  the  difficulty  of  watching  the 
state  of  the  uterus  during  its  administration  must  restrict  its  use  greatly.  But 
if,  notwithstanding  the  employment  of  all  these  measures,  the  spasm  docs  not 
yield,  or  if  it  is  complicated  by  an  alarming  hemorrhage,  we  must  forthwith 
attempt  the  dilatation  of  the  strictured  part.  This  is  effected  by  first  introduc- 
ing one  finger,  then  two,  and  then  three,  with  a  view  of  enlarging  the  orifice  by 
degrees  until  it  will  admit  the  whole  hand.  The  advice  of  M.  Stoltz,  to  smear 
the  fingers  with  belladonna  ointment,  might  prove  serviceable.  Should  a  portion 
of  the  placenta  be  engaged  in  the  retracted  part,  our  course  would  evidently  vary 
under  the  different  circumstances  alluded  to  above.  For  instance,  if  a  very 
small  portion  only  of  the  afterbirth  is  engaged,  the  operator  ought  to  push  it  up, 
and  then  penetrate  into  the  uterine  cavity,  in  the  way  just  described;  but  if 
strangulated  near  its  central  part,  the  fingers  are  to  be  slipped  up  between  it  and 
the  neck,  and  then  the  part  that  is  still  above  the  stricture  is  to  be  gradually 
drawn  down.  Again,  if  most  of  the  placental  mass  is  already  clear,  we  must  get 
hold  of  this  free  portion,  and  by  compressing  it  forciblj^  in  the  hand,  endeavor  to 
reduce  the  size  of  the  strangulated  part,  and  thereby  effect  the  delivery  of  the 
whole. 

C.  Irregular  Contractions  of  the  Body  of  tlie  "Woriib. — The  womb,  in  contract- 
ing, becomes  accurately  applied  on  the  body  contained  within  its  cavity;  and,  of 
course,  where  the  placenta  still  remains  undelivered,  the  womb  retracts  upon  it. 


DELIVERY  OF  THE  AFTER-BIRTH. 


As  the  contractions  operate  at  all  parts,  the  walls  of  this  organ,  beinc;  opposed  to 
the  circumference  of  the  placenta,  and,  consequently,  meeting  with  little  or  no 
resistance,  gradually  approach  each  other,  and  shut  it  up  within  their  cavity ; 
this  constitutes  the  inclusion  of  the  placenta;  and  it  may  assume  two  very  dis- 
tinct forms,  to  which  difierent  names  have  been  applied,  i.  e.,  the  encystment 
and  the  encasement. 

Encystment  is  that  variety  in  which  the  placenta  is  so  surrounded  on  all  sides, 
excepting  at  the  opening  of  the  cell  for  the  entrance  of  the  umbilical  cord,  that 
it  is  absolutely  imprisoned.  Encasement  is  that  in  which  the  uterine  walls  in 
contracting  upon  the  circumference  of  the  placenta,  constitute  around  its  margin 
a  kind  of  collar,  or  frame,  which  encases  it,  just  as  the  turgid  conjunctiva  sur- 
rounds the  cornea  in  chemosis. 

These  two  species  may  either  be  partial  or  complete  :  the  encystment  is  said 
to  be  complete,  when  the  placenta  is  altogether  shut  up  in  the  cell  or  cyst  formed 
by  the  retracted  uterine  walls;  and  incomplete,  where  some  portion  of  it  breaks 
out  of  the  door  of  the  cell.  In  the  latter  case,  the  cell  is  perfect,  being  lined 
throughout  by  the  centre  of  the  placenta,  whilst  the  other  parts  of  the  latter,  that 
have  escaped  from  the  cyst,  are  attached  to  the  neighboring  portions  of  the 
uterine  walls. 

The  encasement  is  complete,  when  the  collar  formed  by  the  retracted  uterine 
fibres  surrounds  or  encases  the  whole  circumference  of  the  placenta ;  and  incom- 
plete, where  it  only  exists  on  a  part  of  the  j')eriphery  of  this  vascular  mass. 

In  some  instances,  the  womb  is  not  moulded  on  the  circumference  alone  of 
the  placenta.  "For  if,"  says  M.  Velpeau,  "the  after-birth  were  solid  and  even, 
like  the  head,  the  womb  in  contracting  would  necessarily  retain  the  form  of 
a  pouch ;  but  the  cotyledons,  in  the  process  of  the  detachment,  may  separate 
from  each  other,  and  the  placenta  would  then  offer  more  resistance  in  some  parts 
than  in  others ;  so  that  the  uterus  soon  divides  into  seve- 
ral compartments,  or  divisions,  more  or  less  distinct  from 
each  other,  and  each  of  which  embraces  some  portion  of 
the  after-birth."  In  these  cases,  the  hand,  in  effecting 
the  artificial  delivery,  Avould  necessarily  have  to  penetrate 
through  four,  five,  or  occasionally  even  six  circular  stric- 
tures, after  having  dilated  them. 

The  encystment  may  be  complicated  by  a  retraction  of 
the  internal  orifice  (see  Fig.  134) ;  but,  in  most  of  the  re- 
corded cases  of  this  kind,  the  resistance  has  easily  been  sur- 
mounted. 

It  may  take  place  at  any  portion  of  the  womb  whatever, 
though  more  rarely  at  the  fundus  than  elsewhere ;  which 
is  probably  owing  to  the  circumstance  of  the  fibres  in  this 
region  being  more  active,  so  that  the  detachment  of  the 
placenta,  when  it  is  inserted  at  the  fundus,  is  accomplished 
much  sooner. 
The  encystment  may  be  recognized  without  much  difficulty ;  for,  by  palpating 


FiK.  134. 


The  hour-glnss  coiilrnc- 
lioii  of  the  womb. 


ARTIFICIAL     DELIVERY. 


889 


135. 


the  lower  part  of  the  belly,  two  tumors  are  detected  just  above  the  pubis, 
formed  by  the  body  of  the  uterus;  the  larger  of  which  contains  the  after-birth, 
and  the  other,  placed  below  or  towards  one  side,  and  joined  to  the  first  by  a  kind 
of  neck,  constitutes  the  remainder  of  the  uterine  globe.  And,  by  following  the 
cord  with  the  index  finger  up  into  the  cavity,  we  find  its  lower  portion  but  little 
retracted ;  though  further  up  the  finger  detects  a  small  rounded  opening,  the 
orifice  of  the  cell  through  which  the  cord  passes ;  and  beyond  it  are  the  irre- 
gular walls  of  the  cyst,  enclosing  the  placenta. 

Here,  also,  the  accoucheur  ought  to  wait,  if  the  encystmcnt  is  not  complicated 
by  any  accident;  endeavoring,  however,  in  the  meanwhile,  to  favor  the  return  of 
the  womb  to  its  normal  form,  by  a  resort  to 
the  measures  before  advised.  When  any  dan- 
ger threatens  the  mother's  life,  he  ought  to 
dilate  the  orifice  of  the  cyst  with  the  ends  of 
the  fingers,  and  thus  penetrate  carefully  into 
its  cavity.     (See  Fig.  135.) 

While  these  attempts  are  being  made  in- 
ternally, the  other  hand,  placed  on  the  hypo- 
gastrium,  must  grasp  the  fundus,  and  keep  it 
in  position.  Douglass,  who  devoted  particu- 
lar attention  to  this  subject,  avers  that  the 
placenta  is  generally  still  adherent;  but  Rams- 
botham,  Dewees,  and  several  others  assert,  on 
the  contrary,  that  it  is  usually  detached.  In 
the  former  case,  the  operator  would  have  to  attempt  its  separation;  always  taking 
the  precautions  mentioned  below.  It  is  to  be  delivered  by  taking  hold  of  one 
border,  with  a  view  of  making  it  clear  the  mouth  of  the  cyst  more  readily;  and 
if  it  is  but  partially  encysted,  the  index  finger  is  entered  and  passed  around  that 
portion  of  the  placenta  hold  by  the  periphery  of  the  opening;  in  this  way  both 
relieving  the  stricture  and  disengaging  the  encysted  part. 

Instead  of  attempting  to  dilate  the  mouth  of  the  cell,  which  is  often  very  diffi- 
cult, M.  Dubroca,  of  Bordeaux,  has  suggested  a  new  plan,  which  is  styled  by 
him  the  method  of  erosion;  it  consists  of  the  introduction  of  a  finger  into  the 
opening  of  the  cell,  and  then,  with  it,  tearing  up  and  reducing  the  placenta  to 
fragments,  which  are  afterwards  expelled.  He  says  this  mode  proved  successful 
in  some  instances  in  which  he  could  not  succeed  in  passing  two  or  three  fingers 
into  the  cyst  in  the  usual  way. 

D.  Spasmodic  Contraction  of  the  whole  Organ. — M.  Stoltz  relates  an  instance 
in  which  he  was  called  to  a  woman  who  had  been  delivered  an  hour  previously, 
by  a  midwife,  after  the  administration  of  two  scruples  of  ergot;  the  latter,  being 
unable  to  extract  the  after-birth,  thought  proper,  before  sending  for  him,  to  ex- 
hibit a  sixth  dose  of  eight  grains.  On  his  arrival,  he  found  the  woman's  general 
condition  favorable ;  the  fundus  of  the  uterus  extended  nearly  up  to  the  umbili- 
cus, and  the  entire  organ  was  developed  as  much  as  at  the  fifth  month;  but  its 
walls  were  contracted  to  such  a  degree  that  it  was  quite  firm  and  hard.     Follow- 


Mode  of  dilating  the  strictured  part. 


800  DELIVERY     OF     THE     AFTER-BIRTH. 

intr  up  the  cord,  the  index  finger  reached  tlie  external  orifice,  which  was  greatly 
retracted,  and  scarcely  permitted  the  introduction  of  the  first  phalanx;  every  part 
of  the  womb  within  reach  was  firm  and  contracted,  just  like  the  fundus  and 
body.  Of  course,  the  delivery  of  the  after-birth  was  out  of  the  question  ;  besides, 
no  complication  indicated  its  necessity.  It  was  then  about  half-past  two  o'clock 
in  the  morning;  a  draught,  consisting  of  half  a  drachm  of  IIoff"mann's  anodyne 
liquor,  and  twenty  minims  of  the  common  tincture  of  opium,  was  administered. 
The  fundus  of  the  womb  did  not  seem  to  be  any  less  contracted  at  nine  o'clock 
in  the  morning;  but,  by  operating  with  care,  M.  Stoltz  succeeded  in  dilating  the 
orifice,  and  in  passing  three  fingers  up  to  the  root  of  the  cord ;  but,  being  unable 
to  get  any  further,  he  withdrew  his  hand,  and  directed  injections  of  a  decoction 
of  belladonna  and  hyoscj'anius.  These  were  repeated  every  half  hour,  and,  at  the 
fifth  injection,  the  midwife  found  a  portion  of  the  placenta  engaged  in  the  vagina; 
she  forthwith  drew  upon  it,  and  succeeded  in  extracting  it,  twelve  hours  after 
the  child's  birth.  Should  a  similar  case  again  occur,  the  prudent  course  of  the 
Strasbourg  professor  ought  certainly  to  be  followed.  In  addition  to  which,  vene- 
section, tepid  bathing,  &c.,  might  be  resorted  to,  if  indicated  by  a  plethoric  con- 
dition of  the  patient. 

On  the  whole,  then,  it  would  appear  that  the  irregular  contraction  is  generally 
partial,  though  it  may  be  seated  at  any  or  every  part  of  the  organ;  and,  further, 
that  all  these  cases  are  to  be  treated  in  the  same  way.  That  is :  1st,  to  wait 
patient!}^;  2d,  in  the  course  of  a  few  hours  to  resort  to  frictions  over  the  fundus, 
to  titillations  of  the  os  uteri,  and  the  opiate  preparations  by  inunctions  or  injec- 
tions, belladonna  to  the  cervix,  either  in  the  form  of  extract  or  decoction,  vene- 
section, and  general  or  local  bathing.  Burns  recommends  the  sudden  application 
of  cold  compresses.  In  most  instances,  the  administration  of  antispasmodics  by 
the  mouth,  such  as  sulphuric  ether,  hyoscyamus,  belladonna,  or  opium,  is  of  un- 
questionable service;  and,  3d,  when  there  is  any  complication  that  endangers  the 
patient,  the  forced,  though  .slow,  gradual,  and  careful  introduction  of  the  hand, 
and  extraction  of  the  placenta. 

§  5.  Abnormal  Adhesions. 

In  the  present  state  of  our  science,  it  is  very  difficult  to  point  out  a  satisfac- 
tory cause  for  thc^e  abnormal  adhesions  of  the  placenta.  According  to  most 
authors,  they  are  owing  to  a  fibrous  transformation  of  the  cellular  filaments  which 
hold  the  placenta  and  uterus  together,  whereby  they  acquire  a  degree  of  solidity 
sufficient  to  withstand  the  uterine  forces.  These  adhesions'  have  also  been  re- 
ferred to  the  degenerations  of  the  placental  tissue  itself,  as  well  as  to  various 

'  Dr.  Dubois  furui.*hes  an  instance  of- an  abnormal  adhesion  of  the  placenta,  in  which  tlie 
latter  was  covered  by  an  osseous  or  cretaceous  substance;  but  Gooch,  who  reports  the  case, 
further  remarks,  that  he  found  the  placenta  partly  ossified  three  times  in  the  same  woman, 
and  that  he  never  had  any  difBculty  in  delivering  the  after-birth. 

Monro  and  Merrinian  also  mention  several  cases  where  they  noticed  patches  cf  ossifica- 
tion on  the  uterine  surface  of  the  placenta ;  in  which  the  latter,  they  go  on  to  say,  adhered, 
perhaps,  a  little  more  than  usual. 


ArvTIFICIAL    DELIVERY.  891 

osseous  and  calcareous  concretions.  In  a  case  detailed  by  M.  Stoltz,  the  bond 
of  union  was  evidently  formed  by  a  layer  of  coagulated  blood,  which  had  served 
to  arrest  a  hemorrhage  at  the  fourth  month  of  gestation.  M.  Dubois  appears  to 
accept  this  view  (Oral  Lessons),  and  attributes  these  adhesions  to  patches  of  a 
whitish  matter  of  a  greater  or  less  degree  of  hardness,  evidently  of  a  fibrinous 
nature,  and  increasing  in  density  with  the  age  of  the  sanguineous  effusion  of 
which  they  are  the  only  remains.  According  to  M.  Gendrin,  the  adhesion  is 
made  by  the  circle  which  the  reflected  decidua  forms  around  the  placenta. 
Sometimes  it  is  only  produced  at  a  few  points  of  the  uterine  surface  of  the 
placenta,  by  the  conversion  of  some  part  of  the  organ  into  a  non-vascular, 
cellulo-fibrous  tissue,  by  the  accidental  atrophy  of  one  or  more  of  the  placental 
cotyledons;  which  atrophy  not  unfrequently  occurs.  The  generally-received 
opinion,  of  the  truth  of  which,  however,  I  have  some  doubts,  is,  that  these  ab- 
normal adhesions  result  in  consequence  of  an  inflaunnation  of  .the  placenta,  or  of 
the  uterine  wall  during  gestation,  which  is  terminated  by  the  exudation  of  jjlastic 
and  coagulable  lymph  between  the  contiguous  surfaces;  and  to  this  effused  mat- 
ter most  modern  writers  attribute  the  adherence.  The  resistance  varies,  they  say, 
according  to  the  progress  of  the  inflammation ;  that,  where  the  latter  has  been 
acute,  and  the  plastic  lymph  is  soft  and  recent,  the  utero-placental  adhesions  are 
scarcely  any  stronger  than  in  the  normal  state.  But,  on  the  other  hand,  if  its 
chronic  character  has  afforded  the  effused  matter  time  enough  to  become  orga- 
nized and  condensed,  the  adhesions  will  prove  very  troublesome.  The  thickness 
of  this  species  of  false  membrane  is  very  variable.  "Wrisberg  declares  that,  in  a 
case  where  it  covered  the  whole  uterine  surface  of  the  placenta,  it  aniountcd  to 
two  lines  and  a  half  at  the  interlobular  fissures,  and  a  line  and  a  half  upon  the 
face  of  each  cotyledon.  But  whatever  may  be  the  cause  that  produces  such 
adhesions,  there  are  certain  persons  who  appear  to  have  an  unfortunate  predispo- 
sition to  them,  since  they  suffer  from  this  accident  at  every  confinement. 

The  adhesion  may  be  more  or  less  extensive;  sometimes  existing  over  the 
whole  placental  surface,  but  at  others  restricted  to  certain  parts ;  for  instance,  it 
may  exist  at  the  margin  or  circumference  of  the  after-birth,  the  centre  being 
detached;'  or  it  may  be  restricted  to  one  or  more  points  of  its  surface.  It  like- 
wise offei-s  various  degrees  of  resistance;  occasionally  being  feeble  enough  to 
yield  readily,  even  to  moderate  tractions ;  though  it  is  sometimes  so  strong  that 
either  the  placental  or  the  uterine  tissue  yields  rather  than  the  bond  of  union. 
In  some  instances,  the  adhesions  are  so  firm  that  they  cannot  be  broken  up  with- 
out the  greatest  difficulty,  even  after  death.  For  example,  Morgagni  found  a 
portion  of  the  detached  placenta  hanging  in  the  uterine  orifice  of  a  woman,  who 
died  thirteen  days  after  her  confinement;  but  the  other  part  of  it  was  so  adhe- 

'  It  frequently  liappens,  says  Leroiix  (Tniite  des  Pates  de  Sang,  page  306),  tliat  the  pla- 
centa is  thus  detached  at  the  miihlle,  but  remains  adherent  by  its  margins.  The  same  thing 
was  ob-erved  by  Albiniis,  in  a  woman  whose  womb  he  has  sketched.  "  The  female,"  he 
says,  "whose  uterus  is  represented  in  several  of  the  plates,  had  a  detached  placenta,  and 
there  was  a  considerable  quantity  of  clotted  blood  beuveen  it  and  the  organ  ;  it  was  adhe- 
rent, however,  around  the  whole  border,  whereby  flooding  was  prevented."'  (Louis'  Trans- 
lation of  Fan  Swieten,  t.  vii,  p.  145,  and  Heistcr,  t.  ii,  chap,  civ,  p.  459.J 


892  DELIVERY    OF    THE    AFTER-BIRTII. 

rent,  that  he  could  scarcely  separate  it  with  a  scalpel.  The  adherent  portion  was 
indurated,  and  some  traces  of  inflammation  were  found  on  the  corresponding  part 
of  the  womb. 

Whenever  a  considerable  period  of  time  has  elapsed  after  the  labor,  without 
the  delivery  of  the  after-birth  being  effected,  and  yet  the  globular  form  of  the 
uterus,*  its  hardness  and  manifest  contraction,  clearly  show  that  it  is  striving  to 
detach  and  to  expel  the  secundines,  and  where  the  finger,  passed  through  the 
cervix  uteri,  does  not  detect  the  placenta,  we  have  every  reason  to  suppose  that 
there  is  an  unnatural  adhesion  of  this  mass.  The  following  signs  will  then  con- 
firm our  suspicions  :  after  drawing  on  the  placenta  by  means  of  the  cord,  the 
latter  will  be  found  to  mount  up  as  soon  as  it  is  relaxed ;  during  the  contraction, 
the  uterine  globe  becomes  harder  and  diminishes  in  volume,  but  after  the  pain  is 
over,  it  returns  to  its  former  condition  much  sooner  and  more  perfectly  than  in 
other  cases;  and,  lastly,  the  existence  of  this  complication  is  rendered  unequivocal 
by  carrying  the  hand  up  into  the  uterus. 

The  abnormal  adhesions  of  the  placenta  may  exist  alone,  or  they  may  be  com- 
plicated with  some  accident;  its  partial  adherence  is  nearly  always  accompanied 
by  a  more  or  less  profuse  hemorrhage.  In  cases  of  simple  adhesion,  the  accou- 
cheur should  always  wait,  for  a  delay  of  a  few  hours  is  often  sufficient  to  effect 
the  separation  ;  then,  after  waiting  for  a  couple  of  hours,  the  uterus  is  stimulated 
to  contraction  by  the  various  means  before  indicated ;  but,  if  these  prove  insuffi- 
cient, an  injection  of  cold  water  is  to  be  thrown  into  the  umbilical  vein.  After 
having  cut  the  end  of  the  cord,  and  squeezed  the  vein  so  as  to  free  it  entirely  of 
any  blood  it  may  contain,  the  cold  liquid  is  injected  into  this  vessel  with  a  suffi- 
cient degree  of  force  to  diffuse  it  throughout  the  placental  mass.  This  ought  to 
be  repeated,  taking  care  to  retain  the  fluid  in  the  after-birth  for  several  minutes 
by  securing  the  cord.  This  injection  evidently  has  a  twofold  operation,  affecting 
both  the  placenta  and  the  womb;  that  is,  it  distends  the  former  by  the  introduc- 
tion of  a  new  liquid  into  its  vessels,  thereby  augmenting  its  size  and  weight; 
and  the  impression  of  cold  on  the  internal  surface  of  the  latter,  brings  on  its 
contraction.     This  measure,  therefore,  ought  not  to  be  overlooked. 

Where  it  fails,  tractions  on  the  umbilical  cord  are  to  be  resorted  te;  though 
always,  as  advised  by  Levret,  perpendicularly  to  the  surface  of  the  placenta.  If 
two  sheets  of  moistened  paper  are  stuck  together,  continues  this  author,  for  the 
purpose  of  illustrating  the  importance  of  his  precept,  and  you  endeavor  to  sepa- 
rate them  by  sliding  one  over  the  other,  that  is  to  say,  by  drawing  them  parallel 
to  their  planes,  you  tear  rather  than  detach  them ;  whilst,  by  pulling  perpendi- 
cularly to  those  planes,  you  will  separate  them  without  the  least  effort,  as  also 
without  any  laceration.  In  order  to  obtain  a  similar  result  in  practice,  the  umbi- 
lical cord  is  carried  towards  the  side  not  occupied  by  the  placenta,  by  the  inter- 
vention of  two  fingers  passed  into  the  vagina  beyond  the  uterine  orifice.  But  it 
is  impossible  to  carry  out  this  rule,  as  Velpeau  and  Guillemot  justly  remark,  be- 

'  I  think,  saj's  John  Ramsbotham,  tliat  I  have  observed  a  slif^ht  alteration  in  the  shape  of 
the  uterus.  It  i)resents  a  less  re<;ularly  spherical  form,  and  its  fundus  also  exhibits  a  certain 
degree  of  conic-ity.   (Obs.  on  Midwifery) 


ARTIFICIAL     DELIVERY. 


893 


cause  both  tbe  foetal  and  the  uterine  surfiices  of  the  after-birth  are  in  contact  with 
the  walls  of  the  organ ;  besides,  the  Angers  can  only  sustain  the  cord  below  the 
cervix,  and  hence,  as  a  natural  consequence,  the  cord  will  always  be  parallel 
with,  not  perpendicular  to,  the  long  axis  of  the  womb,  in  whatever  manner  it  be 
held.  The  same  effect  is  produced  equally  well,  in  their  opinion,  by  drawing  on 
it  without  this  artificial  pulley.  Though  wliichever  plan  be  resorted  to,  the 
operator  must  never  exert  force  enough  in  making  the  tractive  efforts  to  rupture 
the  cord,  and  he  should  desist  as  soon  as  he -finds  it  yielding. 

But,  supposing  all  the  local  and  general  irritants,  tbe  injections  into  the  um- 
bilical vein,  and  the  tractions  upon  the  cord  just  recommended,  have  proved 
ineffectual,  what  is  to  be  done  ?  When  the  adhesions  are  complicated  by  any 
hemorrhacic  or  convulsive  affection,  all  accoucheurs  are  harmonious  on  one 
point,  name'ly,  to  persist  in  the  attempts  to  effect  the  extraction.  But  the  same 
unanimity  docs  not  exist  with  regard  to  cases  of  simple  adhesion ;  for  some, 
dreading  the  disastrous  phenomena  that  may  result  from  the  retention,  and  sub- 
secfuent  putrefliction  of  the  placenta,  and  the  absorption  of  putrid  matters,  are  in 
favor  of  terminating  the  delivery  at  every  hazard;  while  others,  on  the  contrary, 
fearing  still  more  the  consequences  of  the  manipulations  which  are  necessary  for 
effecting  the  detachment  of  the  placenta,  advise  us  to  abandon  the  whole  to 
nature ;  at  the  same  time  recommending  the  ulterior  symptoms  to  be  met  and 
combated  as  they  arise  by  the  appropriate  measures. 

Our  own  opinion  is,  that  the  course  of  Levret,  of  Baudelocque,  of  Desormeaux, 
and  M.  P.  Dubois,  is  the  best  adapted  to  cases  of  this  kind ;  that  is,  after  having 
employed  tl^e  various  means  we  have  spoken  of,  to  introduce  the  hand  into  the 
uterine  cavity,  following  the  cord,  which  is  then  the  best  guide  up  to  the  pla- 
centa. Should  this  have  been  torn  away,  the  latter  could  be  recognized  by  the 
vascular  ramifications  which  characterize  its  foetal  surface,  by  its  elevation  above 
the  inner  face  of  the  uterus,  by  its  consist- 
ence, and  by  the  dull  sensation  felt  by  the 
patient  when  the  fingers  bear  upon  it.  The 
point  of  attachment  being  discovered,  the 
next  step  is  to  ascertain  whether  the  adhe- 
sion is  complete  or  partial ;  in  the  latter  case, 
it  is  recommended  to  insinuate  the  open 
hand  between  the  external  surface  of  the 
placenta  and  the  uterine  wall,  and  then  slit 
up  the  adhesions  with  the  finger,  just  as  you 
would  cut  the  leaves  of  a  book  with  a  paper. 
knife.  (Fig.  13G.)  When  this  is  done,  M. 
P.  Dubois  thinks  it  is  better  to  seize  the  de- 
tached part  with  the  whole  hand,  and  pull 

upon  it,  with  a  view  of  completing  the  separation  of  the  rest ;  but,  if  this  proves 
unsuccessful,  he  next  tears  and  brings  away  all  the  loose  portion,  leaving  the 
ulterior  expulsion  of  those  parts  that  still  remain  adherent,  to  nature,  without 
resorting  to  any  further  attempts.     We  could  bring  forward  numerous  cases  in 


Fi-.  136. 


The  mode  of  lircaking  up  llie  adhesions  of 
the  placenta. 


894  DELIVERY     OF     THE     AFTER-CIRTH. 

proof  of  the  soiTndness  of  this  precept.  For  example,  we  have  known  a  rash 
operator  to  perforate  tlic  uterus  completely  whilst  striving  to  separate  an  adhe- 
rent placenta;  and  Leroux,  of  Dijon,  notwithstandinc;  all  his  dexterity,  had  the 
misfortune  to  detach  quite  a  considerable  part  of  the  internal  muscular  plane,  in 
a  case  of  partial  adhesion,  by  pulling  too  strongly  on  the  detached  upper  portion 
of  the  after-birth,  in  order  to  separate  its  still  adherent  lower  part.  Death  soon 
followed  in  the  case  we  allude  to;  and  the  surgeon  of  Dijon  had  a  profuse  hemor- 
rhage to  encounter  in  his,  but  he  fortunately  succeeded  in  arresting  it  by  the 
application  of  the  tampon. 

"When  the  placenta  becomes  separated  at  its  central  part,  the  margins  being 
still  adherent,  a  cavity  is  usually  created  at  that  point,  in  which  the  blood  accu- 
mulates. Under  such  circumstances,  the  centre  of  the  mass  may  be  perforated, 
and  the  fingers  be  passed  up  through  the  opening,  to  complete  the  detachment; 
at  least,  such  was  the  course  adopted  by  lleister  and  Leroux.  Furthermore, 
where  the  placenta  is  adherent  throughout,  the  accoucheur  operates  on  its  ex- 
ternal face,  by  slipping  up  the  hand  behind  the  membranes;  and  when  it  reaches 
the  circumference  of  the  after-birth,  he  first  endeavors  to  detach  one  part,  and, 
where  successful,  he  pursues  the  same  course  as  if  it  had  originally  been  a  case 
of  partial  adherence. 

Finally,  let  us  add,  that  it  is  not  proper  to  persist  too  long,  when  a  part,  or  even 
the  whole  of  the  placenta  holds  out  against  the  properly-conducted  manipula- 
tions just  advised ;  for  its  expulsion  will  probably  take  place  sooner  or  later, 
either  all  at  once,  or  in  fragments. 

§  G.  Of  the  Partial  or  Complete  Ketention  of  the  Placenta. 

By  conforming  to  the  rules  just  mentioned,  we  shall  rarely  fail  in  extracting 
the  placenta  completely;  but  we  have  seen  that  there  are  nevertheless  some  cases 
in  which  a  larger  or  smaller  portion  of  the  after-birth  is  necessarily  left  behind, 
and  its  expulsion  confided  to  the  resources  of  the  economy.  Whether  this  aban- 
donment be  obligatory,  or  the  result  of  ill-directed  tractions  on  the  cord,  or  of 
improper  attempts  to  eifect  the  separation  of  the  adherent  placenta,  it  may  lead 
to  various  consequences,  some  of  which  are  very  serious.  It  is,  therefore,  very 
important  to  determine  the  fact,  which  may  almost  always  be  done  by  a  careful 
examination  of  the  placenta.  The  only  difficulty  which  could  arise,  would  be 
occasioned  by  its  separation  into  fragments  in  consequence  of  its  very  close 
adhesion. 

A.  Ilemorrliacje  is  almost  always  the  immediate  consequence  of  the  retention 
of  any  considerable  part  of  the  placenta,  and  its  amount  is  generally  proportionate 
to  the  size  of  the  abandoned  portion.  Sometimes,  however,  no  flooding  occurs ; 
cither  because  the  uterus  contracted  properly  after  the  separation  of  the  placenta, 
or  because  the  fragments  left  behind  remain  attached  to  the  walls  of  the  organ. 
In  the  former  case,  the  contraction  of  the  womb  diminishes  the  discharge  after 
the  lapse  of  some  hours;  and,  during  the  few  succeeding  days,  excepting  the 
violent  colics  occasioned  by  the  efforts  of  the  uterus  to  expel  the  foreign  body, 
the  patient  suffers  little  more  than  the  discomforts  attendant  upon  a  moderate 
hemorrhage. 


ARTIFICIAL    DELIVERY.  895 

It  is  not  long,  however,  before  these  frequent  after-pains  seem  to  give  rise  to 
an  unusual  tenderness  of  the  uterine  tumor;  and,  finally,  even  slight  pressure 
becomes  painful.  The  lochia,  which  hitherto  were  composed  entirely  of  blood, 
present  a  different  character.  They  are  mixed  with  a  very  fetid,  sanious  fluid, 
and  become  very  irritating  to  the  genital  parts.  If  the  temperature  should 
chance  to  be  high,  and  especially  if  the  most  scrupulous  regard  is  not  paid  to 
cleanliness,  they  diffuse  such  a  disgusting  odor  as  to  render  the  chamber  unten- 
able; and,  as  M.  Jacquemier  observes,  the  assistants  are  liable  to  suffer  severely 
from  it. 

This  change  in  the  lochia,  is  due  to  the  putrefiction  of  some  portions  of  the 
placenta.  As  parts  of  the  adherent  mass  become  gradually  detached,  they  fall 
into  the  cavity  of  the  uterus,  where  they  are  liable  to  remain  for  some  lime. 
The  contact  of  air  which  readily  reaches  the  uterus  soon  gives  rise  to  putrefac- 
tion, and  the  decomposed  fragments  communicate  to  the  lochia  the  odor  which 
characterizes  them. 

B.  Putrid  ahsorption  of  the  Placenta. — These  local  phenomena  rarely  appear 
without  being  accompanied  by  a  sensible  alteration  of  the  general  health  of  the 
patient.  After  a  longer  or  shorter  time,  a  violent  chill  comes  on,  attended  with 
extreme  restlessness  and  anxiety,  the  pulse  becomes  rapid,  and  the  skin  dry  and 
burning;  the  face  is  alternately  pale  and  flushed,  though  mostly  pale;  the  respi- 
I'ation  is  anxious  and  frequent;  the  tongue,  which  is  always  dry,  is  sometimes 
white  and  sometimes  red;  the  patient  complains  of  pain  in  the  head,  attended 
occasionally  with  throbbing,  and  soon  delirium,  at  first  intermittent  and  finally 
constant,  are  added  to  the  other  symptoms.  The  latter  become  more  and  more 
serious;  the  abdomen  is  distended  and  very  tender;  inclinations  to  vomit,  some- 
times even  profuse  vomiting,  and,  occasionally,  frequent  and  involuntary  alvine 
discharges,  show  that  the  alimentary  canal  shares  in  the  general  affection. 
Finally,  the  pulse  becomes  more  and  more  rapid,  thread-like,  and  undulating ; 
the  debility  and  restlessness  are  extreme,  there  is  no  cessation  of  delirium,  and 
death  closes  this  terrible  scene  five,  ten,  or  fifteen  days  after  the  invasion  of  the 
first  symptoms. 

Peritonitis,  which  is  in  some  cases  indicated  by  the  tenderness  and  distension 
of  the  abdomen,  does  not  always  occur,  and  death  may  result  simply  from  the 
species  of  poisoning,  occasioned  by  the  absorption  of  the  putrefied  fragments  of 
the  placenta.  The  symptoms  presented  by  the  patient,  are  then  simply  those  of 
the  fevers  formerly  called  adynamic  and  ataxic. 

The  result  is  not  necessarily  fatal,  and  especially  when  the  disease  is  uncom- 
plicated with  peritonitis,  the  patient  may  escape  from  the  danger  which  threat- 
ened her. 

After  a  certain  length  of  time,  the  retained  portion  of  the  placenta  may  be- 
come suddenly  detached,  and  be  expelled  bodily;  upon  which,  the  grave  symp- 
toms to  which  its  decomposition  had  given  rise,  cease  almost  immediately. 

Sometimes,  and  under  the  use  of  frequent  injections,  the  discharge  seems  to 
lose  its  fetidity  and  irritating  qualities,  and  becomes  more  decidedly  purulent. 
Some  detached  portions  of  the  placenta  are  found  diffused  in  it,  and  parts  are 


896  DELIVERY     OF     THE    AFTER-BIRTH. 

also  brought  awaj  by  every  injection  ;  rather  larger  portions  occasionally  present 
at  the  cervix  and  may  be  extracted  with  the  finger.  Whilst  the  womb  is  thus 
ridding  itself  of  the  putrid  matter  which  it  contains,  the  general  symptoms  im- 
prove, or,  at  least,  are  not  aggravated.  The  economy  seems  to  resist  the  delete- 
rious influence  to  which  it  is  subjected.  The  patient  may  remain  in  this  condi- 
tion for  several  weeks  with  an  almost  constant  febrile  movement,  accompanied 
now  and  then  with  exacerbations  preceded  by  slight  chilliness,  and  moderate 
disorder  of  the  digestive  apparatus,  until,  finally,  when  the  remainder  of  the 
placenta  is  expelled,  the  fever  ceases,  the  strength  returns,  and  the  patient  is 
restored  to  health. 

These  serious  accidents,  which  are  always  to  be  feared  when  a  considerable 
portion  of  the  placenta  is  retained  within  the  womb,  do  not,  however,  always 
result  from  this  retention.  It  may  remain  there  for  a  long  time  after  the  deli- 
very without  seriously  afl'ecting  the  woman's  health,  and  be  disposed  of  in  two 
different  but  equally  strange  ways.  I  allude  to  the  late  expulsion  and  absorp- 
tion of  the  placenta. 

C.  Late  Expulsion  of  the  Placenta. — The  retention  of  a  portionof  the  pla- 
centa is  almost  alwa3-s  attended  by  a  profuse  hemorrhage.  This,  however,  does 
not  invariably  occur  when  the  entire  after-birth  remains  in  the  cavity  of  the 
uterus,  which  rarely  happens  except  after  abortions.  If,  in  short,  the  adhesions 
are  nowhere  destroyed,  and  the  utero-placental  vessels  are  unruptured,  the  reason 
of  the  absence  of  hemorrhage,  and  often  even  of  the  lochial  discharge  observed 
under  these  circumstances,  is  evident.  The  flooding  then  comes  on  only  when 
the  uterus  at  last  contracts  in  order  to  expel  the  foreign  body. 

This  expulsion  may  be  accomplished  at  once,  and  the  completely-separated 
placenta  be  discharged  whole.  The  hemorrhage,  which  had  lasted  four,  five,  or 
even  ten  days,  being  the  time  sometimes  necessary  for  its  separation,  cease's  im- 
mediately after,  as  by  enchantment.  This  hemorrhage  is  always  far  less  profuse 
when  the  detachment  of  the  placenta  takes  place  at  a  remote  period  from  the 
expulsion  of  the  child.  The  constant  contraction  of  the  uterus,  which  tends 
unceasingly  to  resume  the  dimensions  of  the  unimpregnatcd  condition,  necessa- 
rily lessens  the  calibre  of  the  vessels  and  almost  obliterates  them,  so  that  their 
rupture  at  that  time  is  an  affair  of  little  moment.  On  examining  the  placenta, 
it  is  found  to  have  undergone  no  alteration,  it  exhales  no  unpleasant  odor,  and 
although  it  may  have  remained  several  days,  weeks,  or  even  months,  in  the  cavity 
of  the  uterus  after  the  expulsion  of  the  child,  it  is  as  fresh  as  though  the  latter 
were  just  born.  Its  vitality  had  been  preserved  by  the  integrity  of  its  vascular 
connections,  and  its  prolonged  retention  been  thus  rendered  innoxious. 

I  have  just  had  occasion  to  observe  a  case  of  the  kind,  afforded  by  a  young 
woman  three  months  and  a  half  gone,  who  miscarried  twenty-four  days  ago.  The 
placenta  had  remained  since-  then  within  the  cavity  of  the  uterus,  and  a  profuse 
hemorrhage  having  occurred  in  consequence  of  its  detachment,  I  was  obliged  to 
extract  it  artificially.  It  was  already  engaged  in  the  cervix,  and  its  withdrawal 
presented  no  serious  difficulty;  the  extreme  weakness  of  the  patient  forbade  tem- 
porizing.    It  had  no  appearance  of  decomposition. 


ARTIFICIAL     DELIVERY.  897 

Unfortunately,  the  slowness  with  which  the  detachment  of  the  placenta  sonso- 
tiiues  takes  place,  may  so  prolong  the  discharge  as  to  give  rise  to  another  acci- 
dent. When,  in  fact,  a  cotyledon  is  thus  separated,  it  no  longer  shares  in  the 
circulation  of  the  adhering  parts,  and  remains  suspended  within  the  cavity  of  the 
womb.  After  a  time,  it  becomes  detached  from  the  rest  of  the  placenta,  and  if 
its  size  or  the  contraction  of  the  orifice  prevents  its  being  discharged  imme- 
diately, it  decomposes,  and  may  give  rise  to  some  of  the  accidents  already  men- 
tioned. Generally,  however,  its  expulsion  is  not  long  deferred,  or  else  the 
practitioner  deems  it  proper  to  extract  itj  still,  it  is  impossible  to  avoid  the 
hemorrhages,  the  repetition  of  which  on  the  occasion  of  each  partial  sej)aration 
at  last  weaken  the  patient  greatly,  and  may  even  endanger  her  existence. 

D.  The  complete  ahsovption  of  the  placenta  is  so  extraordinary  a  phenomenon, 
that  the  first  observations  published  were  received  very  doubtfully.  Nothing  short 
of  the  great  authority  of  such  names  as  that  of  NasgMe,  together  with  the  strict 
detail  with  which  the  cases  are  related,  were  required  to  obtain  for  them  a  place 
in  obstetric  science.  Yet  it  is  so  easy  to  be  deceived  in  such  cases,  that  even 
after  the  observations  of  Ntegele,  Salomon,  and  Velpeau,  doubts  will  occasionally 
suggest  themselves.  Is  it  not  possible,  indeed,  that  notwithstanding  the  strictest 
surveillance,  the  placenta  might  have  been  expelled  unconsciously  ?  Is  it  not 
possible  that  the  species  of  sanious  detritus  to  which  its  decomposition  gives  rise, 
may  have  formed  a  part  of  the  putrescent  lochia  discharged  in  such  cases  ? 
Finally,  may  it  not  have  been  that  its  prolonged  retention  and  late  expulsion, 
were  regarded  as  instances  of  absorption  ?  in  fact,  that  after  a  woman  had  thus 
retained  her  placenta  for  several  months  without  her  health  having  suffered  ma- 
terially, it  may  have  become  detached  without  a  great  deal  of  hemorrhage,  and 
small  and  shrivelled  as  it  was,  have  been  discharged  during  strainings  at  stool 
without  the  patient  herself  being  aware  of  it. 

Most  of  the  published  cases  are,  doubtless,  liable  to  one  or  the  other  of  these 
explanations;  yet  it  must  be  confessed  that  there  are  others,  in  which  there 
would  seem  to  be  no  doubt  that  the  placenta  had  really  been  absorbed.  After 
all,  analogous  phenomena  arc  not  wanting.  In  extra-uterine  pregnancies,  has 
not  the  foetus  often  been  found  reduced  to  its  bony  portions  in  consequence  of 
the  absorption  of  the  other  fluid  or  solid  parts  ?  Has  not  the  same  thing  been 
known  to  take  place  within  the  uterus  when  a  dead  foetus  had  been  retained  fur 
a  long  time?  The  absorption  of  a  placenta  is  certainly  not  more  wonderful, 
especially  in  cases  of  abortion,  when  the  placentas  are  small  and  imperfectly 
formed,  as  in  most  of  the  instances  mentioned.  The  possibility  of  the  occur- 
rence cannot,  therefore,  as  yet  be  absolutely  denied,  though  it  should  be  received 
with  a  certain  degree  of  reserve. 

Indications. — We  have  dwelt  sufiiciently  upon  the  proper  means  of  preventing 
the  entire  or  partial  retention  of  the  placenta,  and  have  but  a  word  to  add  re- 
specting the  prudence  which  should  govern  all  attempts  at  extraction.  Although 
the  dangerous  accidents  to  which  the  woman  is  exposed,  require  that  we  should 
attempt  all  that  is  humanly  possible  in  order  to  effect  its  extraction,  it  should  be 
remembered   that  too  long-continued  efforts,  whether  to  introduce   the    hand 

57, 


898  DELIVERY     OF    THE     AFTER-BIIITII. 

through  a  contracted  orifice  or  to  rupture  the  too  strong  adhesions,  are  liable  to 
produce  equally  serious  consequences;  in  fact,  that  post-puerperal  inflammations 
and  even  ruptures  of  the  uterus  have  frequently  resulted  from  these  forcible  de- 
tachments; and,  finally,  that  a  placenta  retained  wholly  or  in  part  within  the 
uterus,  may  not  be  expelled  until  after  the  hipsc  of  several  months,  or  may  be 
absorbed  without  sensibly  affecting  the  health  of  the  mother.  Although  these 
latter  occurrences  are  rare,  they  are  yet  sufficient  to  justify,  and  even  require  the 
relinquishment  of  all  violent  and  dangerous  cflForts.  It  were  impossible  to  fur- 
nish here  an  absolute  rule  of  action,  and  it  must  be  left  to  the  intelligence  and 
prudence  of  the  practitioner,  to  determine  how  far  he  shall  proceed  in  such  cases. 
The  indications  to  be  fulfilled,  when  a  portion  of  the  placenta  has  been  left 
behind,  either  voluntarily,  or  through  awkwardness,  vary  according  to  the  period 
at  which  our  services  are  demanded. 

Very  often  a  quite  profuse  hemorrhage  is  the  first  accident  to  appear,  and 
efforts  should  be  made  to  restrain  it  by  means  of  cold  applications  to  the  'hypo- 
gastrium,  groins,  and  thighs,  by  frictions  upon  the  body  and  neck  of  the  uterus, 
and,  with  the  object  of  obtaining  a  more  thorough  contraction  of  the  organ,  ei'got 
should  be  administered.  These  measures  will  very  rarely  be  found  insufficient 
provided  the  uterus  is  properly  contracted,  but  should  the  accident  be  compli- 
cated by  inertia,  the  measures  to  be  indicated  hereafter  should  be  resorted  to. 

Care  should  be  taken  as  regards  relieving  the  violent  after-pains  which  torment 
the  patient,  by  the  use  of  opiates,  since  the  contractions  of  which  they  are  the 
result,  tend  to  separate  and  expel  the  adherent  mass. 

The  ulterior  conduct  of  the  practitioner  must  be  governed  by  circumstances. 
If  the  neck  of  the  uterus  appears  to  be  strongly  contracted,  if  the  lochia  are 
moderate  in  amount,  and  especially  if  their  composition  is  unaltered  and  their 
color  and  smell  unchanged,  he  should  be  satisfied  with  watching  the  patient 
closely  without  interfering  with  the  tendencies  of  nature  by  an  untiuiely  inter- 
vention. 

As  soon  as  the  lochia  become  sanious  and  fetid,  he  should  resort  to  the  best 
means  of  averting  their  dangerous  influence  upon  the  economy.  Intra- vaginal 
and  intra-uterine  injections  practised  frequently,  and  continued  until  the  return- 
ing fluid  is  no  longer  imbued  with  the  odor  of  decomposition,  are  very  useful. 
M.  YuUyamos  recommends  the  use  of  large  quantities  of  water;  he  throws  up  an 
injection  consisting  of  the  warm  infusion  of  marshmallows,  by  means  of  a  large 
syringe,  every  five  minutes;  he  prefers  cold  water,  however,  in  cases  of  flooding. 
This  operation  is  effected  by  the  use  of  a  long  gum-elastic  tube,  one  end  of  which 
is  fixed  in  the  uterine  orifice,  and  the  other  extends  beyond  the  vulva,  or  even 
the  foot  of  the  bed,  so  as  to  obviate  the  necessity  of  uncovering  her;  the  return- 
ing .fluid  is  collected  in  a  basin  placed  under  the  patient.  (^Gaz.  Med.,  493, 
1840.)     I  think  it  would  be  more  prudent  to  make  use  of  a  double  tube. 

The  patient  should  also  be  examined  frequently,  in  order  to  ascertain  whether 
any  portion  of  the  placenta  presents  at  the  cervix,  and  if  so,  it  should  be  ex- 
tracted immediately,  either  with  the  fingers,  or  with  Levret's  abortion  forceps. 


i 


ARTIFICIAL     DELIVERY.  899 

The  injections,  indeed,  are  not  always  sufficient,  being  incapable  of  bringing  away 
moderate-sized  fragments. 

Extreme  fetidity  of  the  lochia  might  possibly  authorize  the  use  of  slightly 
chlorinated  injections. 

The  patient  should  also  have  the  advantage  of  the  best  hygienic  measures. 
The  chamber  should  be  thoroughly  ventilated  and  purified  by  every  appropriate 
means,  and  the  linen  changed  as  often  as  possible. 

If,  notwithstanding  these  precautions,  upon  which  top  much  stress  cannot  be 
laid,  symptoms  of  general  infection  should  appear,  complicated  with  peritonitis, 
purgatives,  baths,  calomel,  and  mercurial  inunctions,  should  be  used  at  the  out- 
set; but  the  first  adynamic  or  ataxic  phenomena  must  be  met  with  the  tonic  and 
stimulant  treatment  used  in  the  latter  stages  of  low  fevers.  Water  containing 
wine,  preparations  of  cinchona  and  acetate  of  ammonia,  may  all  prove  very  useful. 

ARTICLE   III. 

OF   THE   ACCIDENTS   THAT    MAY   COMPLICATE   THE   DELIVERY   OF   THE 

AFTER-BIRTH. 

The  principal  of  these  are  hemorrhage,  convulsions,  and  inversion  and  rupture 
of  the  womb. 

§  1.  Of  Hemorrhage. 

Of  all  the  accidents  that  may  precede,  accomj-any,  or  follow  the  delivery  of  the 
placenta,  flooding  is  certainly  one  of  the  most  frequent,  and,  at  the  same  time, 
most  terrible  in  its  consequences.  It  may  occur  conjointly  with  either  of  the 
difficulties  just  described  in  the  preceding  article ;  and,  when  this  does  take 
place,  the  indications  then  laid  down  ought  to  be  followed  up  more  promptly. 
But,  in  addition  to  those  circumstances,  a  hemorrhage  may  likewise  take  place 
after  the  child  is  born ;  and  this  claims  our  special  attention,  since  it  is  nearly 
always  accompanied  by  the  complete  or  partial  inertia  of  the  womb.  We  have 
therefore  to  examine  successively  the  causes,  symptoms,  diagnosis,  prognosis,  and 
treatment  of  this  inertia,  considered  with  particular  reference  to  the  accident  in 
question.  We  shall  thus  complete  the  history  of  puerperal  hemorrhage,  which 
was  hitherto  only  described  in  part ;  namely,  during  the  first  six  months,  in  the 
article  on  Abortion;  and  during  the  last  three  months,  as  also  pending  the  labor 
proper,  in  that  on  Accidental  Dystocia. 

A.  Causes. — After  the  delivery  of  the  child,  and  even  during  the  progress  of 
its  expulsion,  the  uterine  tissue  becomes  gradually  retracted  by  the  exercise  of 
its  contractility  of  tissue,  whereby  the  cavity  of  the  organ  is  considerably  dimi- 
nished ;  thus  constricting  the  vessels  that  ramify  in  the  substance  of  its  walls, 
and  reducing  their  calibre  in  a  greater  or  less  degree,  thereby  interrupting  the 
circulation,  and  of  course  preventing  the  utero-placental  vessels,  which  are  torn 
by  the  detachment  of  the  placenta,  from  becoming  the  source  of  a  profuse  hemor- 
rhage.    Xow,  under  certain  circumstances;  this  contractility  of  tissue  is  very 


900  DELIVERY     OF     THE     AFTER-BIRTH. 

feeble,  and  in  others  it  is  altogetlier  wanting;  in  the  former  case  the  inertia  of 
the  womb  is  partial,  in  the  latter  it  is  complete;  again,  it  may  be  total  or  partial, 
according  as  it  affects  the  whole  or  a  part  of  the  uterine  walls.  All  which 
various  degrees  of  the  affection  may  be  developed  under  the  influence  of  the  same 
causes. 

The  causes  of  hemorrhage  from  inertia  are  either  predisposing  or  determining; 
under  the  former  head,  writers  have  enumerated,  1st,  a  plethoric  and  sanguine 
habit,  a  precocious  and  usually  copious  menstruation ;  more  particularly  when 
venesection  has  not  been  resorted  to  in  anticipation,  during  the  latter  months  of 
pregnancy;  2d,  a  lymphatic  temperament;  for  those  women  who  have  a  soft  and 
lax  fibre,  or  possess  but  little  muscular  power,  and  who  are  nervous  and  irritable, 
are  more  liable  than  others  to  this  affection ;  3d,  the  occurrence  of  profuse  flood- 
ing after  former  labors.  We  might  bring  forward  numerous  cases,  all  tending 
to  prove  the  unfavorable  influence  of  previous  floodings ;  and,  therefore,  from  the 
mere  fact  of  their  occurrence  at  one  or  more  antecedent  labors^  the  accoucheur 
ought  to  take  suitable  measures  to  prevent  their  reappearance. 

Under  the  head  of  the  so-called  determining  causes,  we  may  classify,  1st,  the 
exhaustion  incident  to  a  protracted  and  painful  labor;  or,  in  other  words,  all  the 
obstacles  that  may  oppose  the  natural  delivery  of  the  foetus;  2d,  a  very  short 
labor,  and  its  rapid  termination  from  the  stupor  of  the  walls,  caused  by  the  rude 
and  hasty  depletion  of  the  organ ;  hence  a  very  large  pelvis,  a  laceration  of  the 
cervix,  and  a  want  of  resistance  at  the  perineum,  all  which  facilitate  the  rapid 
expulsion  of  the  child,  may,  from  that  fact  alone,  become  sources  of  inertia;  3d, 
an  excessive  distension  of  the  womb,  whether  dependent  on  a  dropsy  of  the 
amnios  or  a  twin  pregnancy,  may  paralyze,  as  it  were,  the  contractility  of  the 
uterine  tissue ;  4th,  according  to  Madame  Lachapelle,  we  must  further  add  a 
dragging  of  the  uterus,  in  consequence  of  an  adhesion  contracted  with  the  omen- 
tum during  gestation ;  whereby  the  perfect  retraction,  of  the  organ  after  labor  is 
impeded. 

There  can  be  no  doubt  that  the  various  circumstances  just  alluded  to,  may  of 
themselves  give  rise  to  inertia;  but,  as  a  general  rule,  their  influence  will  be  of 
short  duration  and  easily  set  aside,  if  it  is  not  favored  by  the  existence  of  some 
predisposing  cause.  It  is  to  the  latter,  especially,  as  M.  Guillemot  observes,  that 
we  must  refer  the  chief  part  in  the  production  of  those  hemorrhages  that  occur 
after  the  child  is  born.  In  fact,  where  they  exist  conjointly  in  the  same  woman, 
there  is  every  reason  to  fearr  the  occurrence  of  that  accident;  whilst,  if  absent, 
the  supposed  determining  causes  usually  have  but  little  or  no  effect. 

The  influence  of  those  causes  is  ordinarily  manifested  in  the  course  of  a  few 
minutes  after  the  child  is  born ;  though  sometimes  the  inertia  is  secondary,  as  it 
were,  not  coming  on  for  several  hours,  or  even  not  until  several  days  afterwards. 
The  womb  having  contracted  properly  immediately  after  the  delivery  of  the  child 
or  after-birth,  then  becomes  relaxed  by  degrees,  and  ultimately  gives  rise  to  a 
frightful  hemorrhage. 

B.  Sj/ynptoms. — Where  the  uterus  contracts  properly  as  soon  as  the  labor  is 
over,  a  hard,  globular,  rounded  tumor  is  found  in  the  hypogastric  region,  occupy- 


ARTIFICIAL     DELIVERY.  901 

ing  nearly  all  the  space  between  the  umbilicus  and  pubis.  This  tumor  is  the 
seat  of  intermittent  pains  of  variable  intensit}-,  and  is  always  harder  while  they 
last.  An  absence  of  these  characters  indicates  an  inertia  of  the  organ ;  that  is, 
by  palpating  the  lower  part  of  the  abdomen,  we  find  nothing  but  softness  and 
flaccidity  throughout;  for  the  abdominal  and  uterine  walls  are  so  easily  depressed, 
that  they  can  be  pushed  back  against  the  posterior  ventral  parictes ;  and,  indeed, 
where  the  inertia  is  complete,  it  is  even  impossible  to  make  out  which  arc  the 
uterine  and  which  the  abdominal  walls.  Again,  by  carrying  the  hand  up  into 
the  womb,  it  readily  passes  through  the  relaxed  cervix,  and  finds  the  uterine 
parietes  everywhere  flabby  and  wrinkled  like  a  bit  of  old  rag.  Should  the  inertia 
be  partial,  the  uterine  structures  seem  to  be  thicker,  and  to  have  a  more  marked 
consistence;  but  they  are  still  readily  distended,  and  are  far  from  off"ering  their 
characteristic  resistance. 

This  condition  may  exist  without  hemorrhage,  if  the  placental  adhesion  still 
remains  intact  at  every  part  of  its  uterine  surface;  but  whenever  a  separation  has 
occurred,  flooding  is  clearly  inevitable.  Of  course,  the  latter  will  be  the  more 
copious  as  the  detachment  is  nearly  or  wholly  completed  at  the  time  the  inertia 
is  manifested. 

The  signs  by  which  the  existence  of  hemorrhage  is  recognized  are  easily  made 
out;  but  the  discharge  is  sometimes  so  sudden  and  profuse,  that  it  is  not  de- 
tected until  the  woman's  life  is  already  seriously  endangered.  .  The  patient  gene- 
rally cotuplains  of  a  feeling  of  weight  about  the  stomach;  and,  soon  after,  pallor 
of  the  face,  dimness  of  vision,  smallness  of  the  pulse,  weakness,  sj'iicope,  and  all 
the  most  alarming  general  symptoms  are  manifested.  To  these  are  added  some 
phenomena  peculiar  to  the  utei'ine  discharge ;  such  as  pains  in  the  loins,  a  spas- 
modic chill,  and  a  dragging  sensation  at  the  epigastrium,  sometimes  resembling 
that  caused  by  hunger;  and,  in  the  latter  moments,  there  not  unfrer^uently  comes 
on  a  hysterical  attack,  or  even  some  convulsive  movements.  As  regards  the 
local  signs,  they  are  variable ;  and  hence,  in  this  respect,  the  flooding  has  been 
characterized  as  the  external  and  the  internal.  When  it  is  external,  the  blood 
which  inundates  the  patient's  bed,  soaks  through  the  mattress,  and  trickles  down 
on  the  floor,  cannot  possibly  permit  any  mistake  as  to  the  cause  of  the  general 
phenomena  just  indicated.  But  when  it  accumulates  in  the  uterine  cavity,  the 
nature  of  the  accident  may  escape  detection,  or  at  least,  may  only  be  recognized 
when  it  is  too  late  to  remedy  it. 

Every  circumstance  whatever  that  constitutes  an  obstacle  to  the  ready  dis- 
charge of  the  blood  through  the  uterine  orifice,  may  give  rise  to  an  internal  hemor- 
rhage :  thus,  a  very  considerable  obliquity  of  the  womb,  in  which  the  neck  is 
carried  high  upwards  and  backwards ;  occlusion  of  the  os  uteri,  by  a  part  or 
the  whole  of  the  placental  mass,  or  by  large  coagula;  a  badly  applied  tampon, 
or  the  closure  of  the  vulva  by  cloths ;  a  spasmodic  contraction  of  the  os  uteri 
(although,  in  cases  of  inertia,  this  contraction  is  seldom  considerable  enough,  of 
itself,  to  obliterate  the  outlet),  must  necessarily  favor  the  formation  of  a  clot  that 
might  easily  block  up  the  already  diminished  cervix.     Let  us  add  further,  that 


902  DELIVERY     OF    THE     AFTER-BIRTH. 

the  elevated  position  in  which  the  pelvis  is  designedly  placed  for  the  purpose  of 
arresting  an  external  discharge,  may  prove  a  cause  of  internal  hemorrhage. 

Whenever  any  obstacle  prevents  the  escape  of  the  blood,  the  latter  accumu- 
lates within  the  uterine  cavity,  the  walls  of  which  readily  yield  to  distension.  If 
the  hand  be  then  placed  on  the  belly,  the  womb  will  be  found  much  enlarged, 
occasionally  even  attaining  the  height  it  had  during  the  latter  months  of  gesta- 
tion ;  the  ball,  formed  by  the  retracted  organ,  is  no  longer  felt  at  the  usual  place, 
its  volume  has  increased,  but  its  hardness  has  decreased;  the  finger  in  the  va- 
gina finds  the  uterine  orifice,  which  is  carried  far  backwards  or  is  spasmodically 
retracted,  obstructed  by  the  placenta,  or  by  a  clot;  and  when  passed  up  into  the 
womb,  it  detects  there  a  large  quantity  of  coagulated  and  fluid  blood.  (C.  Bau- 
delocque.'') 

C.  Diagnosis. — It  is  scarcely  possible  to  mistake  the  nature  of  the  accident, 
when  the  hemorrhage  is  external;  but  this  is  far  from  being  the  case  when  the 
blood  accumulates  in  the  uterine  cavity;  for,  although  we  have  enumerated  the 
general  debility,  syncope,  etc.,  and  the  enlargement  of  the  abdomen,  as  pathog- 
nomonic signs  of  flooding,  yet  these  circumstances  may  all  be  met  with  and  still 
there  may  be  no  hemorrhage. 

The  increased  size  of  the  belly  may  be  owing  to  the  fact  that  the  intestines, 
after  having  been  so  long  compressed  by  the  developed  organ,  become  expanded 
by  the  gas  they  contain ;  and  thus  cause  the  abdominal  walls,  which  are  still  soft 
and  flabby,  to  swell  up  nearly  to  their  previous  size.  But  any  errors  from  this 
source  will  be  corrected  by  the  resonance  of  the  abdomen  on  percussion,  by  the 
vaginal  examination,  and  by  palpating  the  uterine  globe. 

"Sometimes,"  says  Madame  Lachapelle,  "owing  to  the  extensibility  of  the 
vagina,  the  womb  is  carried  up  by  the  distended  bladder  filled  with  urine, 
thereby  singularly  augmenting  the  size  of  the  belly.  In  one  instance  that  came 
under  my  notice,  the  pupils  had  become  much  alarmed  by  this  circumstance; 
but  I  relieved  their  anxiety  in  a  moment  by  the  introduction  of  the  catheter. 
For  the  prominence  of  the  bladder,  which  is  so  easily  recognized  by  an  experi- 
enced person,  satisfied  me  at  once  as  to  the  nature  of  the  case;  and,  besides,  it 
was  not  accompiuiied  by  any  of  the  general  symptoms  of  flooding." 

The  accoucheur  ought  also  to  bear  in  mind  that  a  syncope,  occurring  after 
childbirth,  docs  not  always  depend  on  the  loss  of  blood.  It  is  not  unfrequently 
observed  shortly  after  very  rapid  labors ;  for  then  the  womb  being  emptied  at 
once,  the  compression  to  which  the  hypogastric  vessels  had  been  subjected  during 
the  latter  months  of  gestation  is  suddenly  removed ;  the  circulation  in  them  be- 
comes free  and  unobstructed,  and  the  rapid  determination  of  the  blood  from  the 
head  and  upper  extremities,  towards  the  vessels  of  the  lower  parts,  often  gives 
rise  to  fainting.  When  it  occurs,  the  horizontal  position  and  the  application  of  a 
moderately  drawn  bandage  around  the  belly,  are  usually  sufficient  to  relieve  the 
aflfection. 

An  hysterical  attack,  coming  on  immediately  after  the  labor,  might  be  mis- 
taken for  those  nervous  phenomena  that  so  often  signalize  the  unfavorable  termi- 
nation of  frrave  hcmorrha2;es. 


ARTIFICIAL     DELIVERY.  903 

But  in  all  8ucli  cases,  by  resorting  to  the  vaginal  tDuel),  ana  the  palpation  of 
the  hypogastric  region,  the  accoucheur  will  clearly  ascertain  the  retraction  of  the 
organ;  and,  therefore,  will  not  be  likely  to  confound  them  with  the  symptoms 
dependent  on  inertia  of  the  womb. 

D.  Proynosis. — Flooding  after  labor  is  an  exceedingly  dangerous  accident ; 
for  a  few  minutes  may  decide  the  woman's  fate.  Of  course,  the  discharge  will 
be  the  more  profuse  as  the  inertia  is  more  complete  and  the  separation  of  the 
placenta  more  advanced.  Other  things  being  equal,  an  internal  hemorrhage  is 
more  dangerous,  as  a  general  rule,  than  an  external  one;  simply  because  it  is 
more  apt  to  escape  detection. 

Of  the  symptoms  that  are  common  to  both  varieties  of  flooding,  there  are  some 
which  more  particularly  indicate  the  imminency  of  the  danger,  and  even  a  speedy 
death;  such,  for  instance,  as  severe  chills  or  convulsions,  increasing  dyspnoea, 
prolonged  syncope,  sharp  and  continued  pains  in  the  loins,  together  with  vertigo 
and  loss  of  vision. 

"  It  should  also  be  remarked  that  the  pupil  is  usually  dilated,  that  it  is  at 
times  agitated  by  oscillatojfy  movements,  and  that  the  dilatation  is  particularly 
evident  when  the  syncope  is  most  profound."      (^Lachajielle.) 

E.  Treatment. — The  treatment  of  uterine  hemorrhage  from  inertia  is  either 
preventive  or  curative. 

Tlie  preventive  treatment  consists  in  breaking  up  the  predispositions  just 
alluded  to,  and  in  preventing  the  action  of  those  causes  whicli  might  determine 
an  inertia  of  the  womb  after  labor.  In  women  of  a  full  habit,  whose  menstrual 
discharges  have  usually  been  copious,  and  in  whom  plethoric  phenomena  become 
manifested  during  pregnancy,  it  would  be  proper  to  resort  to  repeated  blood- 
lettings in  the  course  of  the  latter  months;  and,  even  during  the  labor,  if  the 
fullness  of  the  pulse,  headache,  and  flushing  of  the  face,  seem  to  require  it.  In 
those  of  a  feeble  and  delicate  constitution,  who  have  suffered  from  flooding  in 
their  former  labors,  measures  calculated  to  arouse  the  contractility  of  the  uterine 
tissue  ought  to  be  employed  in  the  latter  stages  of  parturition ;  that  is,  to  stimu- 
late the  action  of  the  uterus  by  external  frictions  and  pressure,  by  the  application 
of  compresses  soaked  in  some  cold  fluid  acidulated  with  vinegar,  over  the  belly, 
and  more  especially,  by  the  exhibition  of  fifteen  to  thirty  grains  of  ergot,  divided 
into  three  doses,  about  twenty  minutes  or  half  an  hour  before  the  child  is  born. 

Dr.  Eobert  Lee  {London  Med.  Gaz.,  1839,  p.  713)  recommends  the  following 
course,  namely :  to  rupture  the  membranes  at  the  commencement  of  the  labor, 
in  those  women  whose  previous  history  would  cause  us  to  fear  a  profuse  heuior- 
rhage  after  the  delivery;  without  waiting  for  the  dilatation  of  the  oa  uteri,  or  at 
least  for  the  development  of  strong  pains;  he  then  applies  a  bandage  around  the 
abdomen,  and  gradually  tightens  it  as  the  labor  advances.  The  subsequent  pro- 
gress is  abandoned  to  nature ;  taking  care  to  keep  the  apartment  cool,  and  for- 
bidding the  employment  of  stimulants  of  any  kind.  I  have,  he  says,  several 
times  adopted  this  plan  with  success. 

There  are  still  some  other  prophylactic  measures  of  great  value,  when  there  is 
reason  to  fear  inertia  of  the  womb.     For  instance,  the  best  way  of  modifying  the 


b 


904  DELIVERY     OF     THE     AFTER-BIRTH. 

action  of  the  tletcrmining  causes,  is  to  retard  the  termiuation  of  a  rapid  labor  as 
much  as  possible,  particularly  in  women  of  a  lax  fibre  and  lymphatic  tempera- 
ment; but,  on  the  other  hand,  to  accelerate  a  lonp;  and  painful  one  by  aiding  the 
inefficient  powers  of  nature  before  the  patient  is  wholly  exhausted,  and  before 
the  womb  falls  into  a  state  of  atony.  Doctor  Clarke  very  properly  advises  the 
hand  to  be  placed  over  the  fundus  during  the  expulsion  of  the  child,  with  a 
view  of  affording  it  support,  both  during  and  after  the  contraction.  Burns  adds, 
tliat  moderate  pressure  on  the  abdomen  after  the  delivery  proves  beneflcial  in 
keeping  up,  and  stimulating  the  action  of  the  organ. 

"But,"  says  Madame  Lachapelle,  "if,  notwithstanding  all  your  exertions,  and 
notwithstanding  the  most  perfect  rest,  and  the  express  charge  to  the  patient  not 
to  bear  down,  you  find  the  accouchement  progressing  with  a  fearful  rapidity,  you 
still  have  one  resource  left,  that  is,  to  leave  the  placenta  in  the  womb  until  fresh 
pains  are  excited.  For,  in  most  instances,  this  body  is  not  entirely  detached,  and 
it  resists  the  flooding  so  long  as  the  stupor  of  the  womb,  caused  by  its  too  sudden 
evacuation,  persists.  In  the  opposite  case,  that  is,  when  the  labor  has  been  too 
long,  the  placenta  is  ordinarily  separated  from  the  uterine  wall,  at  least,  in  a  great 
measure;  and  hence  it  can  no  longer  oppose  the  discharge  of  the  blood.  From 
that  time  its  presence  will  only  serve  to  keep  up  the  feebleness  of  the  uterus,  and 
by  irritating  its  walls,  exhaust  it  without  any  benefit ;  you  should  therefore  pro- 
ceed at  once  to  the  delivery  of  the  after-birth,  free  the  womb  from  it  entirely, 
and  take  advantage  of  the  little  energy  remaining  to  the  latter  to  procure  its 
proper  retraction."      (^Pratique  des  Accouchemenfs,  t.  ii.) 

The  English  accoucheurs  have  taken  advantage  of  the  sympathy  which  appears 
to  exist  between  the  mammae  and  the  uterus,  in  order  to  overcome  the  tendency 
of  the  womb  to  inertia  in  certain  women.  Belying  upon  the  well-known  fact, 
that  putting  the  child  to  the  breast  often  excites  after-pains  within  the  few  days 
immediately  succeeding  the  delivery,  they  recommend  this  to  be  done  as  soon  as 
possible  after  the  child  is  born.  So  great  is  their  confidence  in  this  measure, 
that  according  to  Marshall  Hall,  no  practitioner  would  be  justified  in  leaving  a 
woman  who  is  predisposed  to  inertia  of  the  uterus,  without  directing  a  proceed- 
ing which  is  at  once  so  simple,  and  so  sure  to  be  effectual.  Beside  the  sympa- 
thetic excitement  of  the  womb  thus  produced,  the  suction  would  have  the 
additional  advantage  of  diverting  the  blood  from  the  uterus  by  directing  it  to- 
ward the  breasts.' 

I  cannot  too  strongly  insist  upon  the  administration  of  from  15  to  30  grains  of 
ergot  whenever  there  appears  to  be  a  tendency  to  inertia  after  delivery.  It  is 
always  an  innocent  remedy,  and  one  which,  I  am  sure,  has  prevented  many  a 
flooding. 

'  Rigby  advises,  that  whenever  there  is  reason  to  fear  hemorrhage  from  inertia  after  de- 
livery, the  child  be  put  to  the  breast  as  soon  as  the  mother  is  changed  and  put  to  bed.  He 
assures  us,  that  in  several  grave  cases,  in  which  all  other  means  had  failed,  the  uterus  con- 
tracted strongly  and  permanendy  as  soon  as  the  child  had  seized  the  nipple.  In  one  case 
only  did  the  usual  eifect  fail  to  take  place,  and  this,  Rigby  thinks,  was  due  to  the  fact  of  the 
clijld  of  another  woman  having  been  made  use  of. 


ARTIFICIAL     DELIVERY.  905 

Curntive  Treatment. — There  is  one  special  indication  presented  after  the  child 
is  born,  namely,  that  of  arousing  the  uterine  contractions,  which  alone  can  put 
an  end  to  the  heniorrhajie,  as  soon  as  possible.  The  means  suggested  for  this 
purpose  are  exceedingly  various,  but  we  shall  endeavor  to  estimate  their  respec- 
tive values. 

Of  all  the  various  measures  recommended  for  the  flooding  dependent  upon 
inertia  of  the  womb,  the  easiest  and  most  certain  is  a  direct  irritation  made 
simultaneously  over  the  body,  and  on  the  neck  of  this  organ,  by  placing  the 
hand  on  the  lower  front  part  of  the  abdomen  so  as  to  rub,  press,  and  squeeze  the 
uterine  wall,  whilst  at  the  same  time  two  fingers  are  passed  into  the  vagina  to 
irritate  and  titillate  the  os  uteri.  If  these  do  not  eff"ect  the  object,  the  whole 
hand  is  to  be  carried  up  into  the  cavity  of  the  organ,  with  a  view  of  irritating 
and  stimulating  itvS  internal  surfoce  with  the  fingers,  the  other  hand  keeping  up 
the  frictions  on  the  hypogastrium  in  the  meanwhile.  The  operator  is  sometimes 
obliged  to  compress  and  knead  the  organ,  as  it  were,  by  bearing  strongly  on  the 
abdominal  surface,  while  the  hand  in  the  cavity  serves  as  a  point  of  support. 

This  measure  is  preferable  to  all  others,  because  it  can  always  be  resorted  to 
without  alarming  the  patient,  and  is  not  likely  to  bring  on  an  inflammation  of  the 
organ,  as  is  the  case  with  most  of  the  astringent  and  stimulant  articles  advised 
by  some  writers.  The  injection  of  rectified  alcohol,  oil  of  turpentine,  spirit  of 
vitriol,  &c.,  into  the  uterine  cavity,  recommended  by  Pasta  to  be  used  in  such 
cases  as  a  caustic,  ought  to  be  banished  from  practice.  Even  the  employment  of 
strong  vinegar  requires  the  exercise  of  much  discretion. 

Should  the  iriitation  made  by  the  hands  prove  insuflicient  to  rouse  the  con- 
tractility of  the  uterine  tissue,  we  must  resort  to  an  application  of  cold,  which 
acts  both  as  a  sedative  to  the  circulatory  sj'stem,  and  as  an  astringent  on  the 
muscular  fibres.  Compresses  dipped  in  iced  water  are  to  be  applied  over  the 
lower  part  of  the  abdomen,  the  genital  organs,  and  upper  portion  of  the  thighs; 
and  a  quantity  of  cold  water  might  be  injected  into  the  vagina  at  the  same  time, 
taking  care  to  pass  the  extremity  of  the  eanula  into  the  uterine  cavity.  In  a 
serious  case,  the  example  of  M.  Evrat  might  be  advantageously  followed;  this 
gentleman  carried  a  peeled  lemon  up  into  the  womb,  and  then  expressed  its  juice 
with  his  hand,  so  that  the  citric  acid,  by  coming  into  contact  with  all  parts  of 
the  internal  surface,  would  stimulate  the  organic  contractility.  Or  that  of  M. 
Desgranges,  by  introducing  a  sponge  dipped  in  vinegar,  then  squeezing  out  the 
fluid,  and  abandoning  it  in  the  uterine  cavity;  having  previously  taken  the  pre- 
caution of  passing  a  silk  cord  through  it,  by  which  it  can  easily  be  withdrawn, 
when  deemed  advisable. 

Again,  some  persons  have  suggested  that  a  piece  of  ice  be  passed  up  and  left 
for  a  few  moments  in  contact  with  the  uterine  surface.  But,  the  employment  of 
this  measure,  as  well  as  the  external  application  of  cold,  must  not  be  persisted  in 
too  long;  because,  as  Madame  Lachapelle  has  judiciously  remarked,  the  pro- 
longed application  of  snow,  ice,  cold  irrigations,  douches,  and  sponging  with  very 
cold  water,  that  has  been  so  much  vaunted  by  some  authors,  is  not  unattended 
by  danger  to  the  patient;  and,  therefore,  the  use  of  cold  ought  to  be  restricted 


906  DELIVERY     OF    THE     AFTER    BIRTH. 

■\viihin  inodcrate  limits.  Most  generally,  it  becomes  ineffectual  in  the  course  of 
five  or  six  minutes  j  often,  indeed,  it  proves  positively  injurious,  either  by  redu- 
cing the  woman  to  a  state  of  mortal  torpor,  or  by  exposing  her  to  a  violent  in- 
flammatory reaction. 

There  are  some  cases  of  obstinate  hemorrhage,  in  which  all  the  measures  yet 
spoken  of  prove  ineffectual.  For  such  cases  other  remedies  have  been  recom- 
mended, which  now  claim  our  attention.  These  are  the  tampon,  the  introduction 
of  a  bladder  into  the  womb,  the  approximation  of  the  uterine  walls  by  immediate 
pressure,  the  compression  of  the  aorta,  the  use  of  ergot,  of  opium,  and  transfu- 
sion. 

1.  The  Tampon. — Lerous  reports  quite  a  number  of  cases  of  inertia  of  the 
womb,  in  which  the  tampon  arrested  the  flooding,  where  it  seemed  to  be  inevit- 
ably fatal.  But,  as  Desormeaux  remarks,  it  often  happens  that  men,  even  those 
who  are  otherwise  worthy  of  credence,  are  often  more  successful  with  remedies 
of  their  own  invention,  than  any  one  else.  In  fact,  the  only  effect  of  the  tampon 
in  many  oses  is  to  convert  an  external  into  an  internal  discharge.  In  order  to 
obviate  this  disadvantage,  it  has  been  suggested  to  combine  its  employment  with 
compression  of  the  uterine  walls  by  means  of  the  hands.  M.  Chevreul,  who 
is  favorable  to  its  use  after  the  delivery,  adds  that  it  is  necessary  to  irritate  the 
organ  externally  as  much  as  possible.  But  in  the  cases  mentioned,  both  by  him 
and  Leroux,  where  the  tampon  was  apparently  successful,  it  was  not,  as  M. 
Baudelocque  avers,  so  much  in  preventing  the  discharge  of  blood,  and  determin- 
ing its  coagulation,  as  by  irritating  the  internal  surface  of  the  womb,  and  thereby 
producing  a  retraction  of  its  vessels,  that  the  plug  could  have  had  a  salutary 
effect.  The  tampon  itself,  or  rather  the  irritating  substances  M.  Chevreul  satu- 
rates it  with,  conjoined  with  external  stimulation,  may  indeed  bring  on  the  con- 
traction in  many  cases ;  but  the  mere  plugging  up  of  the  vagina,  as  directed  by 
Leroux,  is  useless,  to  say  the  least;  and  therefore  the  introduction  of  some  old 
linen,  steeped  in  vinegar,  into  the  uterine  cavity,  is  in  reality  the  only  efficacious 
part  of  the  plan  ;  but  even  this  will  prove  still  more  beneficial  when  accompanied 
by  a  compression  of  the  hypogastrium,  and  by  frictions  and  stimulations  of  the 
organ  above  the  pubis. 

2.  The  introduction  into  the  womb  of  a  hog's  bladder,  which  has  been  soft- 
ened by  holding  it  a  short  time  in  warm  water,  is  even  a  worse  measure  than  the 
preceding;  and  it  is  really  astonishing  that  Gardien  seems  to  be  in  favor  of  its 
employment.  The  presence  of  a  bladder  would  evidently  be  a  continual  obstacle 
to  the  retraction  of  the  womb.  Great  stress  has  been  laid  upon  the  compression, 
which  it  might  make  on  the  vascular  orifices,  but  to  no  purpose :  for,  even  were 
this  a  constant  result,  which  however  is  far  from  being  the  case,  since  we  are 
never  sure  of  filling  the  uterine  cavity  precisely,  the  difficulty  would  only  be 
delayed,  as  the  hemorrhage  might  reappear  as  soon  as  the  bladder  is  withdrawn; 
and  then,  after  all,  we  should  have  to  fall  back  on  the  contraction  of  the  organ. 

3.  M.  Deneux  conceived  the  happy  idea  of  pressing  the  uterine  walls  together, 
in  a  desperate  case,  by  means  of  a  folded  napkin,  which  he  applied  over  the 
hypogastrium,  and  retained  in  position  by  a  tight  body-bandage;  this  arrested 


ARTIFICIAL     DELIVERY.  907 

the  discharge  of  the  blood  completely.  Notwithstanding  M.  Baudelocque  has 
accorded  the  original  suggestion  of  this  plan  to  M.  Deneux,  it  was  long  since 
reconiin ended,  particularly  by  the  English  writers.  This  procedure  has  been 
unjustly  censured  by  certain  practitioners,  since  it  certainly  may  prove  very 
useful  in  an  extreme  case.  In  saying  that,  from  the  disposition  of  the  posterior 
plane  of  the  trunk,  the  uterine  walls  can  only  be  brought  into  contact  with  each 
other  at  the  point  corresponding  to  the  sacro-vcrtebral  angle,  Madame  Boivin  has 
evidently  confounded  the  bare  skeleton  with  the  one  still  covered  by  its  soft 
parts. 

4.  Quite  recently,  M.  D'Ornellas  has  defended  a  thesis  on  the  compression  of 
the  aorta  as  a  remedy  in  uterine  discharges,  and  he  brings  forward  numerous 
cases  in  support  of  his  theory.  M.  Baudelocque  has  assured  me  that  he  has 
several  times  succeeded  in  arresting  a  flooding  in  this  way,  which  threatened  an 
early  fatal  termination.  This  gentleman,  who  disputes  with  Dr.  Trehan  the 
honor  of  its  revival,  appears  to  have  great  confidence  in  the  efficacy  of  the  mea- 
sure ;  and  we  may  add,  that  a  very  great  number  of  facts  now  militate  in  favor 
of  his  opinion.  He  recommends  the  compression  to  be  made  in  the  following 
manner :  first,  flex  the  patient's  superior  and  inferior  parts  on  the  pelvis  j  then 
depress  the  abdominal  wall  immediately  above  the  fundus  of  the  womb  with  the 
four  fingers  of  one  hand,  when  the  pulsations  of  the  aorta  will  be  more  distinctly 
felt  than  the  beating  of  the  radial  artery.  The  compression  inay  be  kept  up  for 
a  considerable  time  without  causing  any  particular  inconvenience  to  the  woman ; 
M.  Baudelocque  states  that  he  has  persisted  in  it  for  more  than  four  hours.  This 
compression,  however,  is  only  considered,  even  by  its  author  himself,  as  a  mode  of 
gaining  time;  for  he  administers  the  ergot  almost  immediately,  by  the  action  of 
which  the  uterine  contraction  is  soon  established.  The  compression  of  the  aorta, 
though  long  since  recommended,  had  been  generally  proscribed  because  the 
modes  of  efi'ecting  it  were  very  imperfect.  Thus,  some  directed  the  pressure  to 
be  made  through  the  ventral  surface  and  the  double  uterine  wall ;  while  others 
introduced  the  hand  into  the  cavity  of  the  uterus,  and  then  subjected  the  vessel 
to  pressure  through  the  posterior  wall  of  this  organ.  But  both  of  these  modes 
ought  to  be  rejected,  because  they  impede  the  retraction  of  the  womb. 

Notwithstanding  the  numerous  successes  which  have  been  attributed  to  this 
operation,  several  authors,  amonast  whom  M.  Jacquemier  is  conspicuous,  contest 
its  utility,  and  even  go  so  far  as  to  consider  it  injurious.  "  In  the  profuse  flood- 
ings  following  delivery,  the  blood  which  escapes,  says  M.  Jacquemier,  proceeds 
in  great  part  from  the  veins,  and  the  compression  of  the  aorta  could  only  favor 
the  reflux  of  venous  blood  into  the  vena  cava  and  the  branches  which  empty 
into  it."  It  is  not  to  be  supposed  that  the  utero-placental  arteries  could  furnish 
the  enormous  amount  of  blood  that  sometimes  ciscapes  in  a  few  moments  from  a 
recently-delivered  woman,  and  there  can  be  no  doubt  that  a  great  part  of  it  is 
discharged  from  the  large,  gaping  venous  orifices  left  upon  the  internal  surface 
of  the  uterus  by  the  detachment  of  the  placenta.  Though  agreeing  with  M. 
Jacquemier  as  regards  this  point,  I  cannot  unite  with  the  conclusion  which  ho 
draws  from  it.     Such,  in  fact,  are  the  relations  between  the  aorta  and  vena  cava, 


908  DELIVERY     OF     THE     AFTER-BIRTII. 

that  it  is  almost  impossible,  unless  it  be  done  expressly,  to  compress  one  without 
compressing  the  other.  I  am  very  willing  to  adiuit  that  a  mistake  may  have 
been  made  in  respect  to  the  nature  of  the  service  thus  rendered,  and  that  all 
the  credit  hitherto  accordedto  the  compression  of  the  aorta  should  be  transferred 
to  the  flattening  of  the  vena  cava;  but  of  what  importance  is  this  as  regards  the 
practical  result,  since  the  arre^  of  the  hemorrhage  is  no  less 'the  consequence. 
M.  Jacquemier  has  done  a  real  service  in  pointing  out  a  theoretical  error,  but  I 
would  almost  blame  him  for  it,  should  he  thereby  deprive  the  practitioner  of  an 
invaluable  resource.  I  therefore  accept  his  theory,  but  shall  nevertheless  con- 
tinue to  compress  the  aorta,  although  convinced  that  I  shall  compress  the  vena 
cava  at  the  same  time. 

Still  another  objection  has  been  made  to  the  proceeding.  Although  compres- 
sion of  the  aorta,  it  is  said,  may  prevent  the  blood  from  ai-riving  by  the  uterine 
arteries,  it  must  necessarily  increase  the  amount  tliat  passes  through  the  ovarian 
arteries,  inasmuch  as  it  is  generally  performed  below  the  origin  of  the  latter.  .  .  . 
The  objection  loses  much  of  its  value  from  the  fact  that  the  hemorrhage  is 
chiefly  venous.  But  of  four  arteries  supplying  blood,  two  only  are  permeable 
after  the  compression  of  the  aorta;  so  far,  therefore,  it  is  a  marked  advantage. 

M.  Jacquemier  also  regards  the  administration  of  ergot  during  the  compression 
as  useless  and  irrational.  "How  shall  we  admit,"  says  he,  "that  this  agent, 
whose  effects  are  so  prompt  though  evanescent,  can  stimulate  the  uterus,  since 
the  nrterial  blood  is  cut  off  from  it?"  It  is  by  first  acting  upon  the  nervous 
centres  and  stimulating  the  excito-motor  properties  of  the  uterine  nerves,  that 
the  drug  exerts  its  special  action  on  the  uterus;  therefore,  to  suppose  that  after 
having  been  absorbed  by  the  stomach  the  medicament  can  only  act  by  being  car- 
ried by  the  circulation  into  contact  with  the  uterine  fibre,  involves,  I  think,  a 
physiological  error. 

Hitherto,  compression  of  the  aorta  has  been  recommended  only  for  the  purpose 
of  suspending  the  discharge  of  blood,  and  of  giving  the  measures  for  restoring 
the  uterine  contractility  time  to  act.  I  think  that  it  is  capable  of  rendering 
great  service  even  after  the  discharge  is  suspended  and  the  womb  contracted. 
The  fict  is,  that  when  flooding  has  been  profuse,  all  danger  is  not  at  an  end 
from  the  moment  that  we  have  succeeded  in  arresting  the  hemorrhage  and  bring- 
ing about  the  contraction  of  the  uterus ;  for  although  not  a  single  drop  of  blood 
should  be  discharged  afterward,  the  amount  of  this  fluid  remaining  in  the  body 
is  no  longer  sufficient  to  supply  all  the  organs,  and  the  brain  at  the  same,  time, 
with  the  stimulus  necessary  to  the  maintenance  of  the  integrity  of  their  func- 
tions; so  that  women  sometimes  expire  two  or  three  hours  after  the  arrest  of  the 
hemorrhage.  Death  then  takes  place,  because  the  remaining  blood,  being  equally 
diS'used  throughout  the  entire  extent  of  the  circulatory  apparatus,  the  brain,  and 
especially  the  spinal  marrow,  receive  too  small  a  proportion  of  it,  and  conse- 
quently are  not  sufficiently  stimulated  to  enable  them  to  support  the  respiration 
and  the  movements  of  the  heart.  This  being  admitted,  it  is  easy  to  understand 
that  if  by  compressing  the  abdominal  aorta,  we  can  prevent  the  blood  discharged 
by  the  left  ventricle  from  descending  into  the  lower  parts  of  the  body  and  infe- 


ARTIFICIAL    DELIVERY.  909 

riov  extremities,  it  will  necessarily  be  obliged  to.  flow  back  towards  the  brain  in 
greater  quantity,  and  thus  secure  for  this  organ  the  degree  of  stimulus  which  it 
requires  to  enable  it  to  react  in  its  turn  upon  the  functions  of  the  heart  and  lungs. 

The  compression  of  the  aorta  may  be  assisted  powerfully.by  placing  the  woman 
on  an  inclined  plane,  so  that  the  head  shall  be  the  lowest  part  of  the  body. 

I  think,  therefore,  that  the  compression  of  the  aorta  and  vena  cava  is  useful 
whilst  the  flooding  continues  to  be  profuse ;  but,  also,  that  when  the  patient  has 
lost  a  great  amount  of  blood,  it  should  be  continued  for  several  hours  after  the 
arrest  of  the  hemorrhage  and  thorough  contraction  of  the  walls  of  the  uterus. 
In  the  latter  case,  however,  it  is  important  to  separate  the  aorta  from  the  vena 
cava,  so  that  the  compression  may  act  on  the  former  vessel  exclusively.' 

5.  Ergot  has  been  recommended,  as  stated  above,  as  one  of  the  measures  cal- 
culated to  prevent  the  occurrence  of  hemorrhage  in  women  who,  by  their  consti- 
tution and  previous  history,  seem  to  be  highly  predisposed  to  it.  This  remedy 
may  also  be  resorted  to  in  the  curative  treatment  5  unfortunately,  however,  the 
time  necessary  for  procuring  it,  and  for  the  development  of  its  action,  is  always 
too  long  to  secure  a  sufiiciently  prompt  effect  f  and  hence,  in  an  alarming  hemor- 
rhage, one  dependent  on  a  complete  inertia  of  the  womb,  for  example,  the  patient 
would  certainly  die  before  any  benefit  could  be  hoped' for  from  its  employment. 
Under  such  circumstances,  it  would  prove  highly  useful  to  compress  the  aorta  in 
the  meanwhile.  But  with  the  exception  of  these  frightful  cases,  where  a  few 
minutes  decide  the  woman's  fate,  the  secale  cornutum  ought  to  be  employed ;  and 
its  use  would  be  nearly  always  followed  by  success. 

In  some  females,  the  uterine  hemorrhages  have  a  marked  tendency  to  relapse. 
Consequently,  a  few  grains  of  this  substance  ought  to  be  administered  as  soon  as 
it  has  occurred,  whether  it  seems  to  be  finally  arrested  or  not.  For,  in  the 
former  case,  it  can  do  no  harm,  and,  in  the  latter,  it  will  prevent  a  return  of 
even  a  partial  inertia;  which  is  not  an  indifferent  matter  to  a  woman  who  is 
already  exhausted  from  the  previous  lo.ss,  and  who  is  liable  to  succumb  under  a 
fresh  discharge,  however  inconsiderable  it  may  be. 

G.  The  English  authors  (Burns,  and  others)  recommend  the  use  of  opium  in 
full  doses,  both  as  a  preventive  and  a  curative  remedy  in  cases  of  flooding  from 
inertia.  They  bring  forward  some  cases  in  support  of  their  opinion ;  but  I  do 
not  deem  them  conclusive ;  because,  in  every  instance,  they  combine  the  exhibi- 
tion of  opium  with  the  employment  of  tho.se  general  measures  just  indicated  as 
proper  for  arresting  hemorrhage.      Besides,  I  cannot  understand  how  opium, 

'  Compression  of  the  aorta  was  once  resorted  to  by  M.  Roux  in  the  case  of  a  wounded 
patient,  who  was  exhausted  by  frequent  hemorrliages.  I  think,  however,  that  I  was,  my- 
self, tlie  first  to  Suggest  and  perform  it,  in  the  floodings  of  newly-delivered  females.  In  the 
month  of  March,  184.'),  after  staling  the  physiological  principles  upoti  wliich  I  based  my 
concl.isions,  I  proposed  the  operation  in  a  formal  maimer,  in  a  coaimunication  to  the  jMedical 
Society  of  the  department  of  the  Seine.  I  am  the  more  particular  in  stating  this  fact,  as  the 
same  suggestion  has  been  made  in  other  quarters  withuut  acknowledging  my  priority. 

^  Accoucheurs,  especially  those  who  reside  in  the  country,  should  always  be  careful  to 
have  with  them  a  little  ergot  in  the  grain. 


910  DELIVERY     OF    THE     A  F  T  E  K  -  B  I  R  T  11. 

when  administered  alone,  can  have  any  influence  whatever  over  the  contraction 
of  the  uterus,  which  is  here  the  only  hope  of  safety. 

7.  Tramfusion,  which  has  been  so  highly  praised  by  certain  I'^nglish  writers, 
in  whose  hands  it  seems  to  have  succeeded  quite  a  number  of  times,  has  not 
been  followed  by  the  same  success  in  France.  It  is  one  of  those  extreme  mea- 
sures which  might  be  employed  in  desperate  cases,  though  it  cannot  be  relied 
upon  ;  because  the  extent  of  the  flooding,  the  extreme  debility  of  the  patient, 
and  the  slowness  of  its  operation,  generally  render  it  ineff'ectual ;  without  refer- 
ring to  the  nervous  and  inflammatory  symptoms,  and  the  phlebitis,  which  very 
frequently  succeed  the  operation.  ]5esides,  it  evidently  could  only  be  practised 
with  any  chance  of  success  after  the  flooding  had  ceased,  and  the  uterus  was 
thoroughly  contracted,  and  then  I  think  that  compression  of  the  aorta  would 
have  almost  all  its  advantages  without  any  of  its  numerous  dangers.  I  once  saw 
it  performed  at  the  IIotd-Dku  without  any  benefit  whatever.  In  some  of  the 
reported  cases,  a  notable  improvement  was  eff"ected  by  a  moderate  quantity  of 
blood  (three  or  four  ounces);  in  others,  it  was  necessary  to  inject  as  much  as 
ten,  and  even  as  high  as  thirteen  ounces. 

In  M.  Nelaton's  case,  he  injected  first  six,  and  five  minutes  afterwards,  eight 
ounces  of  blood.  The  operation  was  conducted  as  follows.  The  median  basilic 
vein  was  uncovered  by  an  incision  three-quarters  of  an  inch  in  length,  then 
isolated,  and  raised  by  a  loop  of  thread  so  as  to  flatten  it  and  stop  the  circulation 
in  order  to  prevent  any  loss  of  blood.  The  anterior  wall  of  the  vein  was  next 
seized  with  a  pair  of  forceps,  and  half  divided  obliquely  from  below  upward,  so 
as  to  form  a  V-shaped  flap,  which  might  be  raised  or  restored  at  pleasure.  The 
blood  drawn  from  one  of  the  resident  surgeons  was  received  in  a  dish  warmed  to 
the  temperature  of  77°  F.,  and  poured  immediately  into  a  syringe  heated  to  the 
same  degree. 

Everything  being  thus  prepared,  whatever  air  remained  in  the  syringe  was 
expelled,  the  little  V-shaped  flap  was  raised  with  the  forceps,  the  tube  of  the 
instrument  introduced  into  the  vein  beneath  it,  and  the  injection  performed 
slowly.  The  second  injection  was  made  five  minutes  afterward,  and  the  wound  in 
the  arm  closed  by  means  of  collodion. 

8.  Inertia  of  the  womb,  and  the  consequent  hemorrhage,  often  come  on  before 
the  delivery  of  the  after-birth;  and  the  retention  of  the  placenta  here  presents 
some  special  indications  which  are  important  to  be  known.  Whenever  a  hemor- 
rhage takes  place,  a  more  or  less  considerable  portion  of  the  placenta  must  evi- 
dently be  detached ;  sometimes,  even,  it  is  wholly  separated  from  the  uterine 
wall,  being  left  free  and  movable  in  the  cavity  of  the  organ.  The  directions 
given  by  authors  in  this  case  are  very  variable :  thus,  some  advise  us  to  extract 
the  secundines  at  once,  together  with  any  coagula  the  uterine  cavity  may  con- 
tain; others,  on  the  contrary,  to  try  first  to  remedy  the  inertia,  which  is  the  sole 
cause  of  the  accident.  We  do  not  hesitate  to  recommend  the  latter  advice; 
because,  if  the  placenta  is  partially  removed,  we  would  certainly  augujcnt  the 
sources  of  hemorrhage  by  completing  its  separation.  Hence  we  look  upon  it  as 
an  absolute  rule  not  to  attempt  the  extraction,  and  more  particularly  the  detach- 


ARTIFICIAL     DELIVERY.  911 

mcnt  of  the  placenta,  until  the  accoucheur,  by  stimulating  and  irritating  the 
organ  with  his  hand,  has  secured  its  diminution  and  contraction  to  such  an  ex- 
tent, that  it  drives,  as  it  were,  the  coagula  and  after-birth  beyond  his  hand. 

Should  the  adhesions  of  the  placenta  be  unusually  firm,  the  injections  into  the 
umbilical  vein,  spoken  of  in  the  last  chapter,  might  be  resorted  to. 

But  when  the  placenta  is  completely  detached,  or  adheres  to  the  uterus  by 
only  a  very  small  portion  of  its  surface,  it  should  be  extracted  together  with  the 
clots  which  may  have  collected  within  the  cavity  of  the  uterus.  Their  presence 
there  prevents  an  energetic  action  upon  the  walls  of  the  womb  and  may  impede 
their  contraction. 

When  the  physician  has  been  fortunate  enough  to  overcome  the  hemorrhage, 
by  a  resort  to  the  various  measures  just  alluded  to,  he  should  still  continue  with 
his  patient  for  several  hours,  carefully  watching  the  character  and  amount  of  the 
discharge  from  the  vulva,  and  occasionally  placing  a  hand  over  the  hypogastrium, 
so  as  to  detect  any  increase  of  volume  in  the  uterine  globe.  He  ought  also  to 
take  the  precaution  of  applying  cloths  steeped  in  vinegar,  or  alcohol,  or  even  in 
cold  water,  over  the  belly,  and  to  retain  them  there  by  a  moderately-drawn  body- 
bandage;  absolute  quiet  is  to  be  insisted  on.  As  nourishment,  the  patient  might 
have  some  light  cordial,  broth,  sweetened  wine,  &;c.  &c. 

Usually,  the  patient  is  put  to  bed  an  hour  after  her  delivery;  but  after  severe 
floodings,  she  should  be  carefully  protected  from  any  sudden  motion,  and  it  is 
often  necessary  to  let  her  remain  in  the  same  position  for  eight,  ten,  or  twelve 
hours.     The  least  movement  might  cause  a  mortal  syncope. 

After  a  profuse  hemorrhage,  the  patient  is  naturally  inclined  to  sleep;  some 
persons  think  it  better  to  prevent  her  from  slumbering,  lest  the  discharge  be  re- 
newed without  her  knowledge.  But,  as  this  repose  repairs  the  exhausted  forces, 
it  ought  not  to  be  hindered;  but  she  must  never  be  left;  for  the  pulse,  the 
uterus,  and  the  vaginal  discharge  require  a  constant  oversight. 

The  patients  are  frequently  tormented,  after  considerable  floodings,  by  vomit- 
ing, or  at  least  by  sick  stomach,  nausea,  and  retchings.  Independently  of  the 
pain  they  occasion,  these  gastric  symptoms  are  not  wholly  devoid  of  danger;  for 
the  vomiting,  from  the  fatigue  caused  by  the  strainings  to  which  the  woman  gives 
way,  may  produce  a  syncope,  during  which  the  hemorrhagic  discharge  may  be 
renewed  profusely.  If  there  are  only  the  nausea  and  inclination  to  vomit,  the 
women  are  often  so  tormented  thereby  as  to  wear  out  the  little  strength  they 
have  left;  and  this  exhaustion  of  the  muscular  power,  at  a  time  when  the  ute- 
rine contraction  is  so  necessary,  is  a  very  melancholy  condition.  ''  Nothing 
tranquillizes  the  stomach  under  these  circumstances,"  says  Dcwecs,  ''so  far  as  I 
have  observed,  like  opium,  in  the  solid  form.  A  newly  prepared  pill  of  two 
grains  of  the  opium,  with  a  very  small  portion  of  soap,  to  facilitate  its  solution 
in  the  stomach,  should  be  given  every  hour  or  two,  until  the  vomiting  ceases,  or 
the  stomach  becomes  reconciled.  I  have  found  a  sinapism  over  the  region  of  the 
stomach  of  great  service,  and  it  should  be  resorted  to,  if  nece.ssary." 

The  opiates  in  a  fluid  foru),  might  also  be  used  with  advantage.  "When  after 
profuse  flooding  the   patients  are   excited,  uneasy,  or  tormented  by  a  feeling  of 


912  DELIVERY     OF    THE     AFTER-BITxTE. 

extreme  discomfort,  a  few  dessert-spoonfuls  of  tbe  sjrup  of  diacodion  will  jrcnc- 
rally  serve  to  calm  their  ansietj^,  and  procure  the  refreshing  sleep  which  they  so 
greatly  need. 

As  the  patient  begins  to  recover  from  the  extreme  weakness  which  immedi- 
ately follows  a  profuse  loss  of  blood,  symptoms  of  febrile  reaction  begin  to  appear: 
the  pulse  is  small  and  rapid,  sometimes  hard,  and  sometimes  compressible ;  the 
heat  and  dryness  of  skin  arc  increased,  the  tongue  is  dry,  and  the  features  con- 
tracted :  the  patient  is  very  thirsty,  and  feels  disgust  for  solid  food  :  she  is 
startled  by  the  least  sound,  or  by  a  bright  light :  she  complains  of  violent  head- 
ache, and  sometimes  of  palpitations  and  dyspnoea.  She  is  unable  to  sleep,  or  if 
she  dozes,  is  liable  to  be  awakened  by  violent  startings. 

This  condition  evidently  results  from  the  excitement  of  the  nervous  system 
occasioned  by  the  loss  of  blood,  an  cxcitment  which  we  should  endeavor  to  calm 
from  the  outset. 

Evidently,  the  first  indication,  is  to  repair  the  losses  of  the  organism  by  food 
which  shall  be  easily  digested,  and  frequently  administered  in  small  quantities  at 
a  time.     Broths  or  light  soups,  are  eminently  suitable. 

The  best  means  of  calming  the  excitability  of  the  nervous  system,  are  perfect 
rest,  cold  aspersions  upon  the  hands  and  face,  but  especially  opiates,  given  fre- 
quently and  in  small  doses. 

§  2.  Secondary  Hemorrhage. 

In  order  to  complete  the  history  of  puerperal  hemorrhages,  we  have  yet  to 
speak  of  some  accidents  which  occur  at  a  variable  period  after  delivery,  and 
which  on  that  account  have  been  styled  secondco-i/  hemorrhages. 

These  floodings,  which  are  so  jjrofuse  as  seriously  to  endanger  the  health  and 
sometimes  even  the  life  of  the  patient,  have  been  treated  of  very  imperfectly  in  the 
most  recent  treatises,  and  we  ourselves  committed  the  mistake  of  passing  it  over 
with  a  very  slight  notice  in  the  earlier  editions  of  this  work.  Dr.  Clintock  has 
recently  performed  a  valuable  service  in  calling  attention  to  the  various  circum- 
stances which  may  give  rise  to  them.  Sometimes  these  causes  begin  to  act  veiy 
shortly  after  the  delivery  of  the  placenta,  and  the  thorough  contraction  of  the 
uterus,  sometimes  not  until  after  two  or  three  days,  and  occasionally  even  after  three, 
five,  or  six  weeks.  But  at  whatever  time  their  influence  is  manifested,  their 
mode  of  action  is  nearly  always  the  same  as  at  the  other  periods  of  the  puerperal 
state ;  and  the  hemorrhage  may  then  be  accounted  for  either  by  secondary  in- 
ertia, by  a  too  active  congestion,  a  real  vioUmen  hccmorrhagiciim,  or,  finally,  by 
an  alteration  of  the  blood,  consisting  in  a  great  increase  of  its  fluidity. 

The  hemorrhage,  or  rather  the  inertia  which  produced  it,  is  not  confined  to 
the  period  of  delivery,  or  to  that  which  immediately  succeeds  it;  so  that  as  re- 
gards the  time  of  its  appearance,  we  may  distinguish  a  primitive  inertia,  which 
is  that  just  described,  and  a  secondary,- to  which  attention  has  been  especially 
called  by  llamsbotham,  and  of  which  we  have  ourselves  observed  several  ex- 
amples. 

A.   Secondari/  inertia. — Some  moments,  hours,  and  sometimes  even  several 


ARTIFICIAL    DELIVERY.  9l3 

days  after  the  delivery,'  the  uterus,  which  had  contracted  properly  and  had  re- 
mained so  during  all  that  time,  may  suddenly  become  relaxed.  Its  walls  become 
softer,  and  it  increases  in  size.  At  the  same  time  the  patient  grows  weak  and 
pale,  the  pulse  loses  its  strength  and  quickens,  and  if  the  genital  parts  be  care- 
fully examined,  it  is  found  that  very  little  blood  is  discharged,  and  that  the  cloths 
are  but  slightly  soiled.  But  if  the  uterine  tumor  be  compressed  slightly,  or  the 
organ  be  incited  to  contraction  by  frictions  upon  the  hypogastrium,  a  considerable 
amount  of  coagulated  blood  is  suddenly  discharged  by  the  vagina.  After  this 
evacuation  the  size  of  the  uterus  is  diminished,  it  is  harder,  and  remains  so,  so 
long  as  the  hand  continues  to  press  upon  it ;  but  if  the  pressure  be  removed,  the 
softened  walls  are  soon  found  to  become  afresh  distended,  and  then  contract 
again,  driving  out  another  quantity  of  clots,  provided  the  accoucheur  renews  the 
pressure  and  frictions  calculated  to  excite  their  contractility.  This  series  of 
occurrences  may  take  place  several  times,  if  the  accoucheur  relinquishes  too  soon 
the  use  of  the  proper  means  for  making  the  uterus  contract  permanently;  and  if 
the  cause  of  the  hemorrhage  should  not  be  discovered,  it  might  cost  the  woman 
her  life. 

Now  several  circumstances  are  liable  to  lead  into  error.  In  the  first  place,  the 
physician  had  previously  ascertained  the  condition  of  the  womb,  and  it  does  not 
immediately  strike  him  that  it  may  have  become  relaxed  in  a  secondary  manner, 
after  having  remained  so  long  properly  contracted.  Again,  it  frequently  happens 
that  the  patient,  exhausted  by  the  fatigues  of  the  labor,  falls  asleep,  and  does 
not  herself  perceive  her  extreme  weakness,  until  her  condition  has  become  irre- 
mediable. 

Nothing  but  an  examination  of  the  uterus  is  capable  of  clearing  up  the  diag- 
nosis. This  organ  is  then  found  to  be  much  larger  than  it  was  after  the  labor, 
and  the  finger  carried  up  to  the  internal  orifice,  finds  it  blocked  up  by  a  clot  of 
considerable  size. 

The  accoucheur  should  use  every  effort  to  procure  the  contraction  of  the  walls 
of  the  uterus,  and  especially  to  render  it  permanent.  For  this  purpose,  several 
napkins  folded  on  each  other  are  placed  on  the  fundus  of  the  womb,  and  by 
means  of  a  body-bandage  tightly  applied,  the  organ  is  held  strongly  pressed 
against  the  opening  of  the  superior  strait.  I  am  in  the  habit  of  administering 
immediately  fifteen  grains  of  ergot,  and  of  repeating  it  every  half  hour  or  hour, 
according  to  the  degree  of  tendency  to  relaxation,  in  doses  of  from  six  to  eight 
grains. 

B.    Congestions  of  the   Uterus. — Under  this   title,  Madame  Lachapelle   has 

'  Mr.  Fergusson  reports  {New  York  Medical  Journal,  Sept.  1850)  a  case  of  grave  hemor- 
rhage occurring  thirteen  days  after  delivery.  The  cause  was  secondary  inertia.  The  au- 
thor examined  statistics  in  reference  to  this  subject,  with  the  following  result:  out  of  1C,G54 
labors  observed  by  Collins  in  the  Dublin  Hospital,  there  were  43  cases  of  hemorrhage  imme- 
diately after  delivery,  and  40  twelve  hours  afterward.  The  flooding,  in  one  case,  occurred 
only  on  the  fourth,  in  another  on  the  sixth,  and  in  still  another  on  the  tenth  day. 

Drs.  ClJntock  and  Hardy  observed  one  on  the  seventh  day,  and  Dr.  Stimever  another  on 
the  tenth. 

58 


914  DELIVERY    OF    THE    AFTER-BIRTH. 

described  a  flooding,  which  comes  on  some  time  subsequent  to  the  parturition ; 
and  which  is  produced,  as  she  supposes,  under  the  influence  of  a  peculiar  mail- 
men hemorrhof/icum.  This  variety  is  occasionally  developed  even  without  any 
inertia  of  the  womb.  "We  have  known,"  she  continues,  "a  woman  to  perish 
seven  or  eight  days  after  her  confinement,  from  a  profuse  discharge  of  serous 
blood,  which  transuded  from  all  parts  of  the  utero- vaginal  surface,  and  saturated, 
by  imbibition,  the  most  solid  tampon ;  the  womb  was  soft,  but  not  distended  with 
the  blood."  I  have  twice  known  a  hemorrhage  to  take  place  after  the  delivery 
of  the  after-birth,  saj's  M.  Velpeau,  although  the  womb  had  been  contracted  in 
the  one  case  for  four  and  in  the  other  for  seven  hours.  He  further  states  that 
this  accident  is  occasionally  manifested  subsequent  to  the  first  twenty-four  hours. 

These  congestions,  which  in  certain  rare  cases  are  inexplicable,  may  usually  be 
attributed  to  certain  easily-detected,  general,  or  local  causes. 

We  have  already  spoken  (page  894)  of  the  liability  of  the  retention  of  a  por- 
tion of  the  placenta  to  give  rise  to  these  hemorrhages,  and  we  would  now  simply 
add  that  the  presence  of  a  large  clot  within  the  womb  might  have  the  same  effect. 
Both  Collins  and  Madame  Lachapelle  report  cases  of  flooding  coming  on  eight 
and  ten  days  after  delivery,  and  which  ceased  only  upon  the  artificial  extraction 
of  the  coagula. 

The  determination  of  blood  may  also  be  occasioned  by  the  retention  of  a  por- 
tion of  the  membranes,  as  in  the  following  case. 

I  was  sent  for  by  a  physician  to  see  a  lady  living  in  Rue  Gros-Caillou.  On 
arriving  there,  I  found  M.  P.  Dubois,  who  was  called  at  the  same  time,  but  who 
preceded  me,  engaged  in  extracting  a  considerable  portion  of  the  membranes, 
which  had  been  imprudently  left  behind  whilst  delivering  the  placenta.  The 
child  was  born  at  nine  P.  M.,  and  half  an  hour  afterward  hemorrhage  came  on, 
which  could  not  be  arrested  until  half-past  one  in  the  morning,  at  which  time 
the  foreign  body  was  extracted.  The  uterus  had  remained  perfectly  contracted 
throughout. 

The  extraction  of  the  foreign  body  in  the  latter  case,  generally  di.ssipates  the 
symptoms ;  in  the  former,  a  resort  to  revulsives  to  the  upper  parts  of  the  body, 
to  cold  applications,  and  even  to  venesection,  is  evidently  indicated.  These  will 
be  materially  aided  by  a  regulated  diet,  and  absolute  rest  in  the  horizontal  posi- 
tion. 

Intra-uterine  polypi  have  several  times  given  rise  to  mortal  hemorrhage  two  or 
three  weeks  after  delivery.  It  has  been  thought  that  these  bodies  occasion  the 
flooding  only  by  preventing  the  contraction  of  the  uterus.  We  are  disposed  to 
reject  this  opinion,  because,  as  Oldham  observes,  in  these  cases  the  strongly-con- 
tracted uterus  can  readily  be  felt  above  the  pubis.  Besides,  the  cessation  of  the 
flooding  after  ligation  of  the  polypus  without  excision,  justifies  the  belief  that  the 
latter  does  not  act  simply  as  a  foreign  body,  for,  were  it  so,  the  discharge  would 
continue  after  the  ligature  was  applied. 

Irritation  of  the  neighboring  organs  may  give  rise  to  hemorrhagic  congestion 
of  the  uterus.  M.  Moreau  mentions  a  case  of  hemorrhage  which  occurred  on 
the  eighth  day  after  delivery,  and  which  he  very  properly  attributed  to  a  collec- 


ARTIFICIAL    DELIVERY.  915 

tion  of  hardened  feces  in  the  large  intestine.  Injections  were  used  without 
advantage,  and  he  was  obliged  to  empty  the  rectum  by  using  a  sort  of  scoop.  As 
soon  as  this  was  accomplished,  the  discharge  ceased. 

For  a  long  time  after  delivery  the  uterus  continues  to  be  a  centre  of  fluxion, 
toward  which  the  general  disorders  of  the  economy  seem  to  converge.  There 
appears  to  be  no  other  way  of  explaining  such  floodings  as  are  apparently  due  to 
violent  moral  emotions,  the  abuse  of  stimulants,  &c. 

c.  Alteration  of  the  Blood. — M.  Blot  also  mentions,  in  his  excellent  thesis, 
the  case  of  a  woman  whose  uterus  was  firmly  contracted,  and  who  died  in  con- 
sequence of  a  sero-sanguineous  discharge  succeeding  flooding  after  delivery. 
This  hemorrhage,  which  nothing  was  capable  of  arresting,  is  attributed  by  M. 
Blot  to  albuminuria  and  the  consequent  impoverishment  of  the  blood.  I  have 
already  had  occasion  to  remark,  that  new  observations  are  necessary  to  prove  the 
correctness  of  this  assertion. 

I  cannot,  however,  agree  with  Madame  Lachapelle,  who  thinks  thai  these 
floodings  are  produced  by  an  accidental  congestion,  a  sort  of  molimen  hemorrlia- 
gicum.  I  think,  on  the  contrary,  that  they  are  the  result  of  a  serous  condition 
of  the  blood,  preventing  the  formation  of  obliterating  coagula,  and  allowing  the 
fluid  to  exude  from  the  internal  surface  of  the  uterus.  This  sometimes  takes 
place  from  the  surface  of  wounds  in  certain  patients  affected  with  anasmia, 
scurvy,  etc.  But  to  admit  with  M.  Blot  that  it  is  caused  by  albuminuria,  would 
be  going  rather  too  far. 

The  use  of  the  tampon,  assisted  by  compression  of  the  uterus  by  means  of  a 
bandage  drawn  tightly  around  the  abdomen,  would  be  proper  under  these  cir- 
cumstances. Ergot  has  often  been  used  without  any  advantage  whatever,  in 
these  dangerous  cases.  Some  English  physicians  approve  highly  of  styptics 
taken  internally.  In  a  case  of  flooding  occurring  nine  days  after  delivery,  Mr. 
Clintock  used  the  tincture  of  Cannabis  Indica  with  success.  Oxide  of  silver,  is 
also  recommended,  in  the  dose  of  from  half  a  grain  to  a  grain,  three  or  four  times 
a  day,  in  connection  with  a  small  quantity  of  opium.  A  large  blister  over  the 
sacrum,  has  also  been  applied  successfully. 

Hemorrhage  from  the.  Umbilical  Cord. — In  twin  pregnancies,  a  hemorrhage 
may  take  place  from  the  cut  placental  extremity  of  the  cord,  after  the  first  child 
is  born.  For,  although  no  vascular  communication  habitually  exists  between 
the  two  placentas,  yet  the  contrary  has  been  too  often  observed  to  leave  any 
doubt  with  regard  to  the  fact  at  the  present  day ;  and  hence  it  is  admitted  by 
most  practitioners.  Besides,  we  find  cases  recorded  by  Mery,  Baudelocque, 
and  Solayres,  which  fully  prove  that,  even  in  single  pregnancies,  a  hemorrhage 
profuse  enough  to  endanger  the  mother's  life,  may  occur  after  the  division  of  the 
cord ;  as  also,  that  the  umbilical  vein  is  the  sole  source  of  this  discharge.  "  As 
regards  the  bleeding  from  the  placental  end  of  the  cord,  other  than  in  cases  of 
twins,  I  can  aver,"  says  M.  Chevreul,  "having  observed  it  three  times  in 
women  whom  I  had  delivered  with  the  forceps ;  having  cut  the  cord  in  a  hurry 
without  applying  any  ligature,  the  blood  continued  to  flow  abundantly  from  that 
portion  connected  with  the  placenta,  whilst  I  was  devoting  the  necessary  atten- 


916  DELIVERY    OF    THE    AFTER-BIRTH. 

tions  to  the  child.  I  resorted  to  all  the  modes  of  irritation  advised  in  such  cases, 
for  the  purpose  of  rousing  the  contractions;  but  the  discharge  was  only  arrested 
by  tying  the  cord.  The  delivery  of  the  after-birth  shortly  occurred,  and  was 
followed  by  no  untoward  accident."  Quite  recently,  M.  Guillemot  has  met  with 
a  very  similar  case.  Dr.  Albert,  of  Wiesentheid,  saw  the  blood  spring  from  the 
extremity  of  the  cord,  in  a  stream  as  thick  as  a  straw.  The  hemorrhage,  which 
was  considerable,  could  not  be  arrested  except  by  pressure  upon  the  umbilical 
vessels;  and  a  ligature  had  to  be  applied. 

By  reflecting  on  the  mode  of  vascular  connection  heretofore  studied  in  the 
placenta,  it  really  seems  impossible  to  understand  how  the  mother's  blood,  in  a 
natural  condition  of  things,  can  pass  into  the  ramifications  of  the  umbilical  vein, 
and  thence  escape  in  such  profusion.  But  are  we  on  that  account  to  reject  such 
facts,  advanced  by  experienced  men  of  high  standing'?  I  think  not;  besides, 
the  explanation  would  be  rendered  very  intelligible  by  supposing  some  vascular 
anomaly  in  these  exceptional  cases.  I  therefore  consider  a  hemorrhage  possible 
from  the  placental  extremity  of  the  cord,  for  I  cannot  question  the  testimony  of 
the  imposing  authorities  just  quoted.  Under  such  circumstances,  ligature  of 
the  cord  is  evidently  the  only  resource. 

§  3.  Of  Inversion  of  the  Womb. 

This  is  an  aiFection  in  which  the  fundus  of  the  organ,  being  indented  or  de- 
pressed, is  more  or  less  inverted  into  its  cavity,  or  even  passed  down  through  the 
OS  uteri  into  the  vagina,  or  out  at  the  vulva. 

The  inversion  of  the  womb  exhibits  many  different  degrees;  from  a  simple 
depression  of  the  fundus  to  a  complete  inversion,  in  which  case  the  organ  is 
tui'ned  inside  out,  the  internal  or  mucous  surface  becoming  the  external  one,  and 
vice  versa.  For  the  purposes  of  description,  we  shall  admit  three  principal  de- 
grees :  in  the  first  of  which  the  fundus  is  simply  depressed,  approaching  to,  but 
not  engaging  in,  the  os  uteri ;  the  second  is  a  partial  inversion,  in  which  the 
fundus  actually  engages  in  the  orifice,  and  protrudes  into  the  vagina ;  and  the 
third  is  a  complete  inversion,  in  which  the  uterus  is  turned  inside  out,  appear- 
ing at  the  vulva,  or  even  protruding  beyond  it. 

1.  When  the  depression  commences  at  the  fundus,  a  concavity  is  produced  in 
the  tumor  above  the  pubis,  having  its  highest  borders  nearer  to  the  latter  than 
to  the  sacrum ;  or  it  may  commence  at  the  sides  ;  and  when  it  is  the  front  one 
that  is  indented,  the  posterior  border  is  higher  than  the  anterior,  but  when  the 
reverse  happens,  the  posterior  is  the  lower :  again,  when  it  is  depressed  laterally, 
the  concavity  in  the  top  of  the  womb  is  inclined  towards  one  of  the  iliac  fossae. 
If  the  placenta  is  still  undetached,  the  indentation  is  augmented  by  pulling  on 
the  umbilical  cord.  Finally,  when  the  finger  is  passed  into  the  cavity  of  the 
womb,  it  finds  the  fundus  within  half  an  inch,  more  or  less,  of  the  orifice. 

2.  When  the  inversion  is  partial,  we  can  detect  a  hemispherical  tumor  by  the 
vaginal  examination,  varying  in  its  size,  according  to  whether  the  placenta  is 
detached  or  is  still  adherent;  the  neck  of  the  womb  encircles  this  tumor  at  its 
upper  part  like  a  collar.     The  ball  usually  formed  in  the  hypogastric  region  by 


J 


ARTIFICIAL    DELIVERY.  917 

the  uterine  globe,  is  no  longer  felt  on  palpation ;  a  considerable  depression  being 
found  in  its  place. 

3.  AVhere  it  is  complete,  the  tumor  may  either  fill  up  the  vagina  without 
passing  beyond  the  vulva,  or  it  may  hang  down  between  the  woman's  thighs. 
In  the  former  case,  the  whole  vaginal  cavity  is  occupied  by  a  voluminous  tumor, 
the  upper  part  of  which  can  scarcely  be  reached  ;  in  the  latter,  which  is  the 
most  serious  of  all,  the  pelvic  cavity  is  altogether  empty,  and  nothing  can  be  felt 
there  by  the  hand ;  but  a  large  tumor  is  found  between  the  patient's  thighs, 
having  the  placenta-  attached,  wholly  or  in  part.  The  top  of  this  tumor  is 
either  simply  concealed  between  the  labia,  or  extends  up  into  the  vagina.  In 
some  instances,  the  latter  has  also  been  implicated  in  the  displacement,  and  has 
been  inverted  in  a  great  measure,  thereby  giving  a  considerable  length  to  the 
tumor.  *'  We  cannot,  howevei",  say  that  the  inversion  is  strictly  complete," 
says  Burns,  "  for,  in  most  cases,  the  lips  of  the  os  uteri  hang  down,  and  the 
inversion  terminates  at  the  lower  part  of  the  cervix."  Some  writers  assert,  not- 
withstanding, that  the  lips  may  be  completely  inverted. 

This  accident  is  always  accompanied  by  general  phenomena,  which  are  the 
more  serious  as  it  is  the  more  considerable.  The  patient  not  only  suffers  from 
pain,  but  she  is  harassed  by  a  constant  desire  to  urinate,  and  by  strainings  at  the 
close-stool,  which  are  often  sufficient  to  render  an  inversion  complete,  that  would 
otherwise  have  only  been  partial.  The  pain  becomes  excruciating,  and  the 
frightened  sufferer  falls  into  a  state  of  syncope ;  the  pulse  is  feeble,  and  some- 
times is  nearly  or  quite  imperceptible.  The  intensity  of  these  general  pheno- 
mena varies  with  the  state  of  retraction  or  relaxation  of  the  cervix,  and  with  the 
degree  of  inversion.  For  instance,  it  is  much  less  in  a  simple  depression,  than 
where  the  inversion  is  more  complete.  Furthermore,  the  pains  and  dangers  are 
much  greater  in  the  latter  case,  if  the  cervix  uteri  is  firmly  contracted,  than 
when  it  is  dilatable.  Again,  should  the  placenta  be  partially  detached  at  the 
time  of  the  accident,  there  will  be  a  profuse  hemorrhage;  but,  on  the  contrary, 
when  it  is  firmly  adhei'ent  throughout,  no  discharge  occurs,  since  the  latter  only 
begins  with  the  separation  of  the  after-birth,  and  increases  as  this  progresses. 
Lastly,  when  the  inversion  is  complicated  by  inertia,  which  unfortunately  is 
usually  the  case,  the  flooding  is  frightful,  and  can  only  be  moderated  by  the  con- 
traction of  the  womb. 

The  inversion  is  sometimes  produced  by  attempting  to  effect  the  delivery  of 
the  after-birth  before  it  is  entirely  separated,  by  pulling  imprudently  on  the  cord. 
It  may  also  result  from  a  very  rapid  labor,  more  particularly  if  the  woman  hap- 
pens to  be  standing  at  the  time  when  the  child  is  born ;  for  if  the  umbilical  cord 
is  unusually  short,  or  is  wound  around  some  part  of  the  child,  the  fundus  may  be 
pulled  down  by  the  strain  on  the  cord,  and  thus  become  inverted. 

An  inversion  from  this  latter  cause  is  far  more  unusual  than  one  would  sup- 
pose ;  because  the  cord  is  generally  broken  under  such  circumstances,  incompre- 
hensible as  the  fact  may  seem,  when  we  reflect  on  the  amount  of  force  required 
to  rupture  it.  The  rarity  of  the  inversion,  however,  is  more  readily  explained 
by  the  powerful  contraction  at  the  instant  the  foetus  is  expelled,  and  by  the  dif- 


918  DELIVERY    OF    THE    AFTER-BIRTII. 

ference  in  the  line  of  axis  of  the  two  straits ;  the  axis  of  the  superior  strait  form- 
ing nearly  a  right  angle  with  that  of  the  inferior  one,  or  rather  with  that  of  the 
vulva.  In  other  words,  the  cord  passes  around  the  posterior  part  of  the  sym- 
physis pubis,  as  over  a  pulley;  and,  therefore,  the  greater  amount  of  the  tractive 
force  is  spent  on  the  symphysis  before  reaching  the  fundus. 

It  may  happen,  from  the  uterus  being  in  a  momentary  state  of  inertia  after 
delivery,  that  the  pressure  made  by  the  intestinal  mass  indents  its  fundus  like 
the  bottom  of  a  bottle.  Again,  in  cases  of  complete  inertia,  should  the  placenta 
be  attached  directly  to  the  fundus  of  the  organ,  its  weight  alone  might  pull  it 
down.  Such  accidents  are  usually  corrected  by  the  force  of  the  contractions ; 
though,  should  the  operator  pull  on  the  cord  before  noticing  the  depression,  he 
might  increase  the  difficulty  by  converting  it  into  a  partial  inversion.^ 

Dr.  Tyler  Smith  supposes  that  inversion  of  the  uterus  is  always  occasioned  by 
irregular  contractions  of  the  organ ;  even  in  the  cases  generally  attributed  to  pre- 
mature tractions  on  the  cord,  he  considers  that  the  pulling  does  not  act  mechani- 
cally, but  only  by  producing  an  excitement  of  the  fundus  of  the  uterus,  where 
the  placenta  is  inserted,  which  occasions  an  irregular  contraction,  and  conse- 
quently a  simple  depression.  This  first  degree  of  inversion,  according  to  him, 
is  immediately  followed  by  a  sudden  contraction  of  the  fibres  above  the  depressed 
point,  which  tend  by  their  action  to  expel  the  latter  through  the  cervix,  in  abso- 
lutely the  same  manner  as  they  would  act  upon  a  foreign  body. 

Dr.  Smith's  explanation  of  the  mechanism  of  inversion  may  be  true  for  some 
cases ;  but  when  the  walls  of  the  uterus  are  in  a  state  of  complete  relaxation,  it 
is  difficult  to  allow  that  violent  pulling  upon  the  cord  of  an  adherent  placenta 
should  be  incapable  of  producing  inversion. 

'  Although  I  am  only  treating  of  uterine  inversion  here,  as  a  comiilication  of  the  delivery, 
I  cannot  refrain  from  mentioning  a  very  curious  case,  narrated  by  An6,  at  the  Sociele  de 
Medecine,  of  a  w^oman  who  had  a  complete  inversion  of  the  womb  twelve  days  after  her  con- 
finement, and  which  resulted  in  consequence  of  severe  strainings  at  stool.  This  case,  which 
was  confirmed  by  Baudelocque,  who  was  called  in  consultation,  can  leave  no  doubt  as  to  the 
possibility  of  such  an  accident,  however  extraordinary  it  may  appear.  A  still  more  wonder- 
ful case  is  related  by  Mr.  Ebenezer  Skae,  as  occurring  in  a  woman  who  suffered  complete 
inversion  of  the  womb,  two  days  after  aborting  in  the  fourth  month  of  gestation.  [The 
Northern  Journal  of  Medicine.)  I  will  further  add,  that  the  observations  of  Sabatier  would 
seem  to  prove  that  such  an  inversion  may  not  only  take  place  when  the  fundus  of  the  womb 
is  depressed  by  a  polypus,  but  also  in  a  state  of  perfect  vacuity.  The  responsibility  of  the 
assertion  must  rest  with  the  author. 

M.  Roussel  communicated  a  case  to  M.  Martin,  in  which  tlie  inversion  did  not  take  place 
until  nine  hours  after  the  delivery.  The  patient  had  a  frightful  flooding  at  the  time  of  the 
extraction  of  the  placenta,  which  M.  Roussel  arrested  by  the  ordinary  measures;  after  which, 
he  remained  with  her  until  fully  satisfied  of  the  contraction  of  the  womb.  It  was  then  about 
eight  o'clock  in  the  evening.  At  five  the  next  morning,  he  was  summoned  in  great  haste ; 
when  it  appeared  that  tlie  patient  had  got  up  to  evacuate  her  bowels,  and  the  womb  imme- 
diately fell  down  to  the  vulva.  On  his  arrival  she  was  senseless,  and  the  pulse  impercep- 
tible; the  finger,  passed  into  the  vagina,  found  there  a  large  tumor,  formed  by  the  inverted 
fundus,  around  which  the  os  uteri  had  firmly  contracted,  and  doubtless  had  thus  contributed 
to  the  diminution  of  the  hemorrhage. 


ARTIFICIAL    DELIVERY.  919 

When  a  simple  depression  occurs  immediately  after  labor,  it  will  scarcely 
attract  attention,  unless  the  placenta  happens  to  be  detached,  and  a  hemorrhage 
is  thereby  developed.  It  ought  to  be  reduced,  as  soon  as  detected,  by  placing 
the  patient  on  her  back,  and  having  the  abdomen  and  breech  raised  higher  than 
the  chest;  the  legs  and  thighs  are  flexed  and  held  apart,  and  the  head  inclined 
forwards  on  the  breast ;  then  the  operator  carries  his  hand  into  the  uterine  cavity, 
and  gently  pushes  out  the  fundus  with  his  fingers. 

M.  Chevreul  sums  up  so  well  the  indications  presented  by  the  partial  and  com- 
plete itiversions  of  the  womb,  with  reference  to  the  delivery  of  the  after-birth, 
that  I  cannot  do  better  than  transcribe  here  his  remarks  on  this  subject.  He 
says,  "A  partial  inversion  is  easily  reduced  when  detected  shortly  after  its  occur- 
rence. Of  course,  the  placenta  may  either  be  separated  wholly  or  in  part,  or  it 
may  be  still  adherent  throughout  to  the  womb,  at  the  time  of  the  accident.  If 
wholly  detached,  the  hemorrhage  is  very  profuse,  and  requires  immediate  atten- 
tion. The  accident  is  remedied  by  placing  the  woman  in  a  suitable  position,  and 
then,  introducing  the  whole  hand  into  the  vagina,  the  fingers  take  hold  of  the 
inverted  portion  of  the  womb  and  endeavor  to  return  it,  by  first  pushing  up  the 
part  that  came  down  last.  Should  the  placenta  be  partially  detached,  and  the 
remaining  adhesions  be  feeble,  its  separation  ought  to  be  entirely  completed,  by 
passing  the  fingers  between  it  and  the  uterine  wall ;  after  which,  the  reduction 
is  to  be  effected  as  in  the  former  case.  But  if  it  is  still  adherent  throughout, 
the  whole  is  to  be  returned  together ;  and  then  we  may  either  wait  for  the  spon- 
taneous delivery  of  the  after-birth,  or  we  may  attempt  to  separate  it  by  the  hand, 
according  to  circumstances. 

Where  the  inversion  has  existed  for  sevei'al  hours,  it  occasionally  happens  that 
the  protruding  portion  of  the  womb  is  strangulated,  as  it  were,  by  the  os  uteri, 
which  constitutes  a  serious  obstacle  to  its  reduction.  Under  such  circumstances, 
it  is  not  advisable  to  use  forcible  attempts  to  surmount  the  difficulty,  lest  some 
serious  accident  might  result ;  but  rather  to  have  recourse  to  venesection,  to  tepid 
bathing,  to  fomentations,  to  the  use  of  the  ointment  or  the  extract  of  belladonna, 
and  opiates ;  in  a  word,  to  all  the  means  likely  to  relieve  the  constriction  of  the 
OS  uteri,  and  to  moderate  the  force  of  the  inflammatory  symptoms.  The  inhala- 
tion of  chloroform,  which  has  been  used  with  such  fortunate  results  in  analogous 
cases  by  MM.  Barrier,  Valentin,  Charles  West,  and  Gr.  Gonney,  might  here  also 
be  of  very  great  service.  But  if  still  unsuccessful,  the  patient  will  have  to  en- 
dure this  disgusting  infirmity  for  the  remainder  of  her  days.' 

'  However,  two  cases  are  reported,  the  one  by  M.  Delabarre  (jIcc.  de  Ckir.),  and  the  other 
by  Baudelocque,  which  fully  prove  that  a  spontaneous  reduction  of  the  womb  may  take 
place,  even  after  it  has  been  completely  inverted  for  a  long  time. 

M.  Daillies  endeavors  to  explain  this  natural  reduction,  in  his  excellent  thesis,  by  the  toni- 
city of  the  Fallopian  tubes,  and  of  the  round  and  broad  ligaments;  which,  after  having  been 
drawn  down,  at  the  moment  of  the  accident,  will  necessarily  return  to  their  proper  position 
in  the  course  of  time ;  and  thus,  by  acting  on  the  organ  that  involved  them  in  its  descent 
will  gradually  elevate  and  return  it  to  its  original  position. 


920  DELIVERY    OF    THE    AFTER-BirvTH, 

"Where  the  inversion  is  complete,  and  the  placenta  is  detached,  we  must  first 
apply  a  soft  and  dry  napkin  upon  the  tumor,  and  then,  having  brought  the 
fingers  together  in  the  form  of  a  cone,  depress  its  central  part  with  their  points, 
so  as  to  make  the  fundus  and  body  of  this  viscus  gradually  pass  up  through  its 
orifice,  and  thus  regain  its  primitive  position.  Should  the  conjoined  fingers 
prove  too  bulky,  the  stick  proposed  by  M.  Depaul  might  be  substituted  for  them 
with  advantage.  When  the  womb  is  once  reduced,  the  napkin  should  be  with- 
drawn. Should  the  placenta  be  partially  detached,  its  separation  is  first  com- 
pleted, and  then  the  operation  is  terminated  in  the  same  way. 

Again,  if  the  adhesions  are  very  extensive,  or  if  they  exist  throughout,  we 
ousht  to  attempt  the  reduction  of  all  together,  by  proceeding  as  in  the  first  case, 
excepting  the  use  of  the  napkin ;  but,  if  the  orifice  is  not  dilated  enough  to 
permit  the  womb  to  pass  through  with  the  placenta,  it  would  be  necessary  to 
separate  the  latter,  and  then  reduce  the  former  as  promptly  as  possible. 

Whatever  be  the  degree  of  inversion,  the  hand  is  always  to  be  kept  in  the 
womb  for  some  time  after  the  reduction,  for  the  purpose  of  preventing  a  return 
of  the  accident,  and  for  soliciting  the  contraction  of  the  organ.  The  inertia,  if 
any,  must  be  remedied  by  the  appropriate  measures. 

It  is  found  by  experience  that  whenever  an  inversion  has  occurred  in  a  former 
labor,  it  has  a  tendency  to  be  renewed  at  the  subsequent  ones.  Consequently, 
no  tractions  on  the  umbilical  cord,  with  a  view  of  extracting  the  placenta,  should 
ever  be  resorted  to  in  women  who  have  previously  sufi'ered  from  this  accident. 
In  cases  of  this  kind,  many  practitioners  prefer  the  introduction  of  the  hand  into 
the  uterine  cavity,  so  as  to  act  directly  on  the  placenta  itself. 

Such  patients  ought  also  to  be  advised  to  remain  in  bed  for  a  long  time  after 
their  confinement ;  and,  by  the  use  of  mild  laxatives,  to  obviate  the  necessity  of 
strainings  at  stool. 

For  the  proper  course  to  be  pursued  in  eases  of  puerperal  convulsions,  we  refer 
the  reader  to  the  special  articles  on  that  subject.     (^Accidental  Dystocia.) 

§  4.  Rupture  of  the  Womb. 

A  rupture  of  the  uterus  is  one  of  the  most  terrible  accidents  that  can  occur  in 
the  course  of  pregnancy  or  parturition.  But  as  it  only  claims  our  attention  here, 
with  reference  to  the  difficulties  it  may  create  in  the  delivery  of  the  after-birth, 
we  shall  not  revert  to  the  minute  detail  already  given  in  the  Fourth  Part  of  this 
work.  Several  different  conditions  may  here  be  met  with ;  as,  for  instance,  the 
child,  having  partially  or  wholly  escaped  into  the  peritoneal  cavity,  has  permitted 
the  organ  to  retract;  and  this  retraction  of  its  walls  may  have  driven  the  pla- 
centa into  the  vagina,  and  then  beyond  the  vulva ;'  or  the  placenta  may  remain 
adherent  to  the  internal  surface  of  the  womb,  the  child  having  passed  into  the 
peritoneal  cavity;  or  again,  it  as  well  as  the  foetus  may  have  passed  entirely  into 

'  This  spontaneous  expulsion  may  take  place  either  immediately  after  the  accident,  or  not 
for  several  days ;  as  occurred  in  the  case  reported  by  Saucerotte.  (Melanges  de  Chirurffie,  t. 
ii,  p.  295.) 


ARTIFICIAL    DELIVERY.  921 

the  cavity  of  the  abdomen.  In  the  former  case  there  is  evidently  nothing  to  be 
done.  In  the  second,  if  gastrotomy  is  resorted  to,  and  it  is  found  impossible  to 
withdraw  the  placenta  through  the  double  wound  in  the  abdomen  and  womb, 
owing  to  the  closure  of  the  lips  of  the  uterine  rupture,  it  would  be  advisable  to 
cut  the  cord  as  soon  as  the  child  is  extracted ;  and  then,  by  means  of  some  long, 
solid,  and  flexible  instrument,  to  bring  down  the  cord  through  the  rupture,  the 
cervix,  and  the  vagina,  and  out  at  the  vulva  j  after  which  the  delivery  of  the 
placenta  is  to  be  effected  in  the  usual  way.  In  the  third  case,  when  the  after- 
bii'th  has  passed  into  the  peritoneal  cavity  alcng  with  the  foetus,  it  ought  to  be 
extracted  immediately  after  the  latter,  either  by  the  natural  passages,  if  the  child 
is  removed  in  that  way,  or  through  the  abdominal  incision,  if  a  resort  to  gastro- 
tomy be  deemed  necessary. 


PART  YI. 

OF  THE  HYGIENE  OF  CHILDREN  FROM  BIRTH  TO  THE 
PERIOD  OF  WEANING. 


Having  carefully  detailed  the  services  to  be  rendered  by  the  accoucheur  to 
the  child  immediately  after  its  birth,  we  have  now,  in  order  to  complete  the 
study  of  subjects  which  must  subsequently  claim  his  attention,  to  treat  of  the 
physical  education  of  children.  As  the  full  details  into  which  we  have  entered 
have  already  brought  the  work  up  to  a  considerable  size,  we  are  obliged  to  curtail 
greatly  what  we  had  proposed  saying  in  regard  to  the  hygiene  of  early  childhood. 
The  old  and  classic  division  of  Halle  might  be  advantageously  applied  in  this 
place,  so  that,  if  space  allowed,  we  would  treat  successively  of  the  inyesta, 
appUcaia,  percepta,  &c.  &c.  But,  inasmuch  as  we  are  obliged  to  limit  our- 
selves to  a  somewhat  detailed  account  of  alimentation,  we  shall  treat  of  the  other 
parts  of  infantile  hygiene  in  a  general  way  only. 


BOOK   I. 

OF  THE  ALIMENTATION  OF  CHILDREN. 

Although  the  existence  of  the  new-born  child  is  generally  styled  indepen- 
dent, its  physiological  connection  with  the  mother  is  not  entirely  severed  by  the 
delivery.  It  does  not  immediately  cease  to  derive  nourishment  from  the  mater- 
nal organism ;  for  although  no  longer  connected  with  the'  uterus,  nature  has 
prepared  another  organ  for  the  elaboration  of  the  fluid  designed  for  its  future 
support.  This  fluid  is  the  milk.  The  function  by  which  it  is  secreted  is  called 
lactation,  and  the  mode  in  which  it  is  taken  by  the  new-born  child  is  termed 
sudcling. 


LACTATION.  923 

CHAPTER  I. 

LACTATION. 

As  stated  whilst  treating  of  the  phenomena  of  pregnancy,  the  breasts  begin  to 
enlarge  from  the  first  month  of  gestation.  Their  active  vitality,  under  these  cir- 
cumstances, soon  gives  rise  to  the  secretion  of  a  sero-lactescent  fluid,  which  be- 
comes more  abundant  as  the  term  of  gestation  draws  near.  To  this  fluid,  which 
is  viscid  and  yellowish,  the  name  of  colostrum  is  applied.  Under  the  microscope, 
it  presents  the  appearance  of  globules,  much  smaller  than  the  ordinary  milk  glo- 
bules, united  together  by  a  viscid  matter.  Some  irregular  milk  globules  are  scat- 
tered amongst  them.  Peculiar  bodies  (granular  corpuscles),  more  or  less  globular 
in  form,  yellowish,  and  varying  from  -003  to  -019  inches  in  diameter,  are  also 
observed. 

M.  Donne  asserts,  that  there  is  an  almost  constant  relation  between  the  com- 
position of  this  fluid  secreted  during  pregnancy,  and  that  which  will  be  exhibited 
by  the  milk  after  delivery ;  in  other  words,  the  examination  of  the  colostrum  and 
its  principal  characters  will  enable  us  to  judge  of  the  probable  abundance  and 
quality  of  the  milk.  In  reference  to  this,  M.  Donne  divides  women  into  three 
classes  :  1.  If  the  amount  of  colostrxim  secreted  is  so  small  that  barely  a  drop  can 
be  obtained  by  the  best-directed  pressure,  if  it  contains  but  very  few  minute, 
imperfectly-formed  milk  globules,  and  a  very  limited  number  of  granular  cor- 
puscles, the  milk  will  almost  certainly  be  scanty,  poor,  and  insuflBcient  for  the 
nourishment  of  the  child.  2.  If  the  woman  secrete  an  abundant,  but  fluid, 
watery,  and  easy-flowing  colostrum,  resembling  a  thin  solution  of  gum  Arabic, — 
if  it  no  longer  presents  striae  of  a  thick,  yellow,  and  viscid  matter,  and  if  it  be 
poor  in  milk  globules  and  granular  corpuscles,  they  may  have  a  greater  or  less 
amount  of  milk,  but  it  will  be  poor,  watery,  and  unsubstantial.  3.  Lastly,  when 
the  colostrum  is  obtained  readily  and  in  abundance,  when  it  contains  a  more  or 
less  thick  yellow  matter,  and  resembles  somewhat  the  rest  of  the  fluid  as  regards 
consistency  and  color;  when  the  microscope  shows  it  to  be  rich  in  milk  globules, 
well  formed,  and  of  good  size,  and  containing  granular  corpuscles  in  greater  or 
less  amount,  we  may  be  almost  certain  that  the  woman's  milk  will  be  both  rich 
and  abundant. 

This  examination  may  be  made  with  especial  prospect  of  advantage  about  the 
eighth  month.  .  .  .  It  is  well,  however,  to  be  aware,  that  certain  acciden- 
tal causes,  such  as  cold,  or  moral  aifections,  may  occasion  a  momentary  discord- 
ance with  the  results  of  experience  (Donne). 

For  the  first  days  following  the  delivery,  and  until  after  the  milk-fever,  the 
fluid  secreted  by  the  mammae  retains  the  properties  of  colostrum,  but  is  more 
abundant  than  during  pregnancy.  When  the  milk-fever  comes  on,  the  milk 
globules  begin  to  present  a  more  definitely  rounded  contour,  and  are  more  regu- 
lar. Some  histologists  assert  that  the  granular  corpuscles  disappear  about  the 
ninth  day ;  but  M.  Godez  states,  that  he  has  often  met  with  them  after  the 


924  HYGIENE     OF    CHILDREN. 

fifteenth  day,  and  even  after  the  twentieth,  though  only  in  the  milk  of  moderately 
good  nurses.  They  generally  become  more  rare  as  a  longer  time  elapses  from  the 
period  of  the  milk-fever,  and  they  disappear  the  more  quickly,  or,  in  other  words, 
the  milk  is  sooner  formed  when  its  quality  is  good  and  the  woman  in  a  satisfac- 
tory condition.  The  fact  of  their  remaining  after  the  first  fortnight  is  an  indica- 
tion of  an  indifferent  nurse. 

After  the  milk-fever  is  over,  the  mammary  secretion  generally  tends  more  and 
more  to  assume  the  characters  of  true  milk.  The  latter  is  a  white,  opaque  fluid, 
of  a  sweet,  sugary,  and  very  pleasant  taste.  Of  all  the  fluids  of  the  economy,  it 
approaches  the  nearest  to  the  blood  in  composition,  and  like  it,  separates  into 
two  parts  upon  standing.  One  of  these  parts  is  solid  and  the  other  fluid.  The 
solid  part,  which  is  held  in  suspension,  is  formed  of  globules  of  fat  or  butter; 
the  other  holds  in  solution  a  special,  azotized,  and  coagulable  animal  matter 
(caseine),  sugar  of  milk,  salts,  and  a  little  yellow  matter. 

These  several  parts,  gays  M.  Donne,  when  mingled  together  are  not  dis- 
tinguishable by  the  naked  eye ;  but  if  a  drop  of  milk  be  spread  out  upon  a  plate  of 
glass,  and  examined  through  a  microscope  magnifying  two  hundred  diameters, 
a  multitude  of  rounded,  transparent  granules,  brilliant  as  little  pearls,  will  be 
discovered  swimming  in  a  limpid  fluid.  These  small  granules,  which  are  rather 
less  than  -0003  inches  in  diameter,  are  the  milk  globules,  and  are  formed  of 
a  fatty  matter  or  butter.  In  pure  and  unmixed  milk,  nothing  beside  these 
small  globules  is  visible,  and  this  purity  of  the  milk  is  a  certain  indication  of  its 
good  quality. 

The  amount  of  globules  is  liable  to  variation,  their  greater  or  less  abundance 
representing  with  considerable  precision  the  richness  or  poverty  of  the  milk : 
that  is  to  say,  the  more  of  these  globules  the  milk  contains,  the  richer  and  more 
substantial  is  it,  the  caseine  and  sugar  being  themselves  in  proportion  to  the 
amount  of  milk  globules  which  represent  the  fatty  matter  or  butter. 

Not  only  does  the  milk  vary  in  richness  in  diff"erent  individuals,  but  it  varies 
greatly  in  the  same  woman  according  to  the  time  when  drawn,  her  state  of  health 
or  of  disease,  and  the  hygienic  conditions  in  which  she  is  situated.  We  shall, 
hereafter,  have  to  study  these  variations  when  endeavoring  to  judge  of  the  cha- 
racters by  which  to  determine  whether  a  woman  is  or  is  not  a  good  nurse. 

The  lacteal  pecretion  is,  as  we  have  said,  intimately  connected  with  the  function 
of  generation ;  still  it  must  not  be  supposed  that  it  can  only  take  place  in  preg- 
nant or  recently-delivered  females.  It  has  several  times  been  known  to  occur 
in  consequence  of  frequent  excitation  of  the  nipple.  Thus  Belloc  relates,  that 
a  domestic  who  was  obliged  to  sleep  in  the  same  chamber  with  a  recently-weaned 
child,  being  annoyed  by  its  cries,  took  it  into  her  head  to  put  it  to  her  own  breast. 

In  a  very  short  time  she  had  milk  enough  to  satisfy  its  appetite.     Mrs.  B , 

says  George  Semple,  mother  of  nine  children,  the  youngest  of  whom  was  thirteen 
years  old,  lost  her  daughter-in-law  a:  year  before,  she  having  died  four  days  after 
her  delivery.  After  her  death  she  took  charge  of  the  infant,  which  was  thin 
and  puny,  besides  being  so  complaining  and  hard  to  pacify  that  after  passing 
several  sleepless  nights,  she  allowed  it  to  take  her  breast.     Not  more  than  from 


LACTATION.  925 

thirty  to  tbirty-six  hours  had  elapsed,  before  Mrs.  B.  was  astonished  to  find  her 
breast  become  painful  and  enlarged,  and  immediately  afterward  the  secretion  of 
milk  was  established  as  freely  as  had  been  customary  after  her  confinements. 
For  an  entire  year,  the  child  nursed  at  the  same  breast  which  had  given  suck  to 
its  father  twenty-four  years  before.  Baudelocque  mentions  a  little  girl  eight 
years  of  age  who  presented  the  same  peculiarity;  and  the  following  case  is  re- 
lated by  M.  Audebert  : 

Angeline  Chauffaille,  sixty-two  years  of  age,  and  who  had  not  had  children  for 
twenty-seven  years,  undertook  to  nurse  her  granddaughter  artificially.  From 
time  to  time,  in  order  to  amuse  it,  she  presented  it  with  her  nipple ;  but  what 
was  her  surprise  when  she  suddenly  found  both  her  breasts  full  of  an  apparently 
good,  healthy,  and  nutritive  milk  !  She  continued  to  nurse  it  for  a  year,  and 
the  secretion  had  not  entirely  ceased  after  the  child  had  been  weaned  two  months. 
At  this  juncture,  her  daughter  again  became  a  mother,  her  milk  dried  up,  and 
the  grandmother  was  able  to  nurse  the  second  child.  (Audebert,  Gaz.  Med., 
p.  250,  1841.) 

The  duration  of  lactation  varies  greatly  even  in  women  who  do  not  suckle. 
In  some,  it  lasts  several  months  in  spite  of  all  that  can  be  done  to  put  an  end  to 
it.  I  have  just  delivered,  for  the  third  time,  a  young  lady  who  had  an  abundance 
of  milk  after  her  two  first  confinements,  for  the  space  of  three  months,  and  this 
although  her  courses  returned  in  six  weeks.  The  secretion  of  milk  in  nurses 
sometimes  lasts  long  enough  to  enable  them  to  suckle  two  and  three  children 
successively.  A  lady  in  every  way  worthy  to  be  believed,  says  Desormeaux, 
assured  me  that  she  had  known  a  woman  to  suckle  five  children  consecutively, 
which  must  have  involved  a  lactation  of  at  least  six  years'  continuance.  I  find 
amongst  my  notes  the  following  case,  the  origin  of  which  I  am,  unfortunately, 
unable  to  discover :  A  woman  had  so  abundant  a  secretion  of  milk  for  the  forty- 
seven  years  succeeding  the  birth  of  her  first  child,  that  she  was  not  only  able  to 
nurse  six  of  her  own  children,  but  seven  others  also.  She  always  menstruated 
regularly  during  the  lactation,  and  at  eighty-one  years  of  age,  her  breasts  still 
yielded  a  small  quantity  of  milk.  On  the  other  hand,  the  lacteal  secretion  often 
begins  abundantly,  then  declines,  and  ceases  without  our  being  able  to  discover 
the  cause.  Many  gradations  are  observable  between  these  extremes,  but  the 
average  duration  of  lactation  in  women,  is  from  twelve  to  eighteen  months. 

The  quantity  of  milk  varies  still  more  than  the  duration  of  the  secretion,  even 
when  no  account  is  taken  of  the  hygienic  and  moral  influences,  which  have  an 
undoubted  influence  over  it.  One  woman,  in  other  respects  healthy,  may  barely 
be  able  to  supply  the  amount  required  for  the  nourishment  of  a  single  child, 
whilst  another  may  be  able  to  suckle  several  at  a  time.  Haller  says,  that  women 
have  been  known  to  furnish  in  a  single  day  a  pound  and  a  half,  or  even  two, 
three,  or  four  pints  of  milk  5  in  one  case,  the  woman  gave  three  pounds  more 
than  was  required  for  her  child.  Unfortunately,  it  is  difiicult  to  know  before- 
hand what  the  quantity  of  milk  will  be.  The  results  obtained  by  M.  Donn^, 
may,  indeed,  enable  us  to  form  a  probable  diagnosis,  but  are  far  from  being 
certain.    Even  when  the  flow  of  milk  is  well  established,  as  in  the  case  of  a  nurse 


926  HYGIENE    OF    CHILDREN. 

for  example,  it  is  very  difficult  to  say  what  will  be  its  amount.  The  nurse's  ajxe, 
and  the  size  and  form  of  the  breasts,  are,  doubtless,  matters  of  importance,  but 
still  insufficient.  G-enerally,  when  nurses  are  too  young,  as  under  eighteen  or 
twenty  years  of  age,  or  too  old,  as  over  forty  years,  they  give  a  less  amount  of 
milk.  Finally,  it  would  seem  that  in  certain  individuals  the  amount  of  milk  in- 
creases with  the  birth  of  every  child,  inasmuch  as  they  have  it  in  much  greater 
quantity  after  the  second  or  third  confinement  than  after  the  first.  Women  of 
a  lymphatic  temperament,  also  have  less  milk  than  others. 

Is  the  quantity  of  milk  affected  by  the  kind  and  amount  of  food  ?  Although 
such  is  not  proved  to  be  the  case  in  the  human  species,  the  fact  is  too  well  esta- 
blished as  regards  the  females  of  the  superior  animals,  not  to  lead  to  the  same 
conclusion  as  respects  women.  For  my  own  part,  I  knew  a  nurse  whose  flow  of 
milk  was  sensibly  increased  after  several  times  partaking  of  ground  lentils. 

The  quality  of  the  milk  may  be  sensibly  affected  by  numerous  circumstances 
which  have  next  to  claim  attention. 

A.  The  health  of  the  nurse  is  a  matter  of  the  highest  importance.  Chemical 
analysis  shows,  that  in  diseases  of  any  kind,  the  proportion  of  solid  constituents 
increases  at  the  same  time  that  the  proportion  of  water  decreases.  According  to 
the  analyses  of  MM.  Becquerel  and  Ycrnois,  this  fact  is  more  observable  in 
chronic  diseases  than  in  acute  febrile  affections.  Now,  as  M.  Bouchut  judiciously 
observes,  this  increase  in  the  proportion  of  the  solid  principles  of  the  milk  is  an 
unfortunate  alteration,  causing  the  child  to  be  frequently  affected  with  indigestion 
and  consecutive  enteritis.  The  milk  of  women  suffering  from  chronic  diseases, 
phthisis  for  example,  exhibits  great  alteration  of  the  milk  globules.  Every  one 
knows  that  when  an  acute  affection  appears  in  a  recently-delivered  female,  the 
breasts  are  scarcely  swollen  whilst  the  disease  lasts,  and  even  after  recovery  the 
lacteal  secretion  is  sometimes  but  imperfectly  established.  A  slight  and  evanes- 
cent affection  during  lactation  appears  to  have  but  little  influence,  which  is  far 
from  being  the  case  when  it  is  more  severe  and  prolonged.  The  secretion  some- 
times ceases,  and  even  when  it  continues  without  presenting  any  appreciable 
alteration  to  our  means  of  investigation,  the  state  of  the  child,  which  is  observed 
to  become  rapidly  emaciated,  and  to  digest  badly,  indicates  an  alteration  of  the 
milk  as  certainly  as  the  best  chemical  reagent.  An  inflammation,  an  acute  irri- 
tation of  an  important  organ,  or  a  considerable  discharge  of  some  kind,  lessens 
it,  or  even  stops  it  altogether.  The  diseases  of  the  breast,  the  inflammatory  en- 
gorgements, phlegmons,  and  glandular  abscesses,  merit  especial  attention,  not  only 
because  they  diminish  the  secretion  of  the  diseased  organ  considerably,  but 
because  they  communicate  dangerous  properties  to  the  milk.  Nothing  more  than 
a  simple  engorgement  is  needed  to  produce  a  reformation  of  the  granular  cor- 
puscles and  a  viscid  condition  of  the  milk  ;  and  should  an  abscess  be  formed,  the 
microscope  shows  its  presence  even  before  the  exploration  of  the  breast  distin- 
guishes the  collection  of  pus,  by  exhibiting  the  characteristic  globules  of  that ' 
fluid  with  their  granular  appearance,  their  opacity,  and  the  property  of  being 
completely  dissolved  in  alkalies  and  of  resisting  the  action  of  ether. 

B.  Moral  affections,  such  as  fright,  anger,  disappointment,  &c.,  undoubtedly 


LACTATION.  927 

have  a  very  great  influence  upon  the  quantity  and  quality  of  the  milk.  Often 
have  I  been  astonished,  after  choosing  nurses  with  abundance  of  milk,  to  find  the 
secretion  cease  a  few  days  after  having  given  up  their  own  child  for  a  strange 
nursling  j  and  several,  whom  I  had  discharged  simply  because  they  had  no  more 
milk,  returned  a  few  days  after  in  excellent  condition.  Sorrow,  at  being  removed 
from  their  country  and  separated  from  all  that  are  dear  to  them,  especially  the 
relinquishing  of  their  children,  may  often  account  for  this  momentary  suppres- 
sion. A  violent  emotion  is  often  found  to  occasion  an  engorgement  of  the  breasts, 
or  else  their  sudden  subsiding.  Children  are  often  rendered  sleepless,  and 
affected  with  colic  and  diarrhoea,  sometimes  even  with  convulsions,  in  conse- 
quence of  violent  anger  of  the  mother.  A  nurse  in  the  Hospital  Cochin,  was 
very  irascible,  and  indulged  in  high  discussions  with  her  neighbor.  On  one 
occasion  she  was  more  angry  than  usual,  and  her  child  had  violent  convulsions 
on  the  morrow.  She  left  the  hospital,  but  returned  again  some  months  afler. 
Similar  scenes  were  again  enacted,  and  followed  by  the  same  effects  as  regarded 
the  nursling.    This  woman  had  already  lost  her  two  first  children  by  convulsions. 

C.  Influence  of  the  genital  functions. — 1.  Menstruation.  Most  women  cease 
to  be  regular  whilst  they  are  nursing.  Others  have  their  courses  to  appear  after 
four,  five,  or  six  months,  and  some  again,  menstruate  as  regularly  and  freely  as 
usual.  Various  opinions  are  held  respecting  the  influence  of  menstruation  upon 
the  lacteal  secretion,  and  the  diversity  is  certainly  due  to  the  fact  that  this  in- 
fluence varies  greatly  .in  different  individuals.  There  can  be  no  doubt,  that 
whilst  it  is  slight  in  some  cases,  it  is  very  decided  in  others.  In  endeavoring  to 
judge  of  it,  much  greater  regard  must  be  had  to  the  state  of  health  of  the  child 
than  to  the  microscopic  or  chemical  examination  of  the  milk.  Some  authors 
have  manifestly  been  led  into  error  by  asserting  that  the  appearance  of  the 
courses  was  a  matter  of  indifference,  for  there  are  certain  alterations  of  the  milk 
which  escape  the  closest  examination,  but  which  are  nevertheless  indicated  by 
the  effect  which  they  produce  upon  the  health  of  the  child. 

The  milk  of  animals  is  very  different  in  the  rutting  season,  from  what  it  is  at 
other  periods ;  and  this  fact  should  have  led  to  an  anticipation  of  what  takes 
place  in  women,  whose  menstrual  epochs  have  the  strongest  analogy  with  the 
period  of  heat.  The  following  points  are  proved  by  experience  in  relation  to 
nurses  who  have  their  courses :  some,  in  consequence  of  the  uterine  discharge 
in  connection  with  that  from  the  breasts,  fall  into  a  state  of  debility  and  maras- 
mus; some  have  their  milk  to  diminish  in  quantity,  and  to  become  more  serous; 
the  child  too  emaciates,  although  their  general  health  does  not  appear  to  be 
sensibly  affected.  Under  either  of  these  circumstances,  the  rarest  of  all,  it  is 
true,  the  mother  ought  to  relinquish  nursing.  The  milk  of  some  women  does 
not  appear  to  be  altered,  nor  the  nutrition  of  the  child  to  suffer,  except  during 
the  flow  of  the  menses ;  in  which  case,  the  mother's  deficiency  may  be  tempo- 
rarily supplied  by  the  use  of  cow's  milk  diluted.  Finally,  in  many  cases,  the 
children's  health  is  in  nowise  disordered,  either  during  or  after  the  menstrual 
period. 

There  are  certain  substances  whose  excess  in  the  blood  is  necessary  to  the 


928  HYGIENE    OF    CHILDREN. 

nutrition  of  the  child,  phosphate  of  lime,  for  example,  which  are  in  great  part 
eliminated  by  the  menses ;  nor  were  it,  perhaps,  unreasonable  to  trace  some  rela- 
tion of  causality  between  the  rachitis  of  children,  and  the  regular  occurrence  of 
the  menses  during  the  greater  part  of  lactation. 

A  fact  mentioned  by  Godey,  would  seem  to  prove,  that,  contrary  to  what  is 
generally  observed,  the  mammary  secretion  may  be  excited  by  menstruation.  A 
woman,  thirty-two  years  of  age,  entered  the  Lourcine  Hospital  to  be  treated  for 
uterine  hemorrhage.  At  twenty-five  years  of  age  she  was  suckling  her  own 
child,  but  took  another  one  to  nurse  at  the  same  time.  Her  business  soon 
obliged  her  to  give  up  this  double  nursing,  and  the  secretion  of  milk  ceased  with- 
out any  functional  disturbance;  a  month  after,  her  courses  reappeared,  and  with 
them,  a  slight  swelling  of  the  breasts,  which  discharged  a  small  quantity  of  milk. 
At  each  succeeding  period,  the  lacteal  secretion  appeared  in  greater  abundance, 
and  after  some  months  became  so  great,  that  the  painful  distension  of  the  mam- 
ma; obliged  her  to  have  them  drawn  by  another  woman,  as  also  to  use  pumps  to 
assist  in  their  discngorgement.  Each  menstrual  return,  since  then,  has  always 
been  accompanied  by  a  secretion  of  milk,  though  in  much  smaller  quantity, 
which  coincided  remarkably  with  the  uterine  hemorrhages  for  which  she  had 
been  treated  eighteen  months  previously,  and  for  which,  she  of  late  entered  the 
Lourcine. 

2.  The  supervention  o^ pregnancy  during  lactation,  is  almost  always  an  unfor- 
tunate circumstance.  It  is  very  rare  for  the  quantity  of  milk  not  to  be  conside- 
rably diminished,  or,  at  least,  to  lose  a  great  part  of  its  nutritive  qualities.  The 
child  almost  always  wastes  away  in  consequence,  nor,  for  my  own  part,  have  I 
ever  known  a  single  woman  whose  child  did  not  suffer  from  it.  I  have  several 
times  been  consulted  by  young  mothers,  whose  children,  put  out  to  nurse  at 
several  leagues  distance  from  Paris,  were  sensibly  emaciated,  and  I  have  always 
been  able  to  determine,  or  at  least  elicit  an  acknowledgment,  that  the  subsidence 
of  the  breasts  was  occasioned  by  pregnancy.  I,  therefore,  do  not  hesitate  to  re- 
gard pregnancy  as  incompatible  with  proper  nursing.  •  It  is  true  that  cases  are 
recorded  of  women  who  did  not  leave  off  nursing  throughout  the  entire  duration 
of  a  new  pregnancy,  and  who  even,  like  the  one  mentioned  by  Van  Swieten,  gave 
the  breast  to  a  child  of  a  year  old  during  the  early  pains  of  labor;  still,  these 
cases  are  so  exceptional  as  not  to  invalidate  the  general  rule  which  we  have  laid 
down ;  and  besides,  it  is  not  stated  whether  the  women  who  acted  thus  and  had 
fine  children,  suckled  them  exclusively,  without  frequently  administering  in  ad- 
dition cow's  milk  and  often  soups  or  broths. 

3.  Sexual  intercourse,  of  itself,  I  should  regard  as  of  little  danger,  unless  it 
should  be  repeated  too  frequently,  or  with  too  much  ardor ;  in  which  case  it 
might  act  like  any  strong  moral  affection.  It  might  doubtless  result  in  preg- 
nancy, which  should  be  avoided,  and  on  that  account  is  interdicted  to  mercenary 
nurses.  The  case  is  much  more  difficult  for  women  who  nurse  their  own  chil- 
dren. For,  on  the  one  hand,  there  are  certain  constitutions  which  might  suffer 
from  a  complete  abstinence,  and  on  the  other,  there  arc  certain  conjugal  exigen- 
cies which  it  is  impossible  not  to  satisfy.  Only  great  prudence  and  reserve 
should,  therefore,  be  recommended. 


NUESING.  929 

D.  Effect  of  certain  Ah'mentory  or  Medicinal  Substances. — A  multitude  of 
daily  observations  show  that  the  smell,  taste,  and  even  the  color  of  certain  sub- 
stances, may  be  communicated  to  the  milk :  this  is  the  case  with  garlic,  beets, 
turnips,  the  bitter  taste  of  wormwood,  and  the  peculiar  coloring  matter  of  madder 
and  saffron.  This  peculiarity  of  certain  substances  by  which  they  communicate 
a  portion  of  their  properties  to  the  milk  has  long  been  taken  advantage  of  in 
therapeutics.  Thus,  Haller  cured  certain  colics  in  children  by  causing  the  nurses 
to  eat  the  fruit  of  the  Anisum  pimpinella.  Certain  purgatives,  as  rhubarb  and 
gratiola,  purge  the  child  when  administered  to  the  mother.  Iodide  of  potassium 
and  the  proto-iodide  of  mercury,  when  taken  by  the  latter,  cure  the  former  simul- 
taneously of  congenital  or  acquired  syphilis. 

A  new-born  child,  says  M.  Godey,  refused  to  take  the  breast  for  three  days, 
and  the  pump  had  to  be  used  three  times  in  order  to  empty  it.  Finally,  it  con- 
cluded to  suck,  and  immediately  afterward  vomited  the  greater  part  of  the  milk 
ingested.  The  same  thing  occurred  for  several  days  in  succession.  During  the 
night,  it  took  the  breast  of  another  nurse  who  had  been  delivered  for  a  month, 
and  no  longer  vomited.  The  mother's  milk  was  abundant,  but  very  serous; 
under  the  microscope  it  presented  numerous  granular  corpuscles  and  very  small 
milk  globules.  Nitric  acid  produced  in  it,  after  a  few  minutes,  a  lilac  rose  color, 
which  was  retained  under  the  microscope  by  the  masses  of  coagulated  caseine. 
This  woman  had  inhaled  ether  during  her  labor,  and  it  is  a- question  whether 
that  penetrating  fluid  may  not  have  affected  the  mammary  secretion,  so  as  to  pro- 
duce the  disgust  and  regurgitation  remarked  in  the  child  ?  It  can  only  be  deter- 
mined by  further  observation. 


CHAPTER  11. 

NURSING    OF    CHILDREN. 

It  must  be  evident  from  what  we  have  stated,  that  everything  is  wonderfully 
prepared  at  the  time  of  delivery  for  enabling  the  mother  to  suckle  her  child ;  but 
inasmuch  as  all  are  not  equally  fitted  for  fulfilling  the  latter  duty,  several  kinds 
of  nursing  have  been  distinguished,  each  based  upon  the  source  of  the  milk 
designed  for  the  new-born  child,  as  also  upon  the  mode  of  its  administration. 
Generally,  the  mother  supplies  her  infant  with  its  first  nourishment,  and  her  lac- 
teal secretion  is  entirely  sufiicient  to  satisfy  all  its  demands.  The  mother  may 
possibly  be  unable  in  some  cases  to  furnish  of  herself  all  the  milk  that  her  off- 
spring requires,  and  be  obliged  to  supply  her  insufficiency  by  food  from  other 
sources.  Sometimes  she  is  altogether  incapable  of  suckling  her  child,  which  is 
then  confided  to  another  nurse.  Finally,  there  are  cases  in  which,  notwithstand- 
ing the  impossibility  of  nursing  on  the  part  of  the  mother,  she  is  unable  to  pro- 
cure either  a  wet-nurse  or  an  animal,  and  is  compelled  to  have  recourse  to  artifi- 
cial nourishment. 

59 


930  HYGIENE    OF    CHILDREN. 

The  order  whicli  we  shall  follow  in  describing  the  various  modes  of  nursing  is 
based  upon  the  varieties  just  indicated,  and  we  shall  treat  successively :  1,  of 
nursing  by  the  mother ;  2,  of  mixed  nursing ;  3,  of  wet-nursing ;  4,  of  suckling 
by  animals ;  and  5,  of  artificial  nourishment. 

AKTICLE   I. 

NURSING   BY   THE   MOTHER. 

The  mother's  milk,  being  designed  by  nature  for  the  nourishment  of  the 
child,  is  certainly  the  best  adapted  to  its  requirements.  Therefore,  whenever  the 
female  is  in  good  health,  when  her  strength  is  not  prostrated  by  any  serious  dis- 
ease, when  the  antecedents  of  the  family  are  such  as  to  remove  all  doubts  on  the 
score  of  hereditary  influence,  there  is  every  reason  why  she  should  yield  to  the 
promptings  of  nature.  There  is  no  necessity  for  being  so  strict  towards  the 
mother,  as  regards  vigor  of  constitution,  quality  of  the  milk,  and  development  of 
the  breasts,  as  it  is  proper  to  be  in  choosing  a  nurse.  Were  we,  in  fact,  to  regard 
those  women  only  as  capable  of  nursing,  who  have  the  robustness  and  strength 
which  we  require  in  mercenary  nurses,  we  should  be  almost  obliged  to  relinquish 
the  idea  of  seeing  the  majority  of  females  in  the  upper  classes  suckle  their  own 
children.  We  often  find  persons  of  this  description,  who  have  but  little  milk, 
and  that  of  medium  quality,  who  yet  raise  very  fine  children;  and  what  is  sin- 
gular, if  these  very  same  women  should  nurse  another  child,  it  is  found  to  become 
emaciated  for  want  of  sufficient  nourishment. 

Without  admitting  that  suckling  protects  newly-delivered  women  from  many 
diseases  to  which  they  are  liable  when  they  do  not  nurse,  and  whilst  acknowledg- 
ing that  it  exposes  them  in  an  especial  manner  to  fissures  of  the  nipple,  and  to 
engorgement  and  abscess  of  the  breast,  I  regard  it  as  so  important  to  the  child 
that  I  make  it  a  point  to  recommend  it  in  the  absence  of  any  formal  contraindi- 
cation, such  as  a  very  lymphatic  constitution,  the  presence  of  skin  disease,  or  of 
predisposition,  hereditary  or  otherwise,  to  phthisis  pulmonalis. 

When  a  pregnant  woman  proposes  suckling  her  child,  the  physician  is  often 
consulted  in  regard  to  her  fitness  for  the  task,  and  the  future  qualities  of  her 
milk.  This  question  is  usually  very  difficult  to  answer.  Still,  by  taking  in  con- 
sideration the  state  of  the  constitution,  the  changes  which  the  breasts  undergo, 
and  the  quantity  and  quality  of  the  sero-lactescent  fluid  which  they  furnish  (see 
Lactation),  we  may  be  able,  in  the  majority  of  cases,  to  form  a  tolerably  correct 
opinion. 

Sometimes  the  anticipations  of  the  physician  seem  to  be  at  fixult  during  the 
first  weeks  subsequent  to  delivery.  There  are  some  individuals,  who  having 
commenced  nursing  in  opposition  to  the  advice  of  their  accoucheur,  and  finding 
their  milk  abundant  at  the  outset,  think  themselves  excellent  nurses  and  make 
light  of  our  fears;  but,  as  M.  Donne  observes,  this  abundance  at  the  first  is  not 
always  a  surety  for  the  future  :  the  least  promising  women  often  have  consider- 
able milk  at  the  commencement,  and  the  first  milk  is  always  rich  enough  for  a 


NURSING.  931 

new-born  child.  Everything  seems  to  go  on  well,  and  it  is  not  until  after  the 
lapse  of  six  weeks  or  two  months,  that  the  diminution  of  the  milk,  the  emaciation 
of  the  child,  or  the  disordered  health  of  the  mother,  begin  to  be  perceived. 

§  1.  Precautions  to  be  observed  in  relation  to  avomen  who  propose 

NURSING. 

Most  of  the  preliminary  precautions,  have  reference  to  the  conformation  of  the 
nipple.  The  varieties  which  it  presents,  may  call  for  the  employment  of  some 
preparatory  measures,  and  even,  in  some  cases,  constitute  a  formal  contraindica- 
tion to  the  nursing.  Thus,  certain  women  have  a  very  short  nipple,  so  that  it 
barely  reaches  the  level  of  the  breast,  whilst  in  others,  its  place  is  occupied  by  a 
depression  rather  than  a  projection ;  lastly,  in  some,  the  nipple  is  extremely 
sensitive  even  before  pregnancy,  and  during  the  cold  season,  becomes  chapped 
and  fissured.  When  the  nipple  does  not  project  at  all,  and  especially  when  its 
place  is  occupied  by  a  depression,  suckling  would  prove  so  difiicult  for  the  child 
and  so  painful  to  the  mother,  that  I  advise  its  relinquishment  altogether. 
Although  the  means  employed  hitherto  for  drawing  out,  and,  as  it  were,  mould- 
ing the  nipple,  are  sometimes  effectual  when  it  is  only  too  short,  they  rarely 
succeed  in  making  it  project  when  it  does  not  exist  at  all,  and  often  give  rise  to 
serious  accidents.     Thus  it  has  been  recommended : 

1.  To  titillate  the  nipple  frequently  during  the  last  two  months  of  gestation; 
but  this  is  irritating,  often  becomes  painful,  and  has  finally  to  be  given  up. 

2.  To  use  nipple  shields.  These  are  little  concave  plates  of  turned  wood, 
having  a  small  excavation  in  the  centre  for  the  reception  of  the  nipple.  The 
patient  applies  this  plate  when  she  is  dressed,  and  draws  the  gusset  of  her  corset 
so  as  to  press  strongly  upon  it.  The  compression  being  applied  on  all  parts  ex- 
cept the  nipple,  causes  it  to  project  strongly,  so  that  after  wearing  it  for  two  or 
three  months,  the  nipple  is  lengthened  to  the  extent  of  three-eighths  of  an  inch. 
When  the  mere  application  of  the  shield  is  not  found  to  answer,  a  pump  is 
adapted  to  its  extremity,  each  stroke  of  the  piston  of  which  draws  upon  the 
nipple  and  occasions  it  to  project.  But  as  the  skin  of  the  nipple  is  subjected  to 
incessant  rubbing  against  the  sides  of  the  shield,  it  is  liable  to  become  inflamed  in 
conse(|uence.  The  same  remark  applies  to  the  species  of  vials,  furnished  with  a 
narrow  opening,  which  is  applied  upon  the  nipple,  and  provided  with  a  long 
curved  tube,  which  enables  the  woman  to  produce  tractions  by  exhausting  the  air 
with  her  mouth. 

3.  Direct  and  repeated  suction,  is,  doubtless,  the  best  means  that  can  be  em- 
ployed. This  may  be  performed  by  the  husband  or  an  intelligent  servant  maid. 
In  the  want  of  a  sufiiciently  accommodating  individual,  a  large  puppy  may  be 
used,  first  taking  care  to  wrap  up  its  paws.  The  reason  why  suction  is  the  best 
means  that  can  be  used  is,  that  the  gutter  formed  by  the  tongue  keeps  the  nipple 
extended,  and  prevents  the  oscillating  movements  communicated  by  the  pump. 
Besides,  when  the  nipple  is  moistened  by  the  saliva,  it  becomes  more  supple  and 
extensible.  After  this  suction,  says  Gardien,  the  nipple  is  to  be  washed  with 
warm  wine,  in  order  to  give  firmness  to  the  cuticle.    The  washing  completed,  they 


932  HYGIENE    OF    CHILDREN. 

should  be  covered  with  tubes  of  white  wax  or  gum  elastic,  to  keep  them  elongated 
and  protect  them  from  rubbing.  To  make  the  nipple  covers  of  Avax,  a  piece  of 
this  substance  is  put  for  some  time  in  warm  water,  in  order  to  soften  it,  and  its 
centre  is  next  depressed  with  the  finger  or  a  thimble  to  a  sufiicient  extent  to 
receive  the  nipple. 

The  extreme  sensibility  of  this  part  in  some  women  who  have  never  had  chil- 
dren, also  calls  for  the  use  of  some  means  of  hardening,  of  tanning  a  little,  the 
skin  which  covers  it.  This  is  easily  eifected  by  the  use  of  lotions,  consisting  of 
alcohol  and  water  or  astringent  solutions,  continued  for  several  months. 

These  precautions,  judiciously  employed,  often  render  nursing  possible  and 
even  easy,  which  without  them  would  have  been  impossible,  or  at  least  very 
painful  at  the  outset. 

§  2.  Rules  of  Nursing. 

Everything  being  properly  prepared,  the  mother  is  about  to  suckle  her  child. 
Now,  in  order  to  present  in  a  regular  manner  the  practical  precepts  which  should 
govern  the  nursing,  it  will  be  useful  to  divide  the  time  of  its  continuance  into 
several  principal  periods,  which  being  characterized  by  peculiar  phenomena  on 
the  part  of  both  mother  and  child,  give  rise  to  special  indications.  We  shall 
divide  the  nursing  into  three  periods  :  the  first  ending  with  the  milk-fever,  the 
second  extending  beyond  the  term  of  six  months,  and  the  third  until  weaning. 

First  iieriod. — The  first  period  is  of  very  short  duration,  constituting,  so  to 
speak,  the  transition  stage  between  the  intra-uterine  nutrition,  whereby  the  child 
derived  the  nutritive  elements  ready  elaborated  from  the  maternal  economy,  and 
the  suckling,  properly  so  called,  by  which  it  still  receives,  indeed,  a  special  nutri- 
ment from  the  mother,  but  one  which  has  to  undergo  elaboration  in  its  own  in- 
testinal canal  before  being  assimilated.  The  phenomena  which  mark  this  period 
are,  in  fact,  preparatory  on  both  sides ;  on  the  part  of  the  mother,  whose  milk 
gradually  loses  the  characters  of  colostrum,  to  assume  those  of  a  more  nutritive 
fluid ;  and  on  the  part  of  the  child,  who  gradually  becomes  accustomed  to,  and 
skilled  in  the  performance  of  the  new  function,  and  who  also  finds  in  the  fluid 
provided  by  the  mother,  purgative  qualities,  which  clear  out  the  intestinal  canal, 
and  thus  prepare  it  for  the  digestion  of  more  substantial  food. 

As  we  have  already  stated,  the  colostrum  secreted  by  the  mammre  at  the  time 
of  delivery  or  shortly  after,  is  sufficient  in  quantity  to  satisfy  the  requirements  of 
the  child.  It  may,  therefore,  strictly  speaking,  be  put  at  once  to  the  breast,  and 
the  doing  so  would  in  many  cases  be  attended  with  no  inconvenience  whatever. 
The  efforts  which  it  makes  to  suck,  are  generally  sufficient  to  excite  or  increase 
the  secretion  of  milk  in  primipara;.  Still,  as  the  mother's  strength  is  often  ex- 
hausted by  the  pains  of  labor,  and  she  needs  a  season  of  rest  and  quiet  after 
several  sleepless  nights,  it  would  be  cruel  to  oblige  her  to  nurse  her  child  imme- 
diately, there  being  really  no  occasion  therefor.  On  this  account,  it  is  customary 
to  defer  it  for  seven  or  eight  hours,  after  which  time  she  is  presented  with  her 
child.  Ikit  as  the  latter  would  be  inconvenienced  by  remaining  so  long  without 
food,  it  is  well  to  give  it  a  few  dessert-spoonfuls  of  warm  sugar  and  water,  about 


.i 


NURSING.  933 

an  hour  after  its  birth.  This  should  be  repeated  every  two  hours  at  the  soonest, 
or  every  three  hours  at  the  latest,  until  it  is  convenient  to  the  mother  to  put  it 
to  the  breast.  This  mode  of  procedure,  has  the  advantage  of  clearing  the  mouth 
and  fauces  of  the  mucus  which  so  often  obstructs  them.  Should  the  mother 
from  any  cause  be  unable  to  give  it  suck  for  several  days,  a  substitute  should  be 
prepared,  by  adding  about  one  quarter  the  amount  of  cow's  milk  to  the  sugar 
and  water. 

Some  persons  have  imagined  that  the  putting  of  the  child  to  the  breast  might 
be  deferred  with  advantage  for  twenty-four,  thirty-six,  or  even  forty-eight  hours; 
and  some  authors  would  even  have  us  wait  until  the  milk-fever  is  over.  This 
plan  is  liable  to  several  serious  objections.  Thus,  the  child  is  deprived  during 
all  this  time  of  a  fluid  whose  nutritive  qualities  are  perfectly  suited  to  the  condi- 
tion of  the  intestinal  canal,  and  whose  laxative  properties  enable  us  to  dispense 
with  the  purgatives  so  often  required  to  expel  the  meconium  in  children  which 
are  brought  up  artificially.  On  the  other  hand,  the  sucking  of  the  child  facili- 
tates the  flow  of  the  milk,  prevents  the  inordinate  swelling  of  the  breasts  and  the 
pain  which  so  often  results  therefrom;  it  gives  form  to  the  nipple,  which  is  seized 
with  much  greater  difficulty  when  the  breasts  are  swollen  and  tense,  and  obviates 
the  milk  fever  almost  entirely.  Therefore,  in  the  interest  of  both  mother  and 
child,  we  think  it  right  not  to  nurse  immediately  after  delivery,  but  also  not  to 
postpone  it  longer  than  from  six  to  twelve  hours. 

Before  putting  the  child  to  the  breast  for  the  first  time,  it  is  important  to  wash 
the  nipple  with  warm  water,  in  order  to  rciuuve  the  concretions  of  sebaceous 
matter  which  may  have  collected  in  the  bottom  of  the  grooves  in  which  the  lacti- 
ferous ducts  discharge.  The  washing  has  the  additional  efiiect  to  moisten  it, 
make  it  more  supple,  and  render  it  less  unpleasant  to  the  child. 

It  is  necessary  at  the  outset  to  put  the  nipple  in  the  child's  mouth ;  for,  as  it 
is  guided  only  by  a  blind  instinct,  it  seeks  anything  presented  to  it,  and  might 
seek  for  a  long  time  without  success.  Most  children  perform  very  well  at  the 
first  attempts ;  but  this  is  not  always  the  case,  for,  independently  of  the  difficul- 
ties due  to  the  shape  and  size  of  the  breast  and  nipple,  which  difficulties  we  shall 
speak  of  hereafter,  there  are  others  depending  upon  the  manner  in  which  the 
breast  is  presented  to  it :  thus,  the  face  of  the  child  being  applied  against  the 
breast,  if  care  be  not  taken,  its  nose  will  be  stopped  at  the  same  time  that  its 
mouth  is  filled  by  the  nipple,  and,  being  unable  to  breathe,  it  withdraws  from  the 
breast.  Therefore,  it  should  always  be  seen  to  that  the  nostrils  are  kept  free. 
At  other  times,  the  nipple,  instead  of  being  grasped  by  the  upper  surface  of  the 
tongue,  into  the  concavity  of  which  it  should  be  received,  is  placed  beneath  the 
point  of  that  organ  upon  the  floor  of  the  buccal  cavity,  whence  suction  is  impos- 
sible. Levret  mentions  a  remarkable  disposition  of  the  tongue,  which  is  curved 
into  a  gutter,  and  adheres  to  the  palate :  in  this  case,  it  should  be  detached  with 
a  spatula.  The  motions  of  the  tongue  are  sometimes  hindered  by  shortness  of 
the  fragnum,  which  also  prevents  it  from  being  projected  forwards.  In  this  case, 
the  frasnum  should  be  cut.' 

'  The  fraenum  linguae  is  sometimes,  but  more  rarely  than  those  accoucheurs  seem  to  think 


934  HYGIENE     OF    CHILDREN. 

As  other  circumstances  which  may  render  nursing  difficult  or  impossible, 
should  be  noted  certain  sublingual  tumors,  hare-lip  with  division  of  the  hard  and 
soft  palate,  and  the  facial  hemiplegia  which  so  often  follows  the  use  of  the 
forceps.  As  the  latter  accident  is  generally  evanescent,  the  artificial  nursing 
need  be  but  temporary.  The  sublingual  tumors  should  be  incised  or  extirpated 
as  soon  as  j^ossible.  The  division  of  the  hard  and  soft  palate  renders  suckling 
almost  always  impossible. 

Some  children,  either  from  congenital  debility,  or  from  sloth,  or  want  of  ac- 
tivity, seem  as  though  they  would  not  take  the  trouble  to  suck.  After  putting 
the  nipple  far  back  in  the  mouth,  the  mother  should  be  directed  to  move  it  about, 
in  order  to  tickle  the  tongue  and  solicit  its  action.  With  the  same  object,  the 
nipple  might  be  pressed  a  little,  so  as  to  project  a  few  drops,  or  what  is  better, 
since  this  is  difficult  in  primipara3,  a  piece  of  linen  dipped  in  sweetened  water 
should  be  squeezed  upon  the  base  of  the  nipple,  which  would  conduct  the  fluid 
between  the  lips  applied  to  its  extremity. 

Notwithstanding  all  these  efforts,  certain  children  seem  unwilling  to  make  any 
attempt  to  suck,  neither  do  they  indicate  any  want  by  their  cries,  but  sleep 
almost  constantly.  The  mothers  are  gratified  by  this  repose  of  the  child,  which 
affords  them  opportunity  of  enjoying  the  quiet  which  they  so  much  need,  and 
are  careful  not  to  disturb  it  by  putting  it  to  the  breast.  But  when  it  awakens 
after  a  longer  or  shorter  time,  or  when,  becoming  anxious  on  account  of  its  pro- 
longed sleep,  the  parent  takes  it  up,  it  is  found  to  have  lost  all  its  energy,  cries 
very  feebly,  and  is  unable  to  suck.     No  time  should  then  be  lost  in  endeavoring 

who  cut  it  in  most  new-born  children,  too  long  from  before  backward,  at  the  same  time  that 
it  is  too  short  from  below  upward.  The  point,  being  then  arrested  against  the  lower  pari- 
etes  of  the  mouth,  remains  behind  the  alveolar  ridge,  and  can  hardly  be  put  forth  between 
the  lips.  When  the  child  cries  strongly,  the  tongue  is  seen  to  be  held  downward  and 
forward  by  a  transparent  partition,  which  prevents  it  from  being  raised  and  carried  for- 
ward. 

The  operation  to  be  performed  is  of  the  simplest  character.  The  head  of  the  child  being 
held  slightly  backward,  an  assistant  pinches  the  nose  to  oblige  it  to  open  its  mouth.  The 
frcenum  is  engaged  in  the  slit  of  the  plate  attached  to  the  grooved  director,  and  then  raising 
the  tongue  forcibly,  the  surgeon,  holding  a  pair  of  blunt  scissors  in  his  right  hand,  divides 
the  frcenum  at  a  single  stroke,  taking  care  to  direct  the  point  of  the  scissors  downward  and 
the  farthest  possible  from  the  tongue. 

The  accidents  to  which  the  operation  is  liable  are:  1,  the  falling  backward  of  the  tongue 
into  the  pharynx,  witnessed  three  times  by  J.  L.  Petit,  and  which  would  have  suffocated  the 
child  had  not  the  organ  been  promptly  restored  to  its  position  by  the  finger;  2,  hemorrhage 
from  wounding  the  ranine  veins.  It  is  the  more  important  to  detect  and  suppress  this 
hemorrhage,  as  it  would  be  kept  up  by  the  constant  movements  of  suction  or  deglutition.  It 
is  remedied  either  by  touching  the  bottom  of  the  wound  with  a  fluid  caustic  or  by  caute- 
rizing the  injured  vessel  by  means  of  a  stylet  heated  to  whiteness ;  or,  lastly,  by  Petit's 
bandage.  This  consists  of  a  fork  of  wood,  an  inch  and  a  quarter  in  length,  covered  with 
linen,  one  end  of  which  rests  against  the  symphysis  of  the  lower  jaw,  whilst  the  other  em- 
braces the  apex  of  the  wound.  It  is  held  in  place  by  a  small  bandage  placed  across  the 
mouth,  assisted  by  another  turn,  then  crossed  below  the  jaw,  and  carried  up  above  the  ears, 
to  be  fastened  to  the  child's  cap. 


NURSING.  935 

to  stimulate  it  in  every  manner  possible.  It  should  be  undressed,  placed  before 
a  warm  fire,  and  rubbed  actively  with  flannels  either  dry  or  moistened  with  cam- 
phorated spirits.  It  should  be  obliged  to  take  the  nipple  if  possible,  and  not 
succeeding  in  this,  it  should  be  put  to  a  nurse,  whose  milk  flows  freely,  and  who 
can  gradually  express  a  few  spoonfuls  into  its  mouth.  These  poor  children  can 
generally  be  restored  in  this  manner ;  but  we  are  often  obliged  to  let  them  re- 
main for  a  few  days  with  a  wet-nurse,  whose  milk  flows  so  freely  as  scarcely  to 
require  any  efi'ort  at  suction,  before  returning  them  to  their  mothers. 

The  condition  just  mentioned  is  far  from  being  uncommon ;  and,  for  my  own 
part,  I  have  several  times  had  charge  of  children  who,  in  this  way,  have  inspired 
me  with  the  greatest  anxiety.  Therefore,  we  should  always  advise  the  mother 
never  to  allow  more  than  two  or  three  hours  to  pass  without  giving  drink  or  suck 
to  her  child,  and,  at  any  rate,  always  to  waken  it. 

The  first  attempt  at  sucking  soon  fatigues  it,  which  is  explained  both  by  its 
weakness,  and  the  eftbrt  which  it  is  obliged  to  make.  Thus,  during  the  first  two 
days,  it  can  hardly  perform  more  than  four,  six,  or  eight  regular  and  continuous 
suctions,  before  it  is  obliged  to  stop  and  begin  again  after  a  few  moments.  The 
interval  between  each  attempt  is  generally  longer  as  the  child  becomes  weaker, 
either  on  account  of  its  increased  debility,  or  because  it  has  nursed  so  recently. 
Sometimes,  it  even  falls  asleep  upon  the  bosom  after  some  efi"orts,  and  has  to  be 
awakened  by  striking  it  lightly  upon  the  cheeks,  buttocks,  or  feet.  The  acts  of 
sucking  are  occasionally  so  distant,  that  the  child  may  remain  in  this  way  at  the 
breast  for  half  an  hour,  or  even  longer. 

Now,  this  slow  nursing  may  become  very  painful  to  the  mother.  In  France, 
women  generally  sit  up  in  bed  for  the  purpose,  and  when  obliged  to  remain  long 
in  that  position  they  find  it  very  fatiguing.  It  is  precisely  to  avoid  this  that  I 
would  desire  to  popularize  the  practice  that  I  have  seen  adopted  with  the  greatest 
success  by  American  women,  namely,  to  lie  on  the  side  corresponding  to  the  one 
on  which  they  intend  to  nurse,  and  placing  the  child  lengthwise  with  the  breast, 
allow  the  nipple  to  fall  into  its  mouth.  They  may  retain  this  position  for  a  long 
time  without  experiencing  any  fatigue. 

During  the  first  days,  it  is  very  important  to  watch  the  child  very  closely  whilst 
at  the  breast,  so  as  to  be  sure  that  it  really  sucks  and  swallows  the  milk.  Either 
because  the  milk  comes  with  too  great  difiiculty,  or  because  the  child  will  not,  or 
cannot  make  the  necessary  eflbrt,  it  is  seen,  indeed,  to  make  certain  motions  of 
the  cheeks  resembling  suction,  and  yet  does  not  swallow.  If  a  finger  be  placed 
upon  the  larynx,  we  shall  be  able  to  tell  by  its  movements  during  deglutition 
whether  the  latter  is  accomplished.  Besides,  a  sort  of  rustling  sound  is  often 
heard  produced  by  the  passage  of  fluid  from  the  mouth  into  the  oesophagus. 

When  the  child  has  been  put  to  the  breast  from  the  first  day,  the  milk-fever 
will  rarely  be  considerable.  The  fretiuent  emptying  of  the  breasts  by  the  child, 
also  prevents  them  from  becoming  distended  and  painful.  Some  women,  how- 
ever, have  so  much  milk  at  this  time,  that  the  mammae  are  exceedingly  swollen 
and  the  nursing  becomes,  temporarily,  more  annoying  to  the  mother  and  difficult 
for  the  child.     It  is  more  troublesome  to  the  mother,  because  the  sucking  gives 


936  HYGIENE     OF    CHILDREN. 

pain,  and  the  swelling  of  the  gland  extending  even  to  the  axilla,  causes  suffering 
•when  the  arm  is  brought  down  to  the  chest,  which  has  to  be  done  in  order  to 
hold  the  child  properly ;  it  is  more  difficult  for  the  child,  because  this  extreme 
distension  renders  it  less  able  to  seize  the  nipple.  The  swelling  of  the  mammae 
effaces  or  depresses  the  latter,  until  it  can  no  longer  be  grasped  by  the  lips  of  the 
child.  When  this  occurs,  it  is  often  necessary  to  empty  the  breasts  by  means  of 
a  pump.  The  withdrawal  of  a  certain  amount  of  milk  relieves  the  pain  caused 
by  the  swelling,  and  restores  the  nipple  to  its  usual  length. 

As  the  child  obtains  but  very  little  milk  at  a  time  for  the  first  few  days,  it 
should  be  put  to  the  breast  at  very  short  intervals.  Still,  it  is  well  to  accustom 
it  to  a  certain  regularity  in  the  time  of  taking  its  repasts.  Children  always  suffer 
from  irregularity  in  their  meals,  sometimes  leaving  too  long  an  interval  between 
theui,  and  sometimes  introducing  a  fresh  portion  of  milk  into  the  stomach,  before 
giving  them  time  to  digest  what  they  had  recently  taken.  Without  pretending 
to  mathematical  precision,  we  would  state  that  the  new-born  child  ought  to  nurse 
at  intervals  of  about  two  hours  at  the  shortest,  and  of  three  hours  at  the  longest. 
When  it  is  feeble,  or  born  prematurely,  and  therefore  able  to  take  but  very  small 
quantities  at  a  time,  the  intervals  might  be  shortened.  We  must,  I  think,  allow 
it  to  judge  for  itself  of  the  amount  that  it  shall  take  at  each  time,  except  under 
peculiar  circumstances.  What  would  be  plenty  for  one,  would  be  insufficient 
for  another,  besides,  as  children  are  capable  of  rejecting  the  surplus  from  their 
stomachs,  there  is  no  great  harm  in  allowing  them  to  take  rather  more  than  they 
really  need. 

Second  period. — AVhen  the  milk-fever  is  over,  the  breasts  are  in  full  activity, 
and  from  that  time  commences  the  nursing  properly  so  called.  Although  it  is 
unusual  to  have  to  contend  any  longer  with  the  difficulties  mentioned  as  pertain- 
ing to  the  preceding  period,  there  are  yet  some  precepts  which  may  be  usefully 
applied. 

The  first  care  to  be  taken  before  giving  the  child  suck,  is  to  be  sure  that  it 
really  needs  it,  for  it  ought  never  be  put  to  the  breast  for  the  sole  purpose  of 
stilling  its  cries,  as,  unfortunately,  most  young  mothers  are  nearly  certain  to  do. 
The  fact  is,  the  cry  is  not  always  to  be  taken  as  an  expression  of  suffering  or  of 
real  want.  The  child  cries  as  we  speak;  very  often,  it  is  simply  an  act  whereby 
it  indicates  its  individual  existence,  and  is  so  habitual  during  its  earliest  days, 
that  it  sometimes  seems  to  indulge  in  it  as  a  matter  of  enjoyment.  Some  chil- 
dren cry  without  any  appreciable  reason,  and  yet,  notwithstanding  their  continual 
agitation,  and  often  long  sleeplessness,  do  not  seem  to  be  any  the  worse  for  it. 
Such  children  the  nurses  commonly  call  had,  and  the  epithet  is  tolerably  well 
deserved. 

To  judge  whether  the  cries  of  the  child  are  indicative  of  a  desire  to  nurse,  we 
should  take  into  consideration  the  other  signs  which  accompany  them,  as  also 
the  time  of  its  last  repast.  The  cry  of  hunger  is  generally  attended  with  active 
movements  of  the  upper  extremities.  The  child  turns  its  head  from  right  to  left, 
and  opens  its  mouth  as  though  seeking  for  the  breast ;  it  seizes  eagerly  the  end 


NURSING.  937 

of  the  finger,  or  any  soft  and  round  body  that  may  be  placed  between  its  lips, 
and  sucks  at  it  repeatedly. 

When  the  proper  moment  arrives,  before  presenting  the  breast,  the  nipple 
should  always  be  moistened  either  with  a  little  milk  or  saliva.  Then,  the  mother 
holding  the  child  in  her  arms  and  resting  its  head  upon  one  of  them,  puts  the 
nipple  in  its  mouth,  taking  care  to  press  slightly  upon  the  areola  so  as  to  project 
a  little  milk,  and  intimate,  as  it  were,  to  the  child,  that  it  can  suck  with  advan- 
tage. These  precautions  are  hardly  necessary  except  during  the  earliest  weeks, 
for  after  this,  it  throws  itself  upon  the  breast  and  seizes  it  so  powerfully,  as  to 
make  it  a  painful  operation.  In  some  cases  even,  so  far  from  exciting  it,  it  is 
necessary  to  restrain  its  avidity  by  withdrawing  the  nipple  from  time  to  time,  as 
when  not  having  nursed  for  several  hours,  it  swallows  in  a  rapid  and  gluttonous 
manner. 

The  mother  should  put  it  to  both  breasts  at  the  same  meal ;  they  are  thus  kept 
disengorgcd,  and  by  dividing  the  service,  the  nipples  have  time  to  rest  from  the 
effort  of  suction  which  often  irritates  and  inflames  them.  The  child  is  also  thus 
early  accustomed  to  nursing  from  both  sides.  If,  as  often  happens,  it  appears  to 
prefer  one  side  in  particular,  and  refuses  to  nurse  from  the  other,  that  breast 
should  be  first  presented  which  it  seems  to  prefer  the  least.  Hunger  will  soon 
overcome  its  repugnance,  so  that  after  some  hesitation  it  will  conclude  to  take 
the  breast  which  it  would  have  refused  if  presented  the  last. 

It  is  well  to  watch  the  child  attentively  whilst  nursing,  at  least  during  the  first 
weeks.  It  will  then  be  ascertained  whether  the  sucking  is  apparent  or  real  by 
observing  the  motions  of  the  larynx  during  deglutition,  as  also  by  hearing  the 
sort  of  rustling  of  which  we  have  spoken.  The  amount  of  milk  which  it  takes, 
can  be  judged  of  more  certainly  by  noting  the  length  of  time  which  it  rests 
though  still  retaining  the  nipple  in  its  mouth.  It  often  sleeps  after  nursing;  the 
warmth  which  it  receives  from  the  mother  whilst  lying  in  her  arms,  and  the  sort 
of  enjoyment  which  it  finds  in  keeping  hold  of  the  nipple,  also,  when  it  has 
sucked  quite  recently,  the  repletion  of  its  stomach,  all  tend  to  invite  slumber. 

As  soon  as  the  child  is  discovered  to  be  sleeping,  it  should  be  awakened  at 
once  and  caused  to  suck  again,  if  there  is  reason  for  thinking  that  it  has  not  had 
enough;  but  when  the  contrary  is  the  case,  it  should  be  taken  away  immediately 
and  laid  in  its  cradle.  The  infant  soon  contracts  the  habit  of  fiUling  asleep  and 
sleeping  with  the  nipple  in  the  mouth,  and  ere  long  it  becomes  impossible  to  put 
it  to  rest  otherwise.  It  is  plain  that  the  practice  must  be  fatiguing  to  the  mother, 
especially  at  night. 

It  is  very  difficult  to  determine  the  quantity  of  milk  that  it  should  be  allowed 
to  take  at  each  repast,  and  how  long  it  ought  to  be  permitted  to  suck.  The  latter 
will  evidently  vary  with  the  abundance  of  the  milk,  the  ease  with  which  it  flows, 
and  the  length  of  time  that  the  child  rests.  As  we  have  said,  there  is  no  objec- 
tion to  allowing  it  to  become  satisfied  in  the  absence  of  special  indications  sug- 
gested by  disease. 

The  child  should  be  nursed  less  frequently  as  it  grows  older.  After  the  first 
two  or  three  weeks,  it  will  be  sufiicient  to  give  it  the  breast  every  three  hours, 


938  HYGIENE    OF    CHILDREN. 

and  if  the  milk  is  of  good  quality,  the  intervals  between  the  repasts  may  be  still 
further  lengthened  towards  the  third  or  fourth  month;  this  distribution,  must, 
however,  be  somewhat  modified  in  the  day  or  the  night.  The  intervals  of  nursing 
at  night  must  be  greater  from  the  beginning,  so  that  it  shall  suck  but  three  times 
from  ten  o'clock  in  the  evening  to  five  or  six  o'clock  in  the  morning.  After  a 
month,  even  the  intermediate  repast  may  be  relinquished.  If  the  child  sucks 
but  little  at  a  time  on  account  of  debility,  and  therefore  seems  to  require  the 
breast  oftcner,  a  little  diluted  cow's  milk  may  be  given  once  or  twice  in  its  stead. 

There  can  be  nothing  absolute  as  regards  this  determination  of  the  hours  for 
nursing;  for  although  we  have  recommended  that  the  child's  sleep  be  interrupted 
in  order  to  give  it  food,  this  should  not  be  done  at  a  more  advanced  age.  A 
child  of  from  two  to  three  months  old,  will  always  awaken  spontaneously  when  it 
feels  the  want,  and  the  dangers  that  we  have  spoken  of,  are  no  longer  to  be 
feared.  Therefore  it  may  be  allowed  to  sleep  on.  Still,  these  precepts  should 
be  conformed  to,  for  by  leaving  a  proper  interval  between  the  repasts,  the  child 
receives  sufficient  food,  it  has  time  to  digest  what  it  has  taken,  and  the  acid  re- 
gurgitations, and  the  passage  of  curdled  but  otherwise  unaltered  milk,  the  sure 
indications  of  a  bad  digestion,  are  avoided;  besides  this,  it  has  the  advantage  of 
preventing  the  enormous  embonpoint,  the  puffy  cheeks,  and  dead  hue  of  the  skin, 
which  sometimes  indicate  a  weak  constitution. 

This  plan  is  attended  with  the  happiest  results,  especially  for  women  of  the 
upper  ela.sses,  for  whom  sleep,  and  that  undisturbed,  deep,  and  sufficiently  long, 
is  even  more  necessary  than  food  to  the  reparation  of  their  forces.  Most  of  the 
nervous  women  of  large  cities  should  have  at  least  six  or  seven  hours  of  good 
uninterrupted  sleep,  under  the  penalty  of  being  obliged  to  wean  their  children 
very  early ;  then,  after  having  nursed  the  child  about  five  o'clock  in  the  morn- 
ing, they  may  take  another  nap  of  two  or  three  hours,  if  they  require  it.  It 
would  be  a  great  mistake,  says  M.  Donne,  to  suppose  that  the  children  suffer 
from  this  system.  When  observed  from  the  beginning,  they  sometimes  become 
accustomed  to  it,  without  having  any  trouble  in  sleeping  as  long  as  their  mother, 
and  they  never  suffer  from  the  cow's  milk  that  is  given  to  them.  They  are  thus 
trained  to  take  the  bottle,  so  that  should  anything  afterward  oblige  the  mother 
to  suspend  nursing  temporarily,  there  would  be  much  less  difficulty  in  engaging 
them  to  accept  the  artificial  nourishment,  for  which  children  who  have  never 
known  anything  but  the  breast  sometimes  manifest  an  invincible  repugnance. 

Sleep  is  so  necessary  to  nursing  women,  that  not  only  should  they  never  give 
suck,  but  whenever  possible,  the  child  should  be  kept  from  its  mother  at  night. 
Having  obtained  an  intelligent  and  faithful  nurse,  she  should  be  intrusted  with 
the  care  of  watching  over  the  child,  giving  it  drink  at  night,  and  taking  it  to  the 
mother  only  at  stated  times. 

Third  j)eriod. — As  the  object  of  the  first  period  was  to  prepare  the  child  for 
receiving  a  special  elementary  nourishment,  it  is  proposed  in  the  latter,  gradually 
to  remove  it  from  the  mother,  and  so  accustom  it  to  all  kinds  of  food ;  in  a  word, 
to  render  its  existence  entirely  independent.  Therefore,  the  office  of  the  physi- 
cian is  limited  to  determining  the  period  at  which  other  food  may  be  added  to 


J 


NURSING.  939 

the  motlier's  milk,  as  also  the  time  when  it  may  be  proper  to  wean  the  child 
entirely. 

Practitioners  are  far  from  being  unanimous  in  relation  to  the  period  at  which 
other  food  than  the  mother's  milk  should  be  given  to  the  child.  "  Nurses  from 
the  country/'  says  Desormeaux,  ''are  usually  in  the  habit  of  giving  to  their  chil- 
dren a  sort  of  pap  made  of  fine  wheat  flour  and  cow's  milk,  after  the  first  week 
they  are  impressed  with  the  idea  that  this  food  relieves  the  colic,  to  which  new- 
born children  are  very  subject.  Whether  it  really  has  this  effect,  or  whether  the 
digestion,  by  being  made  still  more  difficult,  throws  the  child  into  a  kind  of  tor- 
pid condition,  it  is  often  observed  to  be  more  quiet  after  taking  it ;  at  the  same 
time  it  produces  a  favorable  change  in  the  color  and  consistence  of  the  excre- 
ments. On  the  other  hand,  when  the  children  are  confined  to  the  mother's  milk, 
provided  it  is  sufficiently  rich  and  abundant,  they  are  not  more  subject  to  flatu- 
lent colic  than  others.  From  all  this  I  am  disposed  to  infer,  that  the  first 
metlfod,  when  prudently  followed,  is  without  inconvenience  in  the  majority  of 
cases,  whilst  in  certain  others,  it  may  be  advantageous.  Nevertheless,  I  am  per- 
suaded that  the  latter  is  the  best  and  surest,  especially  for  weakly  children." 
Desormeaux's  conclusion  seems  to  me  to  lack  precision,  and  I  only  quote  it  here 
for  the  purpose  of  opposing  the  tendency  it  might  have  to  encourage  certain  pre- 
judices which,  unfortunately,  are  but  too  widely  prevalent.  The  paps,  soups, 
&c.,  which  are  given  to  children  in  certain  countries  almost  .as  soon  as  they  are 
born,  are  at  least  useless  and  often  dangerous.  There  are,  doubtless,  strong  and 
robust  children  who  may  swallow  them  without  inconvenience.  But  would  they 
have  thriven  less  had  they  been  confined  to  their  mother's  milk  ?  This  is  what 
I  deny,  and  have  at  the  same  time  no  hesitation  in  asserting,  that  such  a  regimen 
would  prove  dangerous  to  the  greater  number. 

When  the  mother  is  a  good  nurse,  that  is  to  say,  when  the  performance  of  her 
duties  does  not  fatigue  her,  and  the  milk  remains  unchanged  in  quality  and 
amount,  the  child  should  be  restricted  to  it  as  far  as  possible  for  the  first  sis 
months,  with  the  exception  of  the  additions  mentioned  for  the  night.  We  shall 
see  hereafter,  when  treating  of  the  mixed  method,  what  the  reasons  are  which 
may  lead  to  a  modification  of  this  nile,  and  to  which  I  shall  submit  unreservedly 
whenever  a  hired  nurse  is  concerned.  Desormeaux  thinks  that  the  air  of  large 
cities  is  generally  less  pure  and  stimulating  than  that  of  the  country ;  and  there- 
fore, that  the  child  should  be  supplied  sooner  with  a  species  of  nourishment 
capable  of  supplying,  to  some  extent,  the  deficiencies  of  the  air.  He  adds  that 
the  same  is  true  as  regards  children  brought  up  in  low  and  moist  places,  as  also 
for  those  of  a  lymphatic  temperament,  or  whose  parents  are  feeble.  Neither  can 
I  agree  on  this  point  with  the  celebrated  accoucheur.  Doubtless,  when  the  bad 
constitution  of  the  children  is  due  to  the  mother's  weakness  or  the  defective 
quality  of  her  milk,  cow's  milk,  and  not  broths  or  pap,  should  be  substituted  for 
it;  but  I  cannot  think  that  a  residence  in  cities,  or  in  low  and  moist  places,  are 
a  sufficient  reason  for  an  earlier  administration  of  food,  which  is  unnatural  to  the 
child.  Infants  living  under  bad  hygienic  conditions,  suS"er  from  a  susceptibility 
on  the  part  of  the  intestinal  canal,  to  which  the  robust  children  of  the  country, 


940  HYGIENE    OF    CHILDREN. 

•whose  digestive  powers  are  far  more  developed,  are  not  liable.  To  give  a  feeble 
and  delicate  child  food  of  difficult  digestion,  is  to  task  its  alimentary  canal  beyond 
its  powers,  and  could  only  result  in  incomplete  elaboration  and  imperfect  assimi- 
lation ;  fortunate  indeed  would  it  be,  should  it  not  give  rise  to  chronic  enteritis, 
with  its  attendant  diarrhoea  and  emaciation. 

Kinds  of  food. — Farinaceous  substances  ought  to  be  prepared,  such  as  wheat 
and  rice  flour,  potato  starch,  and  arrow-root,  in  connection  with  milk,  so  as  to 
form  a  well-cooked  pap  of  variable  consistency;  wheat  flour  silghtly  dried  in  the 
oven,  taking  care  to  avoid  roasting  or  browning  it,  which  would  injure  a  portion 
of  its  nutritive  elements,  is  generally  chosen.  This  flour,  which  contains  a  large 
proportion  of  gluten,  is  very  nutritious.  The  articles  mentioned  may,  however, 
be  varied  to  suit  the  taste  and  condition  of  the  child.  Thus,  rice  cream  would 
be  preferred  if  the  child  were  somewhat  debilitated,  potato  starch  as  a  refreshing 
diet,  and  arrow-root  as  a  light  food.  Panada  made  of  well-baked  wheaten  bread, 
dried  in  the  oven  and  then  reduced  to  a  coarse  powder,  forms  an  excellent -"diet. 
It  is  boiled  for  several  hours  with  a  sufficient  amount  of  water,  and  afterward 
passed  through  a  silk  or  hair  sieve. 

About  five  or  six  dessert-spoonfuls  of  these  preparations  may  be  given  at  first 
every  morning.  Before  long,  they  may  be  administered  twice  a  day,  besides 
having  added  to  them  shortly,  semoule  or  vermicelli,  well  cooked.  When  the 
child  is  seven  or  eight  months  old,  it  may  take  chicken  broth  or  light  soups.  A 
little  later  it  can  have  the  yelk  of  a  boiled  egg,  carefully  rejecting  the  white,  and 
finally,  it  may  be  allowed  to  suck  a  piece  of  fowl,  or  preferably,  a  bone  of  fowl, 
also  a  crust  of  bread  which  it  can  chew  and  swallow  only  after  having  moistened 
it  sufficiently  with  saliva. 

The  water  reddened  with  claret  and  sweetened  slightly,  which  M.  Donne  re- 
commends giving  after  the  age  of  six  months,  should,  I  think,  be  withheld  rather 
longer,  and  even  then,  ought  to  be  administered  very  carefully. 

As  the  child  becomes  accustomed  to  other  food,  it  seeks  the  breast  with  less 
avidity,  although  still  retaining  a  marked  predilection  for  it.  The  mother  can 
then  suckle  it  less  frequently  without  disadvantage.  Toward  the  seventh  or 
eighth  month,  she  need  nurse  it  but  four  or  five  times  a  day,  and  still  later,  two 
or  three  times,  in  the  meanwhile  ceasing  to  give  it  the  breast  at  night  altogether. 

This  progressive  diminution  habituates  the  child  to  doing  without  the  breast, 
develops  its  taste  for  other  food,  and,  also,  decreases  the  flow  of  milk  ;  so  that 
weaning  becomes  easier  for  the  child  and  less  troublesome  to  the  mother. 

ARTICLE    11. 

WEANING. 

At  what  age  ought  the  child  to  he  weaned?  The  natural  period,  is  that  at 
which  the  first  dentition  is  accomplished ;  for  not  until  then  is  the  child  provided 
with  the  organs  necessary  to  the  mastication  and  insalivation  of  the  food.  But 
it  often  happens  that  the  first  dentition  is  not  completed  for  a  year  or  a  year  and 


NURSING.  941 

a  half,  and  it  is  very  unusual  to  defer  taking  the  child  from  the  hreast  so  long  as 
this.  The  delay  would  be  attended  with  serious  disadvantage  to  both  mother 
and  child 5  the  mother  would  become  exhausted  by  her  long  nursing,  and  her 
milk  finally  lose  its  good  qualities ;  beside  this,  the  children  themselves,  after 
a  certain  age.  seem  to  require  more  substantial  food  ',  some,  in  fact,  retain  a  pallor 
and  puffiness  of  the  features,  as  well  as  general  debility  so  long  as  they  continue 
to  nurse,  and  assume  a  rosy  hue,  a  lively  and  happy  expression,  and  firmness  of 
flesh,  as  soon  as  they  become  accustomed  to  a  more  nutritious  food. 

When  care  has  been  taken  to  habituate  the  child  to  something  else  than  milk 
from  the  time  it  is  six  or  seven  months  old,  but  little  difiiculty  will  be  experienced 
in  weaning  it  completely ;  and  nursing  may  be  given  up  without  disadvantage, 
as  soon  as  dentition  has  made  considerable  progress.  Still,  I  think  it  very  im- 
portant to  take  into  account  the  greater  or  less  rapidity  and  facility  with  which 
the  evolution  of  the  teeth  is  accomplished.  As  a  general  rule,  weaning  is  not  to 
be  tltought  of,  before  the  child  has  from  eight  to  ten  teeth,  which  would  be  about 
the  age  of  twelve  or  sixteen  months.  But  if  the  dentition  is  delayed,  painful, 
or  accompanied  by  some  of  the  afi"ections  to  which  the  child  is  liable  in  its  second 
year,  there  is  an  advantage,  whilst  giving  the  child  other  food,  to  keep  it  at  the 
breast,  allowing  it  to  suck  at  least  two  or  three  times  a  day. 

It  is,  indeed,  an  invaluable  resource  during  the  sufferings  of  painful  dentition. 
The  child  then  refuses  other  kinds  of  food,  and  will  take  nothing  but  the  breast, 
so  that  it  would  be  very  difficult  to  nourish  it  if  weaned  prematurely.  Therefore, 
a  system  which  at  once  provides  it  with  food  and  alleviates  its  sufferings,  must 
be  very  desirable.  In  cases  of  retarded  and  painful  dentition  it  would  be  pru- 
dent to  continue  the  nursing  till  the  child  is  eighteen  or  twenty  months  old. 

To  fix  upon  any  particular  period  for  weaning,  says  M.  Trousseau,  is  simply 
absurd,  and  for  this  reason  :  Weaning  should  always  be  subordinate  to  dentition. 
The  fact  is,  the  period  of  the  first  dentition,  from  the  appearance  of  the  first  in- 
cisors to  that  of  the  last  molars,  is  fraught  with  peril  to  the  child.  It  is  subject 
to  a  multitude  of  disorders  aff"ecting  the  abdomen,  the  chest,  and  the  head,  espe- 
cially the  former.  Now,  as  the  so-called  disorders  of  digestion  are  the  most  fre- 
quently observed,  it  is  important  to  be  provided  with  a  diet  which  the  child  shall 
not  refuse,  and  which  can  neither  aggravate  its  condition,  nor  give  rise  to  any 
other  disease.  But  dentition  lasts  for  three  years  :  must  the  suckling  be  continued 
all  that  time?  No,  not  absolutely;  we  should  be  guided  by  the  following  rules 
they  are  very  easily  remembered. 

The  teeth  are  evolved  in  groups.  How  do  they  appear  ?  There  are  several 
series,  as  follows  :  in  the  first,  appear  the  two  lower  median  incisors ;  in  the 
second,  the  four  upper  incisors ;  in  the  third,  the  four  first  molars  and  usually 
after  them  the  two  lower  lateral  incisors;  in  the  fourth,  the  four  canines;  and 
finally,  in  the  fifth,  the  four  last  molars.  These  are  the  deciduous  teeth. 
Let  us  next  see  how  the  groups  make  their  appearance  : 

1.  The  first  incisors  come  through  at  an  interval  of  from  one  to  fifteen  days, 
though  generally,  on  the  same  day;  and  when  these  two  first  do  not  appear 
within  two  or  three  days  of  each  other,  the  dentition  is  irregular.     When  this 


942  HYGIENE    OF    CHILDREN. 

is  over,  the  child  rests ;  a  fact  of  immense  importance  as  regards  therapeutical 
measures.  It  rests  from  three  to  sis  months.  The  two  first  teeth  usually  appear 
between  the  seventh  and  eighth  month,  and  the  child  has  afterward  at  least  six 
weeks  of  quiet. 

2.  The  four  upper  incisors  are  a  month  in  coming  through.  First  the  middle, 
and  then  the  lateral  ones  appear,  and  that  between  the  tenth  and  twelfth  month. 

3.  From  the  twelfth  to  the  fifteenth  month,  those  of  the  third  series  come 
through  :  then  the  child  rests  for  four  or  five  months,  during  all  which  time  the 
evolution  of  teeth  is  suspended. 

4.  Between  the  eighteenth  and  twenty-second  month,  the  four  canines  make 
their  appearance,  and  are  three  months  in  coming  through,  after  which  there  is 
a  very  long  repose. 

5.  Lastly,  the  child  gets  its  four  last  molars. 

It  is  well  to  know  that  the  teeth  appear  in  groups,  inasmuch  as  the  child  is 
sick  during  the  period  of  a  dental  evolution.  It  coughs  and  has  fever,  bui»after 
the  teeth  are  through,  recovers  with  astonishing  rapidity.  Thus  it  is,  through- 
out the  entire  period  of  dentition.  Now,  what  is  the  right  time  for  weaning? 
Evidently,  it  should  be  in  the  interval  between  one  evolution  and  another,  and 
about  seven  or  eight  days  after  the  teeth  are  through,  and  while  the  organs  are 
in  a  state  of  rest.  We  have  thus  an  advantage  of  several  months,  wherein  the 
child  can  be  accustomed  to  a  new  diet. 

After  which  of  these  evolutions  is  it  best  to  wean  the  child  ?  After  that  of 
the  canines,  as  being  the  most  dangerous  :  the  latter  appear  singly,  and  are  the 
only  ones  which  are  crowded.  The  others  meet  with  no  impediments,  and  none 
but  the  canines  are  embraced  by  the  neighboring  teeth,  which  they  are  obliged 
to  press  asunder.  Therefore  it  is,  that  the  cutting  of  these  teeth  is  accompanied 
with  more  severe  symptoms. 

AVhen  it  is  decided  to  wean  a  child  which  has  been  for  some  time  accustomed 
to  eating,  it  is  generally  better  to  do  it  at  once  than  to  leave  off  nursing  gradu- 
ally ;  for  by  continuing  to  allow  it  to  suck  only  once  or  twice  in  the  twenty-four 
hours  the  milk  becomes  altered,  and  might  prove  injurious.  It  is,  however, 
advisable  to  begin  at  night,  and,  without  considering  it  a  matter  of  great  impor- 
tance, I  would  prefer  the  spring  or  summer  to  winter  for  commencing. 

The  mother  ought,  as  far  as  possible,  to  give  up  her  child  to  another  person, 
who  should  supply  it  with  drink,  and  render  it  all  necessary  attention.  Some 
children,  so  long  as  they  know  that  their  mother  is  near  them,  refuse  to  take  any 
other  food,  and  it  is  hard  for  a  parent  to  resist  the  tears  and  entreaties  of  her 
infant.  Should  it  be  impossible  for  the  mother  to  put  away  her  child,  she  ought 
to  try  to  disgust  it  by  covering  the  nipple  with  some  substance  of  disagreeable 
taste  and  odor,  such,  for  instance,  as  aloes  or  mustard.  I  have  rarely  failed  to 
succeed  with  the  latter,  for  most  children  reject  the  breast  with  disgust  after 
havins:  once  tasted  or  even  smelled  it. 


NURSING.  943 

ARTICLE   III. 

REGIMEN   OP   NURSING   WOMEN. 

We  have  but  few  remarks  to  make  in  relation  to  the  precautions  which  should 
be  observed  by  a  young  woman  who  proposes  nursing  her  child.  A  good  diet  is 
indispensable  for  women  who  have  to  support  the  fatigues  of  nursing.  Rich  and 
succulent  food,  beef  broth,  white  and  dark  meats,  whether  roast  or  boiled,  should, 
doubtless,  form  in  great  measure  the  principal  elements  of  the  meals ;  still,  they 
ought  not  to  be  debarred  from  vegetables,  milk,  chocolate,  and  boiled  prepara- 
tions of  the  various  farinaceous  substances.  They  should  avoid  highly-seasoned 
ragouts,  and  an  excess  of  salt,  pepper,  vinegar,  and  other  strong  and  indi- 
gestible condiments.  The  usual  drink  should  be  claret  and  water,  the  use  of  pure 
wine,  alcoholic  liquors,  and  coffee,  require  great  discretion,  and  it  were  far  better 
to  ^stain  from  them  altogether. 

The  number  of  meals  should  generally  be  governed  by  the  habits  of  the  indi- 
vidual. It  is  well,  however,  that  they  should  not  be  too  far  apart,  nor  so  copious 
as  to  give  rise  to  indigestion. 

We  have  already  insisted  on  the  propriety  of  the  mother's  obtaining  a  suffi- 
cient amount  of  sleep,  and  revert  to  it  only  for  the  purpose  of  fixing  attention 
upon  its  importance;  for  without  it,  most  of  the  females  in  large  cities  would 
find  it  impossible  to  nurse. 

A  nursing  mother  ought  to  breathe  a  pure  air,  avoid  dampness  and  cold,  and 
take  a  sufficient  amount  of  exercise.  The  warm  bathing  which  some  persons 
prescribe,  I  approve  of  when  not  too  long  continued,  and  only  for  the  preserva- 
tion of  cleanliness. 

A  residence  in  the  country  certainly  is  one  of  the  best  hygienic  conditions  both 
for  herself  and  child,  which  often  finds  in  frequent  insolation  and  pure  air  a 
substitute  for  deficiencies  in  the  quality  of  the  milk. 

The  breasts  should  be  carefully  protected  from  the  air,  especially  at  the  out- 
set, and  the  child  should  not  be  suckled  in  a  cold  and  damp  garden.  I  have 
known  several  ladies  to  be  attacked  with  inflammatory  engorgement  of  the  breasts 
from  a  neglect  of  this  precaution. 

The  chest  ought  to  be  kept  constantly  covered  with  a  piece  of  soft  linen  folded 
in  several  thicknesses,  and  changed  as  soon  as  it  becomes  moist.  When  the 
breasts  are  very  large,  they  should  be  supported  by  corsets  with  ample  gussets ; 
for  the  mere  weight  of  the  glands  is  sometimes  sufficient  to  render  them  painful, 
and  give  rise  to  engorgement. 

Some  women  have  so  much  milk,  that  when  the  child  sucks  on  one  side,  it 
escapes  freely  from  the  other.  To  prevent  the  linen  from  becoming  too  much 
moistened  in  this  way,  the  nipple  is  sometimes  introduced  into  the  neck  of  a 
sort  of  very  flat  bottle,  which  receives  the  milk  as  it  escapes. 

Finally,  nursing  women  cannot  be  too  strongly  recommended  to  avoid  sadness 
and  violent  moral  emotions  ;  we  have  already  explained  at  length  the  efiect  which 
they  might  produce.     "It  may  be  said,  in  a  general  way,"  M.  Donne  remarks, 


944  HYGIENE    OF    CHILDREN. 

"  that  calmness  and  equanimity  are  what  young  women  most  frequently  lack." 
So  essential  a  condition  is  this,  that  I  take  into  deep  consideration  the  nervous 
condition  of  the  mother  when  judging  of  the  propriety  of  her  nursing,  and  if  she 
is  too  excitable,  I  prefer  intrusting  the  child  to  a  wet  nurse.  A  mother,  whom 
the  least  cry  of  her  child  fills  with  anxiety,  and  who  cannot  see  it  fretful  or  in 
pain  without  being  overcome,  will  hardly  fail  to  make  a  bad  nurse.  A  child  is 
rarely  brought  up  without  suifering  some  derangement  or  other  of  its  health,  and 
sometimes  even  serious  disease.  It  is  precisely  on  such  occasions  most  important 
to  have  the  milk  perfectly  pure,  which  it  never  can  be  from  the  breast  of  a 
mother  who  will  not,  or  cannot  control  her  emotions. 


ARTICLE   IV. 

OF  THE  CIRCUMSTANCES  WHICH  MAY  RENDER  NURSING  BY  THE  MOfHER 
DIFFICULT,  AND  OF  THE  ACCIDENTS  THAT  ARE  LIABLE  TO  INTERFERE  WITH 
IT. 

§  1.  Impediments  to  Nursing. 

We  have  already  treated  of  such  malformations  of  the  nipple  as  may  sometimes 
be  remedied  by  timely  interference.  There  are  some,  however,  such  as  the  ab- 
sence of  this  part,  and  its  entire  imperforation,  which  render  nursing  impossible; 
but  even  those  of  the  kind  first  mentioned,  such  as  shortness  of  the  nipple,  may 
make  it  equally  impracticable,  when  not  discovered  until  after  the  birth  of  the 
child,  and  when  about  to  put  it  to  the  breast. 

This  shortness  of  the  nipple  may  be  only  relative,  that  is  to  say,  though  long 
enough  for  a  strong  child  accustomed  to  sucking,  it  is  too  short  for  the  new-born 
infant,  who  cannot  take  it,  or  is  unwilling  to  do  so.  In  such  cases,  it  is  well 
before  putting  the  child  to  the  breast  to  render  the  nipple  rather  more  project- 
ing by  titillating  it  with  the  fingers,  drawing  it  out  by  a  pump,  or  having  it 
sucked  by  a  puppy,  an  adult  person,  or,  still  better,  by  a  child  from  six  weeks  to 
two  months  old.  The  latter  is  preferable  when  it  is  reasonable  to  suppose  that 
the  difficulties  resulting  from  the  shortness  of  the  nipple  are  increased  by  the 
weakness  or  the  unwillingness  of  the  child.  A  strong  and  vigorous  infant,  fur- 
nished by  another  nurse,  would  be  able  to  take  the  breast  of  the  recently-deli- 
vered female,  and  give  shape  to  the  nipples,  whilst,  on  the  other  hand,  the  new- 
born child,  deriving  its  nourishment  with  ease  .and  in  abundance  from  the  breasts 
of  the  nurse,  grows  rapidly  stronger,  becomes  accustomed  to  sucking,  and  after 
a  few  days  may  be  returned  to  the  mother,  who  is  then  able  to  present  it  with 
properly-formed  breasts.  Care  should  be  taken  not  to  select  too  old  a  child ;  for, 
knowing  its  nurse,  it  would  be  unwilling  to  take  the  breast  of  another  woman. 

Finally,  as  a  last  resort,  the  artificial  nipples,  in  their  most  modern  and  im- 
proved form,  may  be  tried.  Those  made  by  M.  Charri5rc  of  softened  ivory,  I 
think  preferable  to  any  others. 


NURSING.  945 

§  2.  Erosions,  Excoriations,  Chaps,  Fissures,  and  Cracks  of  the 
Nipple. 

These  various  affections,  implicating  the  nipple  or  its  base,  bear  the  strongest 
resemblance  to  each  other,  and  hardly  differ  except  in  extent,  and  more  espe- 
cially in  their  situation. 

Excoriation,  of  which  erosion  is  but  the  first  degree,  is  a  small,  superficial 
wound  of  the  skin,  in  which  the  derm  is  laid  bare  by  the  removal  of  the  epi- 
dermis. 

When  it  has  become  so  large  and  deep  as  to  destroy  the  surface  of  the  derm, 
it  constitutes  an  ulceration. 

It  has  no  special  seat,  but  may  affect  the  entire  surface,  or  only  one  or  a  few 
points  of  the  nipple.  Its  surface  is  often  of  a  bright  red  color,  granulated,  and 
frequently  swollen ;  sometimes  it  is  always  moist,  at  others  covered  with  thin 
scabs.     Occasionally,  sucking  is  followed  by  a  slight  effusion  of  blood. 

The  chap  results  from  the  drying  up,  and  imperfect  removal  of  the  epidermis, 
the  dried  cells  of  which  resemble  small  scales. 

The  fissure  is  an  elongated  ulceration,  generally  deeper  than  the  simple  exco- 
riation. It  forms  at  the  bottom  of  the  furrows,  and  takes  their  direction; 
usually,  and  then  too  it  is  the  most  painful,  it  occupies  the  groove  separating  the 
base  of  the  nipple  from  the  rest  of  the  skin. 

Cracks  are  an  exaggeration  of  the  fissures,  from  which  they  almost  always 
originate.  They  differ  from  the  latter  by  the  cracked,  swollen,  and  extremely 
sensitive  condition  of  the  surrounding  skin. 

Inflammation  of  the  skin  of  the  nipple  is  the  usual  cause  of  the  erosions,  exco- 
riations, and  ulcerations  which  succeed  them ;  though  in  some  cases,  according 
to  M.  Deluze  (^Inav(/itral  Thesis),  they  are  formed  in  the  following  manner: 
When  the  child  seizes  the  nipple,  it  is  placed  in  a  gutter  between  the  tongue  and 
the  palate,  so  that  all  the  efforts  at  suction  are  brought  to  bear  upon  the  extre- 
mity of  the  nipple  towards  which  the  fluids  tend ;  as  this  part  is  supported  by 
nothing,  it  gives  way,  and  a  small,  bloody  streak  can  be  detected  upon  it  after 
nursing.  In  some  cases,  the  only  effect  of  the  suction  is  to  raise  the  epidermis, 
and  form  a  sort  of  pouch  or  red  spot,  beneath  which  a  slight  ecchymosis  is  dis- 
coverable; finally,  either  in  consequence  of  another  act  of  nursing,  or  sponta- 
neously, the  raised  portion  of  epidermis  dries  and  falls  off,  and  excoriation  fol- 
lows. 

The  extension  of  the  latter  into  the  grooves  of  the  nipple  gives  rise  to  the 
fissures. 

Simple  excoriation  is  far  more  common  than  fissures  produced  at  once  or  by 
rupture.  Thus,  of  17  cases  observed  at  the  Clinique  by  M.  Deluze,  there  were 
but  4  cases  of  a  spontaneous  character. 

I  regard  exposure  of  the  nipple  to  cold,  when  yet  warm  and  moist  after  suck- 
ing, as  the  most  frequent  cause  of  chapping.  Fissures  and  cracks  may,  no  doubt, 
also  take  their  origin  in  inflammation  or  the  impression  of  coldj  inasmuch  as  they 
so  often  follow  ulcerations  and  chaps ;  but  besides  this,  they  may  often  be  pro- 

60 


94»3  HYGIENE    OF    CHILDREN. 

duced  mechanically,  by  the  violent  tractions  upon  the  nipple  during  the  act  of 
sucking. 

They  occasionally  appear  after  the  child  has  taken  the  breast  two  or  three 
times.  The  sucking  first  produces  acute  pain,  followed  by  violent  smarting.  A 
superficial  examination  of  the  breast  discovers  nothing,  but  if  the  nipple  be 
drawn  upon  gently,  so  as  to  widen  the  furrows  which  traverse  it,  a  slight  redness 
with  serous  efi"usion  will  be  found  at  the  bottom  of  one  or  several  of  them.  The 
fissure  is  not  yet  formed,  but  soon  makes  its  appearance  after  a  few  more  nurs- 
ings ;  as  each  application  of  the  child  to  the  breast  tends  to  increase  it,  a  true 
crack  is  shortly  formed,  which  becomes  covered  with  a  scab  or  crust,  beneath 
which  it  is  common  to  find  a  small  amount  of  extravasated  blood. 

However  produced,  these  accidents  generally  occur  in  the  early  days  of  lacta- 
tion. The  normal  sensitiveness  of  the  nipple  is  not  as  yet  blunted,  nor  has  the 
skin  covering  it  had  time  to  become  accustomed  to  the  pressure  and  tractions 
which  it  is  destined  to  undergo.  However,  although  these  ulcers  or  crackscarely 
occur  after  the  tenth  day,  I  have  known  them  to  be  formed  at  a  much  later 
period,  in  which  case  they  seemed  to  me  to  have  been  occasioned  by  the  biting 
of  the  child,  and  sometimes  by  an  aphthous  inflammation  afi'ecting  the  latter. 

These  slight  accidents  are  generally  suffered  by  women  who  nurse  for  the  first 
time :  such  as  have  a  fine  and  irritable  skin,  whose  breasts  were  very  sensitive 
even  before  pregnancy,  those  whose  nipples  are  badly  formed,  or  who  wait  for 
several  days  for  the  milk  to  come  before  putting  the  child  to  the  breast,  thus 
obliging  it  to  grasp  the  nipple  more  strongly  with  its  lips,  and  to  make  greater 
effort  to  extract  the  milk,  are  peculiarly  exposed  to  them. 

Slight  excoriations  and  ulcerations  are  generally  supported  without  much 
trouble ;  which  is  for  from  being  the  case  with  the  fissures  and  cracks,  which  are 
commonly  exceedingly  painful.  Those  situated  at  the  base  of  the  nipple,  I  have 
thought,  occasion  the  most  suffering.  When  we  remember  the  painful  sensations 
resulting  from  the  cracks  that  are  liable  to  form  on  the  median  line  of  the  lower 
lip  in  winter,  we  may  easily  imagine  the  effect  of  those  on  the  nipple.  The  evi- 
dent tendency  of  each  act  of  suction  is  to  separate  the  margins  of  the  little  ulcer. 
Notwithstanding  her  desire  to  nurse  the  child,  the  mother  dreads  the  approach 
of  the  stated  times,  and  instinctively  recoils  when  the  babe  is  brought  for  the 
purpose.  At  the  moment  of  seizing  the  nipple,  she  is  often  compelled  to  cry 
out,  and  continues  to  groan  for  several  minutes.  Generally,  the  sensation  is  less 
acute  after  the  first  few  moments,  but  is  renewed  with  dreadful  intensity  when- 
ever the  child  recommences  sucking  after  having  stopped,  and  especially  when  it 
seizes  the  nipple  again  greedily,  after  having  relinquished  it  altogether.  The 
suffering  is  sometimes  so  intolerable,  that  these  unfortunates  are  observed  to  bite 
their  clothes  or  coverings,  to  avoid  crying  out,  whilst  others  writhe  or  are  even 
affected  with  conv-ulsive  movements. 

If  the  crack  is  deep  and  the  suction  strong,  some  blood  flows  from  the  edge  of 
the  wound.  This  becomes  mixed  with  the  milk  and  is  swallowed.  Should  the 
child  vomit,  it  is  found  in  what  is  thrown  up,  but  if  not,  it  is  expelled  in  the 
stools,  and  leaves  its  mark  on  the  din  per.     The  physician  should  remember  this 


NURSING.  947 

fact,  for  he  is  often  consulted  by  parents  who  inquire  in  great  alarm  the  meaning 
of  these  bloody  passages.  The  explanation  is  almost  always  to  be  found  in 
fissures  of  the  nipple,  of  which  the  woman  had  not,  perhaps,  complained  hitherto; 
but  should  he  neglect  making  the  examination,  he  might  suspect  hemorrhage  of 
the  bowels,  and  thus  help  to  continue  fears  which  are  really  without  foundation. 

The  irritation  affecting  the  fissures  is  very  often  propagated  to  the  skin  of  the 
nipple,  thence  to  the  areola  or  the  cellular  tissue  which  lines  it,  and  next,  more 
deeply  to  the  gland  itself  or  to  the  interlobular  tissue,  thus  giving  rise  to  ab- 
scesses of  the  areola,  or  to  those  of  a  phlegmonous  or  glandular  character.  On 
the  other  hand,  the  suffering  is  sometimes  so  severe  that  the  mother  avoids 
nursing  from  the  affected  breast  as  much  as  possible,  thus  helping  to  produce  its 
engorgement  and  the  abscess  to  which  it  gives  rise.  We  would  add,  finally,  that 
in  consequence  of  the  long  detention  of  the  milk  in  the  ducts,  it  becomes  dete- 
riorated, and  assumes  the  characters  of  colostrum. 

The  sufferings  occasioned  by  these  ulcerations  of  the  nipple,  and  the  serious 
accidents  which  often  result  from  them,  show,  evidently,  that  they  ought  to  be 
prevented,  and  when  they  exist,  to  be  cured  as  soon  as  possible. 

The  difficulties  in  nursing  due  to  the  shortness  and  malformation  of  the  nipple 
being  generally  the  cause,  the  best  prophylactic  means  are  those  already  men- 
tioned. (See  page  944.)  The  delicacy  of  the  skin,  and  extreme  sensitiveness  of 
the  nipple,  will  be  advantageously  treated  by  astringent  lotions,  frequently  ap- 
plied during  the  latter  months  of  gestation.  Without  having  any  great  confi- 
dence in  the  value  of  ointments  for  producing  this  result,  M.  Dubois  made  some 
experiments  for  the  purpose  of  testing  them.  He  caused  frictious  with  the  fol- 
lowing compositions,  to  be  made  for  a  month  before  delivery,  viz.,  tannin,  one 
drachm ;  lard,  one  ounce ;  or  with  a  mixture  of  equal  parts  of  cocoa  butter,  oil 
of  sweet  almonds,  and  tannin.  For  my  own  part,  I  prefer  the  astringent  lotions; 
they  have  not,  like  most  fats,  the  inconvenience  of  soiling  the  linen,  becoming 
rancid,  and  sometimes  of  irritating  very  delicate  skins. 

Like  M.  Trousseau,  I  am  convinced  that  when  the  woman  begins  nursing,  the 
best  prophylactic  measure  is  simply  to  wash  the  nipple  with  a  fine  sponge  as  soon 
as  the  child  quits  the  breast.  Its  saliva  is  acid,  and  should  a  little  ca.seine 
remain  behind,  nothing  more  is  required  to  produce  excoriation.  It  is  well  to 
make  these  lotions  with  a  slightly  astringent  solution.  They  should,  however, 
be  done  quickly,  so  as  to  expose  the  breast  to  the  air  for  the  shortest  time  pos- 
sible, and  the  nipple  ought  to  be  covered  at  once  with  a  little  hood  of  lead  with 
a  hole  through  its  extremity,  in  order  to  protect  it  from  the  contact  of  cold  air 
and  the  friction  of  the  clothing. 

The  use  of  prophylactic  measures  cannot  be  insisted  on  too  strongly,  for,  un- 
fortunately, the  curative  means  hitherto  employed  leave  much  to  be  desired. 
They  are,  however,  numerous,  and  I  know  of  no  disease  against  which  so  many 
ointments,  solutions,  &c.,  have  been  recommended ;  but  here,  as  is  always  the 
case  in  therapeutics,  abundance  means  dearth ;  there  is  much  less  seeking  when 
an  infallible  remedy  is  at  hand. 

In  order  to  account  for  the  popularity  which  some  of  these  preparations  have 


948  HYGIENE    OF    CHILDREN. 

enjoyed,  it  is  only  necessary  to  be  aware  that  happily,  in  a  great  number  of  in- 
stances, these  fissures  or  excoriations  get  well  of  themselves.  The  poor  mother 
gradually  becomes  accustomed  to  the  pain  ;  she  continues  to  nurse,  and  when  the 
cracks  are  not  very  deep,  and  especially  when  not  situated  at  the  base  of  the 
nipple,  they  undergo  spontaneous  cicatrization. 

The  cessation  of  nursing  is  the  best  remedy  of  all ;  but  it  must  be  confessed 
that  this  is  too  discouraging  to  certain  mothers  who  attach  great  importance  to 
suckling  the  child.  We  shall  therefore  mention  some  of  the  chief  topical  appli- 
cations which  have  been  used  with  a  certain  amount  of  success. 

M.  Trousseau  recommends,  that  when  excoriations  or  fissures  appear  around 
the  nipple,  that  lotions  with  warm  water  should  first  be  practised,  and  followed 
by  a  weak  solution  of  nitrate  of  silver.  If  these  are  not  sufiicient,  a  solution  of 
sulphate  of  copper  or  of  zinc  may  be  employed ;  and,  finally,  when  the  afi'ection 
persists,  he  would  have  recourse  to  the  white  precipitate  ointment,  viz. : 

White  precipitate,'         ......         4  grains. 

Lard,    .  .         .         .         .         .         .         .         .         2  to  4  drachms. 

I  have  used  this  ointment  with  some  success  at  the  Clinique.  It  is  necessary 
to  clean  the  breast  well  before  putting  the  child  to  it,  and  to  renew  the  ointment 
immediately  afterward.  Although  I  have  observed  nothing  which  could  be  attri- 
buted to  absorption  of  the  ointment,  there  is  reason  to  fear  lest  the  health  of  the 
child  might  sufi"er  if  the  breast  is  not  carefully  wiped. 

M.  Dubois  appears  to  have  tried  without  advantage,  the  oil  of  cocoa,  nitrate  of 
silver,  collodion,  and  creasote.  The  first  acts  like  any  other  fatty  matter,  by  pro- 
tecting the  wound  from  contact  with  the  air.  Collodion,  which  promised  much 
in  the  way  of  shielding  the  diseased  surface  from  the  action  of  the  infant's 
mouth,  and  of  preventing  the  dragging  of  the  lips  of  the  wound,  whilst  per- 
mitting the  nursing  to  continue,  has  failed.  The  saliva  gradually  detaches  the 
solidified  lamina  of  this  substance,  and  not  unfrequently  it  is  loosened  by  the 
cutaneous  perspiration.  The  application  of  creasote  is  very  painful  to  the  mother, 
and  its  smell  is  so  repulsive  that  the  child  refuses  to  take  the  breast. 

Cauterization  with  the  nitrate  of  silver,  sometimes  succeeds  when  the  pencil 
is  finely-pointed  and  carried  to  the  deepest  part  of  the  ulcer;  but  almost  always 
upon  condition  that  the  nursing  shall  be  suspended  immediately  afterward. 
This,  however,  is  not  practicable  when  both  breasts  are  affected;  it  exposes 
greatly  to  engorgement  when  it  can  be  done ;  and  facts  which  have  come  under 
my  observation,  incline  me  strongly  to  believe  that  the  cauterization  itself  may 
give  rise  to  phlegmonous  inflammation  of  the  breast.  Finally,  I  would  add,  that 
if  nursing  is  resumed  too  soon  after  the  ulcer  is  cicatrized,  it  would  open  again 
upon  the  first  suctions.  It  is,  therefore,  upon  the  whole,  useless  when  the  nurs- 
ing is  continued,  and  uncertain,  and  often  dangerous,  when  the  latter  is  inter- 
rupted. 

'  The  white  precipitate  (precipite  blanc)  here  alluded  to,  is  the  same  as  the  precipitated 
calomel  of  the  Dublin  Pharmacopcria:  not  the  white  precipitate  (hydrargyrum  ammoniatum) 
of  the  Unitctl  States  Pharniacopujia. — Tkaxslator. 


NURSING.  949 

Mr.  Startin,  a  London  physician,  has  recently  extolled  the  use  of  glycerine, 
or  the  sweet  principle  of  oils.  It  is  a  substance  produced  abundantly  during  the 
saponification  of  fats,  and  especially  in  the  manufacture  of  stearine  candles. 
Glycerine  does  not  evaporate  at  ordinary  temperatures ;  on  the  contrary,  it  absorbs 
moisture  from  the  air ;  it  is  soluble  to  any  extent  in  water,  so  that  it  may  be 
easily  removed  from  the  part  to  which  it  is  applied. 

The  following  are  Mr.  Startin's  formuliB  against  excoriations  and  fissures  : 

R. — Gum  Tragacanth  (pure), 2  to  4  drachms. 

Lime  Water, 4  ounces. 

Dibtilled  Rose  Water, 3      " 

Purified  Glycerine,  ......  1       " 

!M.  A  soft  jelly,  to  be  used  as  an  ointment  or  embrocation. 

Against  fissures  of  the  nipple  : 

R. — Biborate  of  Soda, half  a  drachm  to  a  drachm. 

Purified  Glycerine, half  an  ounce. 

Distilled  Rose  Water,       .         .         .         .  Tg  ounces. 
M.S.  For  lotions  to  the  affected  parts. 

All  these  measures  may  be  greatly  assisted  by  the  use  of  artificial  nipples, 
which  should  be  had  recourse  to  whenever  the  child  will  submit  to  them.  To 
overcome  the  repugnance  which  some  evince  for  their  employment,  it  is  well  to 
fill  it  with  warm  milk  before  applying  it,  so  th;,t  the  milk  will  flow  readily  into 
the  mouth  with  the  first  suctions.  The  child  soon  becomes  accustomed  to  it,  for 
whilst  emptying  the  artificial  nipple  it  forms  a  vacuum,  and  draws  out  the 
mother's  milk  gently.  If  the  child  can  be  prevailed  on  to  accept  it,  the  artifi- 
cial nipple  will  almost  always  be  sufficient  of  itself  when  the  fissures  and  cavities 
are  situated  upon  the  free  portion  of  the  nipple,  especially  when  the  former  are 
parallel  with  its  length.  Unfortunately,  the  case  is  very  difierent  when  the  fis- 
sures have  a  transverse  direction,  and  especially  when  situated  at  the  base.  The 
artificial  nipple,  it  is  true,  protects  the  natural  one  against  the  direct  contact  with 
the  lips  and  tongue  of  the  child,  but  is  incapable,  in  the  latter  case,  of  prevent- 
ing the  separation  of  the  edges  of  the  wound. 

If,  notwithstanding  all  these  precautions,  nursing  is  so  painful  that  the  mother 
defers  suckling  too  long,  and  there  is  danger  of  engorgement,  pumps  for  extract- 
ing the  milk  artificially  will  have  to  be  made  use  of.  I  should  give  preference 
to  the  one  invented  by  M.  Tier,  and  called  teterelle,  for  its  action  is  but  slightly 
painful  to  the  mother,  and  the  lower  chamber  receives  the  milk,  which  may  sub- 
sequently be  given  to  the  child.  A  new  instrument,  for  the  same  purpose,  was 
presented  to  the  Academy  of  Sciences  by  Dr.  Lamperiere,  of  Versailles,  but  not 
having  seen  it  operate,  I  am  unqualified  to  judge  of  the  many  advantages  claimed 
for  it  by  the  inventor. 

Beside  these  altogether  local  lesions,  there  are  some  other  accidents  which  may 
require  nursing  to  be  given  up,  either  because  they  injure  the  milk  or  deteriorate 
the  general  health  of  the  mother. 


950  hygiene  of  children. 

§  3.  Circumstances  which  may  Interfere  with  Nursing. 

Whenever  the  mother  sufifers  an  attack  of  acute  disease  shortly  after  delivery, 
the  secretion  of  milk  is  generally  so  far  suspended,  as  no  longer  to  be  sufficient 
for  the  wants  of  the  child.  The  same  is  the  case  with  some  others,  who,  although 
apparently  in  good  health,  have  no  milk  before  the  fifth  or  sixth  day,  without 
our  being  able  to  account  for  the  delay. 

Lastly,  the  strength  of  some  women  is  so  exhausted  by  a  tedious  labor,  that 
it  is  indispensable  to  allow  them  two  or  three  days  of  perfect  rest.  Under  all  these 
circumstances,  the  place  of  the  colostrum  must  be  supplied  by  a  little  sugar  and 
water  mixed  with  one-fourth  the  quantity  of  milk ;  and  should  the  mother's  re- 
covery be  postponed  longer  than  three  or  four  days,  the  child  ought  to  be  given 
temporarily  to  a  wet  nurse,  which  were  far  preferable  to  artificial  feeding. 

Even  when  lactation  has  commenced  regularly  and  properly,  accidents  are  still 
liable  to  happen,  all  tending  to  lessen  the  quantity  and  injure  the  quality  of  the 
milk. 

A.  Alterations  in  quantify. — The  quantity  of  milk  may  be  altered  in  two 
ways  :  there  may  be  too  little  of  it  or  none  at  all,  or  there  may  be  far  more  of  it 
than  the  child  requires.  The  former  condition  has  received  the  name  of  agalac- 
tia, and  the  latter,  that  oi  galactorrhea. 

Agalactia. — Nature  seems  to  have  left  her  work  unfinished  in  some  women, 
who  although  capable  of  becoming  mothers,  are  often  unable  to  nurse  their  child 
on  account  of  their  having  little  or  no  milk.  The  agalactia  may  be  either  com- 
plete or  partial  :  complete,  when  the  secretion  is  absolutely  wanting,  and  partial, 
when  merely  insufficient  for  the  nourishment  of  the  child.  In  both  cases,  it  may 
be  either  original  or  accidental ;  original,  when  the  breasts  are  the  seat  of  no 
fluxion  whatever  after  delivery,  or  when  what  secretion  may  take  place,  is  in- 
sufficient for  the  requirements  of  the  child ;  secondary,  when  the  milk,  though 
abundant  at  the  outset,  lessens  considerably  in  amount  or  even  ceases  to  be 
secreted  altogether. 

It  is  very  difficult  to  determine  the  causes  of  primitive  agalactia.  Imperfect 
development  of  the  mammary  gland,  its  atrophy,  and  the  various  diseases  to 
which  it  is  liable,  may  certainly  occasion  it  in  some  instances.  There  are  others, 
however,  in  which,  unless  we  attribute  it  like  M.  Trousseau  to  deficient  vital 
energy,  due  probably  to  imperfect  development  of  the  vessels  supplying  the  gland, 
it  is  almost  impossible  to  explain  it.  We  have  already  studied  the  causes  which 
may  give  rise  to  accidental  agalactia,  in  the  chapter  on  Lactation, 

It  is  generally  quite  easy  to  ascertain  the  existence  of  complete  agalactia ;  but 
when  the  nurse  has  any  interest  to  practise  deception,  it  is  necessary  to  be  very 
careful,  if  we  would  detect  it  when  only  partial.  The  first  and  best  sign,  is  the 
emaciation  of  the  child,  or,  at  least,  its  arrested  development.  On  examination, 
the  mother's  breasts  are  found  to  be  soft  and  flaccid,  even  when  the  child  has 
not  sucked  for  a  long  while.  The  latter  is  always  hungry,  and  even  putting  it 
to  the  breast  does  not  quiet  its  cries ;  it  abandons  the  nipple  at  every  instant, 
and  sometimes  even  discards  it  angrily,  as  though  enraged  at  finding  nothing  in 
it;  finally,  if  after  allowing  it  to  suck  for  a  long  while,  it  is  presented  with  a 
bottle  of  milk  and  sweetened  water,  it  takes  it  with  avidity. 


NURSING.  951 

When  the  absence  of  milk  is  due  to  an  organic  cause,  all  hope  of  re-establish- 
ing the ,  secretion  will  have  to  be  given  up  and  the  mixed  method  resorted  to, 
or  else  the  child  committed  to  a  wet  nurse  altogether.  But  when  it  is  accidental, 
and  especially  when  it  is  the  consequence  of  a  violent  moral  emotion,  of  a  slight 
indisposition,  or  an  evanescent  febrile  movement,  it  will  be  necessary  to  rest 
satisfied  with  artificial  nursing  for  a  few  da^-s  ;  and  after  the  cause  is  removed, 
the  gland  may  be  excited  by  frequently  putting  the  child  to  the  breast. 

I  have  very  little  confidence  in  the  medicines  or  articles  of  food,  which  have 
long  enjoyed  a  reputation  for  increasing  the  flow  of  milk.  Still,  we  have  the 
authority  of  Desormeaus  in  fovor  of  anise,  fennel,  and  lentils,  which  he  asserts 
having  known  to  increase  the  lacteal  secretion  in  some  of  his  patients. 

Galaciorrhoea,  or  the  too  abundant  secretion  of  milk,  presents  two  varieties 
which  it  is  very  important  to  distinguish.  In  the  one,  the  milk  retains  all  its 
properties ;  it  is  a  mere  hypersecretion,  which  ordinarily  diminishes  of  itself  after 
a  time,  and  is  only  inconvenient  to  the  mother  and  the  child.  The  stream  is  so 
large  and  rapid,  as  to  give  the  latter  no  time  to  swallow,  so  that  it  is  every 
moment  threatened  with  suffocation ;  often,  also,  the  milk  escapes  from  both 
sides  whilst  the  child  is  nursing  and  wets  the  mother.  Sometimes,  again,  the 
breasts  are  so  swollen  as  to  be  painful,  and  the  mother  is  then  obliged  to  use  the 
breast  pump  herself,  or  have  it  applied  by  another  person. 

In  the  other  variety,  the  milk  is  clear,  serous,  and  manifestly  altered  3  it  also 
flows  passively  and  almost  continually  from  the  nipple.  The  latter  variety  is  the 
only  serious  one.  The  poverty  of  the  milk  soon  injures  the  child  ;  but  the  mother 
especially,  suffers  from  this  sort  of  mammary  diabetes.  Should  it  continue, 
general  debility,  loss  of  appetite,  notwithstanding  the  almost  constant  feeling  of 
need  of  food,  a  sensation  of  heat  in  the  stomach  and  fauces,  and  pains  and  drag- 
ging sensations  in  the  back  and  chest,  soon  make  their  appearance.  Rather 
later,  symptoms  of  the  nurse's  phthisis,  as  Morton  called  it,  show  themselves,  and 
these  unfortunates,  feeble  and  emaciated,  are  quickly  brought  by  hectic  fever  to 
an  early  death. 

Weaning  is  the  only  means  of  preventing  this  fatal  termination.  The  milk 
ceases  to  be  secreted  immediately  afterward,  and  it  then  remains  to  restore  the 
exhausted  strength  of  the  mother  by  the  administration  of  iron,  proper  nourish- 
ment, and  a  residence  in  the  country. 

General  deterioration  of  the  mother's  health. — The  strength  of  some  women 
who  were  well  at  the  commencement  of  lactation,  fails  rapidly  after  a  few  months. 
They  become  more  and  more  emaciated,  lose  their  appetite,  and  may  suffer  all 
the  consequences  of  galactorrhcea.  In  some  cases,  this  altered  state  of  health 
seems  to  affect  injuriously  both  the  quantity  and  quality  of  the  milk ;  yet  I  have 
seen  others,  in  which  the  increasing  debility  of  the  mother  inspired  serious  ap- 
prehensions, although  the  child  continued  to  thrive,  as  though  she  supplied  it 
with  good  nourishment  at  the  expense  of  her  own  exhaustion  ;  and  this  fact  they 
give  as  a  reason  for  objecting  to  weaning.  I  am  a  very  good  nurse,  say  they,  for 
my  child  thrives  well.  Whatever  may  be  the  condition  of  the  child's  health 
when  that  of  the  mother  is  endangered  by  the  continuance  of  nursing,  it  should 
be  weaned  at  once,  under  the  penalty  of  falling  into  consumption. 


952  HYGIENE     OF    CHILDREN. 

B.  Altered  quality  of  the  milk. — M.  Donne  was  the  first  to  call  particular 
attention  to  the  changes  which  the  nutritive  elements  of  the  milk  are  liable  to 
undergo,  and  to  the  unfavorable  effect  which  its  poverty  or  richness,  or  its  altera- 
tion by  deleterious  principles,  might  have  upon  the  health  of  the  child.  I  am 
indebted  to  him  for  the  following  details. 

Unfavorable  effect  of  a  poor  milk. — A  milk  poor  in  globules  or  cream,  is 
■watery,  and  not  containing  a  proper  amount  of  nutritive  elements,  affords  insuffi- 
cient nourishment  for  the  development  of  the  child  :  it  is  one  of  the  commonest 
causes  of  poor  success  in  nursing,  and  escapes  observation  the  more  easily,  as  it 
often  coincides  with  a  notable  amount  of  the  fluid,  and,  apparently,  with  the 
right  kind  of  physical  properties.  This  coincidence  is  far  more  unfortunate  than 
when  the  poverty  of  the  milk  is  accompanied  by  diminution  in  quantity;  for,  in 
the  latter  case,  not  only  is  the  child  imperfectly  nourished,  but  a  milk  which  is 
at  once  abundant  and  of  inferior  quality,  fatigues  the  organs  by  keeping  them 
engorged  with  a  large  amount  of  fluid. 

The  effect  of  extreme  richness  of  the  milk  is  far  more  surprising ;  for,  at  first, 
it  would  seem  as  though  this  quality  could  hardly  be  otherwise  than  advanta- 
geous. Such,  however,  is  far  from  being  the  case,  for  certain  very  delicate  chil- 
dren are  often  inconvenienced  by  too  substantial  a  food.  Frequent  vomiting, 
diarrhoea,  and  the  affection  called  crusta  lactea  (impetigo  capitis)  often  result 
from  it. 

Nothing  short  of  microscopic  examination,  or  the  use  of  the  lactoscope,  can 
inform  us  in  respect  to  the  richness  or  poverty  of  the  milk,  and  acquaint  us  with 
the  true  cause  of  numerous  disorders  or  morbid  conditions  of  the  new-born  child, 
which  otherwise  would  remain  inexplicable.  The  number,  size,  and  regularity 
of  the  globules,  will  establish  the  diagnosis  in  both  cases. 

Poverty  of  the  milk,  unless  it  is  mei*ely  temporary,  requires  absolutely  either 
the  addition  of  a  certain  amount  of  cow's  milk,  or  a  change  of  nurse. 

Its  extreme  richness  may  be  remedied  either  by  making  the  nurse's  diet  less 
substantial,  or  by  occasionally  giving  the  child  a  little  sweetened  water  after  each 
repast.  M.  Donne  has  profited  by  the  experiments  of  M.  Peligot,  so  far  as  to 
deduce  from  them  some  modifications  of  the  plan  of  nursing,  which  it  seems  to 
me  are  likely  to  prove  very  useful. 

It  results  from  M.  Peligot's  analyses,  that  the  milk  becomes  clearer  and  more 
watery  the  longer  it  remains  in  the  breasts.  He  has  shown  that  if  the  product 
of  any  one  milking  be  divided  into  three  parts,  that  is  to  say,  all  the  milk  that 
is  given  at  once  by  a  cow  or  she-ass,  the  first  milk,  which  is  certainly  the  longest 
secreted,  is  the  most  watery  and  the  poorest,  what  comes  next  is  richer,  and  the 
last  is  the  best  of  all.  The  same  has  been  proved  to  be  the  case  with  women 
whose  milk  is  far  more  watery  before  than  after  suckling.  From  these  facts, 
which  are  now  well  established,  result  the  most  important  practical  consequences. 
When,  in  fact,  a  child  appears  to  be  suffering  from  the  richness  of  its  mother's 
milk,  all  that  is  requisite  is,  simply,  to  leave  a  longer  interval  between  its  repasts, 
and  not  allow  it  to  suck  too  long,  that  it  may  obtain  each  time  a  lighter  milk, 
abounding  less  in  nutritive  matters ;  for,  on  the  one  hand,  the  milk  is  weakened 


NURSING.  953 

by  allowing  it  to  remain  longer  in  the  breasts,  and  on  tbe  other,  the  child  has 
time  to  digest  better  what  it  has  already  taken. 

Alteration  of  the  milk  hy  the  elements  of  Colostrum. — The  elements  of  the 
colostrum,  which  generally  disappear  a  few  days  after  the  milk-fever,  persist  in 
some  women  indefinitely,  and  are  discoverable  in  many  others  after  a  month,  six 
weeks,  and  even  several  months,  so  that  the  milk  never  attains  a  state  of  entire 
purity.  This  alteration,  which  can  be  discovered  only  by  the  use  of  the  micro- 
scope, is  often  a  morbid  condition,  or,  at  least,  results  from  a  deranged  state  of 
secretion.  It  is,  in  fact,  produced  under  the  influence  of  general  or  local  dis- 
eases affecting  the  nurse.  Thus,  whether  they  are  taken  with  fever,  or  suffer 
from  engorgement  of  the  mammary  gland,  the  characteristic  granular  corpuscles 
appear  almost  immediately. 

The  effect  of  this  alteration  on  the  child  is  easily  determined,  as  it  produces 
all  the  effects  of  imperfect  nutrition.  "  Never,"  says  M.  Donne,  "  have  I  met 
with  it,  without  at  the  same  time  finding  the  children  puny,  sickly,  and  more  or 
less  affected  with  diarrhoea."  A  change  of  nurse  is  then  absolutely  indicated, 
unless,  indeed,  the  alteration  is  due  to  an  evanescent  affection. 

Admixture  of  Pus  with  the  Milk. — Engorgements  of  the  breast,  whether 
spontaneous,  or  consequent  upon  fissures  and  excoriations  of  the  nipple,  are  ex- 
ceedingly common  with  nursing  women,  and  have  a  great  tendency  to  end  in 
suppuration.  These  abscesses,  the  history  of  which  belongs  to  the  pathology  of 
the  female,  will  claim  our  attention  only  in  respect  to  the  alterations  of  the  milk 
which  they  are  liable  to  produce.  In  reference  to  this,  it  is  very  important  to 
distinguish  from  all  others  the  parenchymatous  abscesses  seated  in  the  tissue  of 
the  gland  itself,  and  those  which,  commencing  by  a  true  lacteal  engorgement, 
begin  in  a  milk  duct,  whose  walls,  inflamed  and  distended  into  a  sort  of  cyst, 
secrete  pus.  In  these  only  can  the  pus  become  diffused  in  the  milk.  The 
superficial,  or  submammary  abscesses,  which  do  not  open  into  the  proper  milk 
ducts,  do  not  affect  this  fluid  by  admixture  of  pus,  and  alter  its  composition  only 
by  the  reaction  which  a  morbid  condition  of  the  kind  exerts  upon  a  neighboring 
organ. 

When  the  glandular  abscess  is  apparent,  the  presence  of  pus  in  the  milk 
should  be  suspected,  and  nursing  relinquished;  but,  as  M.  Donne  remarks,  it 
often  happens  that  suppuration  has  taken  place  in  some  deep-seated  parts  of  the 
gland,  without  being  indicated  by  any  external  sign.  The  slowness  with  which 
the  suppuration  is  accomplished,  suflSciently  explains  this  insidious  course. 
Therefore,  if  the  breast  was  affected  at  the  outset  with  simple  engorgement 
attended  with  deep-seated  lancinating  pains,  we  should  be  on  the  watch,  and 
subject  the  milk  to  microscopic  examination.  ■  If  it  is  impossible  to  make  this 
examination,  which  is  the  only  possible  way  of  removing  all  uncertainty,  prudence 
would  dictate  the  relinquishment  of  nursing,  for  there  seems  to  be  no  doubt  that 
it  would  prove  injurious  to  the  child.  The  breasts  should  be  emptied,  if  neces- 
sary, by  the  use  of  the  pumps  hitherto  mentioned. 


954  HYGIENE     OF    CHILDREN. 

ARTICLE   V. 

OP   MIXED   NURSING. 

It  has  been  shown  in  the  preceding  pages,  that  a  great  many  women  are  in- 
capable of  affording  a  full  supply  of  nourishment  to  their  children.  The  consti- 
tution, health,  and  conformation  of  the  breasts  of  some,  are  all  that  could  be 
desired ;  still  their  lactation  is  defective,  either  in  quality,  the  milk  being  suffi- 
ciently abundant  but  too  unsubstantial,  or,  what  is  more  common,  deficient  in 
quantity,  though  of  excellent  quality.  Others,  on  the  contrary,  have  very  good 
milk,  but  their  feeble  and  delicate  constitution  excite  fears  lest  a  too  free  secre- 
tion and  prolonged  nursing  should  injure  their  future  health.  Lastly,  there  are 
some  who,  in  the  midst  of  conditions  apparently  the  most  favorable,  find  their 
milk  fail,  and  even  disappear  very  rapidly.  To  supply  this  deficiency,  it  becomes 
necessary  to  give  the  child  other  nourishment  than  what  it  is  able  to  obtain  from 
its  mother's  breast.  This  mixture  constitutes  precisely  what  is  termed  mixed 
nursing.  It  should  be  understood  that  I  do  not  include  in  this  appellation  that 
system  of  nursing  in  which  the  child  is  kept  from  the  mother  at  night,  giving  it 
diluted  milk  to  drink,  once  or  twice,  for  the  purpose  of  enabling  her  to  take  what 
sleep  her  condition  requires. 

The  indications  presented  by  insufficiency  of  the  mother's  milk,  vary  accord- 
ing to  the  causes  which  produce  it;  they  are  also  subject  to  the  influence  of  a 
multitude  of  circumstances,  foreign,  it  is  true,  to  the  question  in  its  purely  medi- 
cal aspect,  but  which  it  is  impossible  not  to  take  account  of  in  practice. 

There  are  women  who,  having  no  great  desii'e  to  nurse,  and  alarmed  at  the 
sacrifices  which  the  fulfilment  of  this  duty  involves,  as  also  by  the  fatigues  inse- 
parable from  it,  consent  to  nurse  their  child  only  on  account  of  the  solicitation  of 
their  husbands  or  their  family,  and  sometimes  even  by  a  sort  of  respect  to  huma- 
nity, but  who  would  like  nothing  better  than  a  good  excuse  for  avoiding  it  alto- 
gether. With  a  little  tact  and  experience,  the  physician  is  soon  able  to  know 
just  what  to  depend  upon,  and  under  these  circumstances  he  ought  not  to  hesi- 
tate, but,  provided  the  position  of  the  family  is  such  as  to  permit  of  the  employ- 
ment of  a  wet  nurse,  he  should  encourage  the  woman  to  give  up  the  idea  of 
suckling. 

On  the  other  hand,  there  are  women  who  possess  the  maternal  instinct  even  to 
jealousy,  and  who  cannot  become  reconciled  to  the  idea  of  allowing  their  chil- 
dren to  be  nursed  by  another.  They  are  fully  determined  to  run  all  risks  before 
intrusting  them  with  a  hireling.  A  sentiment  of  this  kind  is  certainly  too 
laudable  for  the  physician  to  pass  over  it  lightly.  Besides,  the  advantages  which 
the  little  one  derives  from  the  attentive  and  affectionate  cares  lavished  upon  it 
by  its  mother,  compensate  for  the  imperfection  of  her  milk.  Nor  do  I  see  why 
in  the  majority  of  these  cases  there  should  be  any  impropriety  in  trying  the 
mixed  method,  on  the  condition,  however,  of  watching  carefully  over  the  child's 
health,  and  having  recourse  to  another  nurse  as  soon  as  it  shall  appear  to  suffer 
from  it. 


NURSING.  955 

The  same  remark  applies  to  young  mothers  whose  condition  in  life  does  not 
permit  them  to  take  in  a  wet  nurse.  Children  removed  from  the  parental  abode 
incur  too  many  unfavorable  risks,  and  it  is  so  rare  to  meet  with  women  who,  when 
free  from  all  oversight,  perform  the  immense  duty  which  they  accept,  conscien- 
tiously, that  I  make  no  hesitation  in  preferring  the  mixed  method  to  the  removal 
of  the  child. 

There  are  still  some  other  circumstances  which  may  render  necessary  the  latter 
method  of  nursing.  Thus,  when  a  woman  has  been  delivered  of  twins,  it  is  very 
rarely  that  she  will  not  be  obliged  to  supply  the  deficiency  of  her  lacteal  secretion 
by  artificial  nursing.  The  same  is  the  case  when  the  mother  is  able  to  suckle 
from  one  side  only ;  for,  although  it  is  strictly  possible  for  a  single  breast  to  suffice, 
the  co-operation  of  both  is  commonly  necessary. 

During  the  first  days  subsequent  to  birth,  the  child  needs  so  little  food  that  it 
will  always  find  a  sufficiency  in  its  mother's  breasts ;  and,  except  in  cases  where 
some  circumstance  or  other  prevents  nursing,  it  were  useless  to  give  it  anything 
else.  Besides,  this  first  milk  possesses  very  useful  properties,  which  might  be 
interfered  with  by  paps,  or  the  milk  of  an  animal.  However,  when  the  mixed 
method  is  decided  upon,  it  should  be  commenced  as  soon  as  possible,  for  other- 
wise, the  child  having  become  accustomed  to  the  breast,  would  be  prevailed  upon 
with  great  difficulty  to  take  any  other  food.  In  the  majority  of  cases,  also, 
although  there  is  a  sufficiency  of  milk  during  the  first  week,  there  would  soon  be 
too  little  should  the  nursing  be  deferred.  Cow's  or  goat's  milk,  given  subject  to 
the  rules  to  be  mentioned  hereafter  when  treating  of  artificial  nursing,  are  cer- 
tainly the  kinds  of  food  best  suited  to  the  child,  and  the  only  ones  that  we  re- 
commend to  be  used  for  the  first  three  or  four  months. 

If  the  child  is  in  a  satisfactory  condition,  the  paps,  panadas,  &;c.,  mentioned 
in  connection  with  weaning,  may  be  given  rather  sooner  than  in  the  maternal 
nursing  proper.  The  child,  having  been  long  accustomed  to  a  rather  more  sub- 
stantial nourishment  than  it  derives  from  the  mother's  breast  exclusively,  may 
commence  taking  some  farinaceous  paps  about  the  fourth  or  fifth  month.  It  will 
be  thus  prepared  for  the  weaning,  which  will  probably  have  to  be  effected  about 
the  tenth  or  eleventh  month. 

The  mixed  method,  thus  understood,  and  continued  for  ten  months  or  a  year, 
is  certainly  preferable  to  a  purely  artificial  nursing.  I  confess  even,  that  when 
the  mothers  are  obliged  to  send  their  children  away,  if  committed  at  all  to  a  wet 
nurse,  the  absence  of  the  parent's  oversight  is  attended  with  so  many  inconve- 
niences, that  I  prefer  the  mixed  method  to  putting  out  to  nurse.  Could  the 
mother  only  give  it  suck  two  or  three  times  in  the  twenty-four  hours,  I  would 
advise  her  to  keep  her  child. 

"What  has  just  been  said  applies  also  to  women  whose  secretion  of  milk, 
although  small  in  amount,  is  yet  kept  up  regularly  for  nearly  a  year.  But  there 
are  some  who  secrete  abundantly  during  the  early  months,  and  then  suddenly 
lose  it  altogether;  in  others  the  milk  continues  to  be  formed,  but  their  health 
suffers  so  greatly  from  the  fatigues  of  nursing,  as  to  oblige  them  absolutely  to 
give  it  up. 


956  HYGIENE    OF    CHILDREN. 

In  both  cases,  the  choice  lies  between  an  early  weaning  and  the  continuation 
of  nursing  by  a  wet  nurse — the  mixed  method  being  here  out  of  the  question. 
I  begin  by  declaring,  that  whenever  the  general  health  or  the  antecedents  of  the 
woman  are  such  as  to  cause  me  to  fear  lest  she  should  not  be  able  to  continue 
nursing  longer  than  two  or  three  months,  I  would  advise  her  not  to  undertake  a 
task  beyond  her  powers.  She  would  thus  be  spared  one  of  the  severest  disap- 
pointments that  a  woman  can  suffer,  namely,  that  of  giving  up  her  child  to 
another,  after  nursing  it  for  several  months.  But,  whether  because  our  advice  is 
not  followed,  or  that  nursing  by  the  mother  has  to  be  relinquished  suddenly  on 
account  of  some  accident,  ought  the  child  to  be  raised  by  the  bottle,  or  should  it 
be  supplied  with  a  nurse  ?  I  am  of  Desormeaux's  opinion,  that  artificial  nursing 
is  attended  with  far  greater  chance  of  success  in  the  case  of  a  child  which  has 
sucked  for  several  months,  than  with  one  newly  born ;  but  experience  has  so 
often  proved  to  me  the  great  difficulties  and  inconveniences  of  artificial  nursing 
in  large  cities,  that  I  much  prefer  a  nurse,  even  for  a  child  four  or  five  months 
old.  I  do  all  in  my  power  to  overcome  the  repugnance  of  the  mother  in  reference 
thereto,  and  unless  both  herself  and  the  child  can  go  into  the  country  to  reside, 
I  persist  in  my  opinion. 

Should  the  child,  however,  be  strong  and  vigorous,  if  it  is  born  of  robust 
parents,  if  nothing  but  an  accident  has  obliged  the  mother  to  suspend  nursing, 
and  if  our  views  meet  with  great  opposition,  an  attempt  may  be  made  to  bring 
it  up  with  the  bottle,  but  still,  on  the  condition  of  observing  attentively  its  diges- 
tive functions,  and  having  recourse  to  a  nurse  as  soon  as  the  necessity  shall  be 
manifest. 

Before  finishing  what  we  have  to  say  of  the  mixed  method,  we  ought  to  insist 
upon  the  necessity  of  supplying  the  deficiency  in  the  mother's  milk  by  a  species 
of  food  approaching  the  nearest  to  it  in  quality.  We  repeat,  therefore,  cow's 
milk,  pure  or  diluted,  according  to  the  age  of  the  child,  and  goat's  milk,  seem 
to  us  far  preferable  during  the  four  first  months.  Paps  and  panadas,  when  given 
prematurely,  may  be  successful  under  certain  exceptional  circumstances ;  but  this 
success,  which  is  constantly  thrown  up  to  us,  cannot  make  us  forget  the  disastrous 
effect  which  it  has  on  some  weak  constitutions,  and  on  many  children  in  large 
cities.  We  repeat,  therefore,  that  children  born  in  the  country  of  robust  parents, 
and  who  are  constantly  exposed  to  the  vivifying  influence  of  the  sun  and  fresh 
air,  derive  from  the  good  hygienic  conditions  in  which  they  live,  a  power  of 
digestion  which  enables  them  to  assimilate  with  advantage  a  food  which  would 
be  indio-estible  for  others. 


ARTICLE   VI. 

SUCKLING   BY   NURSES. 

Some  women  cannot,  and  others  will  not,  nurse  their  children.    Now,  the  latter 
should  be  subjected  as  little  as  possible  to  the  bad  effects  of  this  incapacity  or 


NURSING.  957 

unwillingness ;  and  the  best  substitute  for  the  mother's  milk,  is,  certainly,  that 
of  a  nurse. 

§  1.  Of  Choosing  a  Nurse. 

The  physician  generally  is,  and  always  ought  to  be,  charged  with  the  selection 
of  a  nurse.  Now,  this  choice  is  one  of  the  most  delicate  and  compromising  acts 
of  medical  practice,  for  its  conscientious  performance  necessitates  precautions  and 
investigations,  which,  to  speak  frankly,  it  is  impossible  to  make  in  the  majority 
of  cases.  To  choose  a  nurse  properly,  is  to  guarantee  the  family  a  full  supply  of 
milk  of  good  quality,  and  to  assure  them  as  to  the  excellence  of  her  constitution, 
and  especially  that  she  is  not,  nor  ever  has  been,  affected  with  any  disease  capable 
of  being  transmitted  to  the  nursling. 

Now,  it  must  be  acknowledged,  that  if  an  examination  of  the  milk  properly  per- 
formed is  capable  of  affording  us  a  tolerably  correct  idea  of  its  composition  ;  if  an 
investigation  of  the  principal  organs  of  the  chest  and  abdomen,  and  the  explora- 
tion of  the  mouth,  teeth,  and  cervical,  and  even  inguinal  glands,  are  competent 
to  assure  us  as  to  her  good  health ;  if  the  development  of  the  muscles  of  the 
body  and  limbs,  and  the  color  of  the  skin,  can  enable  us  to  appreciate  the  strength 
and  vigor  of  constitution,  it  is  about  all  that  we   can  expect  to  accomplish. 
To  require  a  nurse  to  submit  to  a  thorough  examination  of  the  genital  parts  and 
the  use  of  the  speculum,  which  is  indispensable  to  a  strict  diagnosis,  would  be 
to  receive  an  almost  certain  refusal.     Perhaps  some  shameless  women,  or  unfor- 
tunates, whom  hunger  allows  to  object  to  nothing,  would  not  decline;  but  I  am 
convinced  that  we  should  fail  with  those  good  and  chaste  country  nurses,  whose 
simple  habits  are  foreign  to  the  debasedness  of  cities.     Such  examination  could 
be  made  obligatory  only  by  public  authority,  and  then  by  confining  exclusively 
to  a  single  physician,  who  should  be  charged  with  the  examination  of  all.     These 
poor  women  would  then  have  to  submit  to  a  single  visit  only.     But  it  must  not 
be  forgotten  that  in  Paris  especially,  before  a  woman  is  received  by  any  one  phy- 
sician, she  has  often  been  presented  to  ten  different  families.     She  would,  there- 
fore, have  been  obliged  to  submit  to  the  examination  ten  times.     It  is  plain  that 
this  could  not  be  done,  or  if  it  were,  I  would  find  it  difficult  to  confide  in  one 
who  had  allowed  it  j  for  though  I  might  feel  satisfied  as  to  her  physical  condi- 
tion, I  should  certainly  have  strong  doubts  as  to  her  moral  qualities.     Besides, 
would  this  examination  always  be  so  conclusive  as  to  justify  an  absolute  assurance 
to  the  families  ?     Doubtless,  we  might  be  able,  in  the  majority  of  cases,  to  certify 
that  there  does  not  exist,  at  the  time,  any  symptom  of  syphilis ;  but  is  the  present 
any  security  for  the  past  ?     The  local  symptoms  disappear,  but  does  not  the 
general  infection  remain,  which  may  sooner  or  later  become  manifest  ?     We  see, 
therefore,  that  were  the  examination  always  possible,  the  evidence  of  a  recent 
attack  of  syphilis  might  be  overlooked,  and  could  give  us  little  or  no  information 
in  respect  to  the  antecedents.     I  coincide,  therefore,  with  M.  Donne,  in  the 
belief  that  the  examination  would  be  useful,  and  would  even  be  disposed  to  direct 
the  attention  of  the  authorities  to  the  propriety  of  causing  a  medical  inspection 


958  HYGIENE     OF    CHILDREN. 

of  nurses  j  but  in  the  present  condition  of  things,  I  believe  it  impossible  that  each 
one  should  require  this  thorough  examination.  . 

After  examining  the  chest,  and  ascertaining  the  absence  of  scrofulous  cica- 
trices, the  healthy  condition  of  the  cervical  glands,  and,  if  possible,  of  the  ingui- 
nal glands,  and  after  inspecting  the  development  of  the  muscular  system  in  order 
to  appreciate  the  vigor  of  constitution,  the  physician  should  next  give  his 
attention  to  the  milk,  and  the  organs  which  secrete  it.  I  confess  regarding  the 
color  of  the  hair  and  soundness  of  the  teeth  as  of  minor  importance ;  for  blondes 
make  as  good  nurses  as  brunettes,  and,  in  some  countries,  the  teeth  are  subject 
to  early  decay  without  the  health  of  the  inhabitants  being  any  the  less  robust. 
Neither  is  it  important  that  the  nurse  should  be  of  the  same  age,  stature,  and 
temperament  as  the  mother  whose  child  is  to  be  submitted  to  her  charge.  With- 
out paying  too  much  regard  to  attractiveness  and  beauty  of  external  configura- 
tion, it  is  proper  that  there  should  be  nothing  unpleasant  about  the  woman,  and 
especially  that  she  should  be  physically  agreeable  to  the  young  mother.  The 
latter  is  obliged  to  live  for  a  year  or  eighteen  months  almost  constantly  in  the 
presence  of  her  child's  nurse,  and  it  is  far  from  immaterial  whether  she  is  to  be 
in  continual  relation  with  a  repulsive  countenance.  Much  consideration  should 
be  had  for  whatever  information  is  attainable  in  respect  to  her  intelligence,  cha- 
racter, and  general  disposition.  A  nurse  who  is  gentle,  good-natured,  and  who 
knows  how  to  amuse  a  child,  ought,  other  things  being  equal,  to  be  preferred. 
It  were  useless  to  remark,  that  no  woman  should  be  introduced  into  a  family  of 
whose  probity  and  morality  there  can  be  the  least  doubt :  unfortunately,  how- 
ever, we  are  but  too  commonly  obliged  to  trust  to  chance  in  regard  to  the  latter 
point.  ^ 

The  nurse's  age  is  not  a  matter  of  indiflPerence.  I  think  it  better  to  choose 
one  between  the  ages  of  twenty  and  thirty  years;  and  would  advise  declining  all 
who  are  over  thirt3'-five.  As  a  general  rule,  women  who  have  already  had  several 
children,  and  who  are  consequently  familiar  with  all  the  offices  which  they  require, 
are  received  more  willingly  than  priraipara3.  It  is  far  better  that  an  inexpe- 
rienced mother  should  have  an  experienced  nurse,  who  is  accustomed  to  handle 
and  take  charge  of  children.  Besides,  by  inquiring  of  families  where  they  have 
already  nursed,  we  may  have  more  certain  information  as  regards  their  disposi- 
tion, their  honesty,  and  the  amount  and  quality  of  their  milk  in  a  previous 
nursing,  which  may  serve,  to  a  certain  extent,  as  a  guarantee  for  the  future. 

'  It  were  better,  as  a  general  rule,  not  to  engage  nurses  too  long  in  advance.  I  think  it 
prudent  to  reserve  the  right  of  examination  at  the  time  when  they  shall  be  needed ;  for  there 
are  cases  in  abundance,  in  which,  notwithstanding  the  most  favorable  appearances,  the  lac- 
tation is  defective.  For  a  still  stronger  reason  would  it  be  wrong  in  parents  to  retain  a 
pregnant  woman  without  consulting  their  physician,  because  she  had  already  nursed  for  one 
of  their  acquaintances,  who  had  recommended  her  highly.  So  many  circumstances  are 
liable  to  interfere  with  lactation,  and  so  nifmy  accidents  may  happen  after  delivery  capable, 
of  seriously  injuring  a  health  which  had  been  perfectly  good  up  to  that  time,  that  I  advise 
all  my  patients  never  to  treat  with  their  nurses  otherwise  than  provisionally,  and  to  promise 
only  conditionally,  and  always  subject  to  the  final  recommendation  of  their  physician.  Dis- 
regard to  this  limitation  has  given  rise  to  many  unpleasant  occurrences  in  families. 


NURSING.  959 

Finally,  they  are  much  less  affected  by  putting  away  their  own  child  than  primi- 
parse,  and,  therefore,  are  far  less  likely  to  lose  their  milk  suddenly.  The  former 
have,  therefore,  undoubted  advantages  over  the  latter,  but  they  are  also  liable  to 
some  objections :  thus  they  have  acquired  habits  which  they  relinquish  with 
difficulty;  it  is  much  harder  to  subject  them  to  the  regimen  which  you  wish 
them  to  follow ;  lastly,  provided  they  do  not  find  in  their  new  position  the  pecu- 
niary advantages,  the  indulgences  and  attentions  of  which  some  parents  are 
lavish,  they  make  unfavorable  comparisons,  and  become  discontented  and  ex- 
acting. 

The  woman  who  offers  herself  as  a  nurse  may  be  still  pregnant,  or  have  been 
delivered  for  some  time. 

If  she  is  still  pregnant,  it  is  important  to  be  sure,  in  the  first  place,  that  her 
labor  will  be  over  at  least  two  months  before  that  of  the  mother  of  the  child. 
The  organs  have  hardly  returned  to  their  normal  condition,  and  the  woman  is 
barely  recovered  before  two  months  after  delivery,  and  not  before  then  ought 
she  to  be  intrusted  with  a  new  nursling.  Earlier  than  this,  the  new-born  child 
would  have  a  milk  better  adapted  to  its  digestive  powers ;  but  a  woman  is  liable 
to  so  many  accidents  during  the  first  sis  weeks  after  delivery,  that  it  is  impossible 
to  answer  for  the  future. 

It  is  much  more  difficult  to  judge  of  the  future  qualities  of  a  nurse  during 
pregnancy,  and  whatever  may  be  the  result  of  a  first  examination,  it  is  necessary 
to  be  very  cautious  as  to  what  one  says  in  regard  to  it. 

We  have  already  noticed  the  points  of  useful  information  to  be  ascertained  by 
an  examination  of  the  colostrum  secreted  during  the  latter  months  of  gestation, 
and  we  shall  not  recur  to  the  subject  (see  page  923);  it  is  almost  the  only  ele- 
ment of  importance  in  the  question  under  consideration.  The  form  and  size  of 
the  breasts  are  of  but  secondary  value. 

Voluminous  breasts  are  by  no  means  a  certain  indication  of  a  full  supply  of 
milk  in  the  future ;  for  generally  the  entire  mass  is  in  great  part  made  up  of  fat. 
This  remark  does  not  always  apply  to  the  size  of  the  gland  itself,  which  can  often 
be  distinguished  from  the  thick  layers  surrounding  it.  It  is  important,  in  fact, 
that  it  should  not  be  too  small.  But,  provided  it  is  of  about  the  normal  size,  the 
flow  of  milk  may  be  sufficient  or  even  abundant  if  the  veins  of  the  breast  are 
largely  developed. 

Dealers  in  cows,  says  M.  Trousseau,  know  very  well  that  their  milking  quali- 
ties cannot  be  judged  of  by  the  size  of  the  udder.  Thus,  a  cow  whose  udder  has 
a  cubic  capacity  of  four  quarts  may  give  ten  quarts  of  milk,  being  six  quarts 
more  than  the  apparent  size,  which  proves  that  milk  is  secreted  during  the  act 
of  sucking  or  of  milking.  The  same  is  the  case  in  the  human  species;  the  size 
of  the  breast  is  not  an  absolute  indication  of  good  nursing  qualities. 

M.  Trousseau  thinks  that  very  important  information  may  be  derived  from  the 
phenomena  observed  in  the  breasts  of  certain  women  at  each  menstrual  period. 
"When,  says  he,  there  is  a  strong  determination  to  the  breasts  at  each  period, 
when  the  latter  grow  hard  and  painful,  and  the  globules  of  the  gland  become 
more  distinct  and  form  projections,  the  woman  is  likely  to  be  a  good  nurse.  .  .  . 
I  have  never  had  an  opportunity  of  testing  the  value  of  this  conclusion. 


960  nvaiENB   op  children. 

When  the  woman  has  been  delivered  and  nursed  for  some  time,  the  physician 
ought  to  direct  his  attention  especially  to  the  amount  and  quality  of  the  milk. 
I  shall  not  revert  to  the  means  for  determining  the  richness  or  poverty  of  the 
milk,  its  purity,  or  its  alteration  by  heterogeneous  elements.  I  ■would*  however, 
remark,  that  to  have  ascertained,  by  placing  a  few  drops  of  milk  in  a  spoon,  that 
it  is  opaque,  homogeneous,  of  medium  consistency,  and  without  any  peculiar  taste 
or  odor,  does  not  obviate  the  necessity  of  having  recourse  to  the  microscope 
whenever  possible.  By  it  alone,  can  be  estimated  the  number,  regularity,  and 
size  of  the  globules,  and  consequently,  the  amount  of  cream  or  buttery  part  which 
they  constitute.  Unfortunately,  but  few  physicians  have  this  instrument  at  their 
disposal  or  know  how  to  use  it ;  and  still  less  are  they  accustomed  to  chemical 
analysis.  In  ordinary  cases,  and  in  the  absence  of  a  better  process,  the  richness 
of  the  milk  may  be  estimated  by  measuring  the  thickness  of  the  layer  of  cream  ; 
for  this  purpose,  M.  Donne's  little  graduated  test-tubes  may  be  used,  or  still 
better,  the  lactoscope  of  the  same  author,  whose  application  requires  but  a  few 
minutes. 

It  is  important  to  bear  in  mind  the  variations  in  the  milk  pointed  out  by  M. 
Peligot  according  to  the  time  it  has  remained  in  the  breasts  (see  page  952).  If 
a  woman  presents  herself  with  breasts  much  distended,  it  is  necessary  that  she 
should  allow  her  child  to  suck  for  some  time,  before  we  shall  be  able  to  form  a 
correct  idea  of  the  density  of  the  milk  ;  for  the  first  milk  is  much  thinner  and 
more  watery  than  that  which  is  secreted  a  short  time  before  its  extraction. 

Lastly,  the  best  means  of  judging  of  the  quantity  of  milk,  is  to  examine  the 
physical  condition  of  the  nurse's  child;  to  be  certain,  as  far  as  possible,  that  it 
takes  no  other  food ;  to  witness  it  suck  several  times,  and  determine  whether  its 
appetite  seems  satisfied,  although  the  breasts  still  retain  a  considerable  degree  of 
firmness.  Again,  like  M.  Natalis  Guillot,  we  may  cause  the  child  to  be  weighed 
before  and  afterputting  to  the  breast;  the  quantityof  milk  swallowed  being  indicated 
by  the  difi'erence  in  weight.  From  2  J  to  5  or  6  ounces,  should  be  withdrawn  at 
each  suckling ;  but  less  than  2^  ounces  is  insufficient  for  the  purposes  of  nutrition. 

The  complete  absence  of  glandular  engorgement  should  lead  us  to  suppose  that 
the  milk  is  uncontaminated  with  a  single  globule  of  pus;  but  if  the  condition  of 
the  ^reast  is  such  as  to  leave  any  doubt  in  the  mind,  nothing  but  microscopic 
examination  is  capable  of  settling  the  question.  This  instrument  is  still  more 
necessary  for  ascertaining  the  presence  of  the  elements  of  colostrum  at  a  period 
when  they  ought  to  have  disappeared  altogether. 

Lastly,  the  age  of  the  milk  should  be  taken  into  serious  consideration  :  as  we 
are  obliged  to  allow  the  nurse  at  least  two  months  for  the  purpose  of  recovering 
from  the  fatigues  of  labor,  the  accoucheur  cannot  supply  the  child  with  a  very 
young  milk,  such,  for  instance,  as  its  mother  might  furnish  it;  but  it  is  at  least 
better  not  to  give  it  milk  from  a  nurse  who  has  been  delivered  longer  than  from 
eight  to  ten  months.  At  this  time,  it  is  no  longer  adapted  to  the  requirements 
of  the  child,  and  as  most  women  are  barely  able  to  nurse  longer  than  from 
eighteen  to  twenty  months,  there  would  be  some  risk  of  finding  the  secretion 
cease  altogether,  before  the  natural  period  of  weaning.  A  milk  of  from  two  to 
six  months  should  therefore  be  preferred. 


NURSING.  961 

Women  who  have  nursed  for  a  year  or  fifteen  months  and  desire  to  take  charge 
of  another  child,  say  that  a  young  infant  restores  the  milk,  but  the  responsibility 
of  the  assertion  must  be  left  with  the  good  women  themselves. 

Most  of  the  precepts  which  we  have  laid  down  for  natural  nursing,  are  entirely 
applicable  to  wet-nursing;  there  are,  however,  some  peculiarities  which  it  is  pro- 
per to  indicate. 

§  2.  Of  the  Regulation  of  Wet-nursing. 

At  what  time  ought  the  nurse  to  give  the  breast  to  a  new-horn  child? — A 
nurse  who  has  been  delivered  for  three  or  four  months,  is,  at  the  outset,  incapa- 
ble of  providing  the  young  infant  with  as  suitable  a  nourishment  as  it  would 
have  derived  from  the  mother's  breast.  The  colostrum  secreted  by  the  mamma) 
of  a  recently-delivered  female,  is  not  merely  a  food,  but  possesses  laxative  pro- 
perties eminently  adapted  to  the  expulsion  of  the  meconium.  Though  slightly 
charged  with  nutritive  matters  at  first,  this  colostrum  is  perfectly  suited  to  the 
digestive  powers  of  the  new-born  child ;  for  to  load  its  stomach  with  anything 
more  substantial,  would  expose  it  to  imperfect  elaboration  and  all  its  unfortunate 
consequences.  Struck  with  these  inconveniences,  some  practitioners  advise  the 
mother  to  begin  suckling  for  the  first  few  days,  and  not  to  give  the  child  to  the 
nurse  until  it  is  better  able  to  digest  her  milk.  Besides,  say  they,  it  is  not  only 
for  the  interest  of  the  child,  but  of  the  mother  also,  for  the  secretion  of  milk  is 
a  natural  emunctory,  well  adapted  by  the  sort  of  derivation  it  occasions,  to  lessen 
the  tendency  to  the  various  inflammations  to  which  lying-in  women  are  so  fre- 
quently exposed. 

I  cannot  accept  this  view.  If  we  regard  only  the  interests  of  the  child,  there 
can  Be  no  doubt  that  the  lactescent  serosity  furnished  by  the  breasts  at  the  out- 
set, is  the  kind  of  nourishment  best  adapted  to  its  condition,  and  that  in  this 
respect,  the  milk  of  a  nu'^se  of  three  or  four  months  would  be  less  suitable ;  but 
we  shall  see  how  easily  the  too  great  density  of  the  latter  kind  of  milk  may  be 
remedied  by  a  sort  of  mixed  nursing,  and  daily  observation  proves,  that  with  such 
precautions,  the  health  of  the  child  is  in  nowise  endangered.  Now,  a  nursing 
once  begun,  and  suddenly  interrupted  after  four  or  five  days,  is  ftir  from  being 
devoid  of  danger  and  inconvenience  to  the  mother.  The  fact  is,  that  women 
sufiier  the  most  from  nursing  at  the  outset.  Then  it  is  that  fissures  and  cracks 
of  the  nipple,  lacteal  engorgements,  and  inflammation  and  abscesses  of  the  breast, 
make  their  appearance.  That  a  female  who  is  determined  to  nurse  should  brave 
all  these  dangers,  may  be  easily  understood,  for  she  is  sufficiently  compensated 
by  the  fulfilment  of  a  grateful  duty;  but  that  one. who  cannot  nurse,  should  ex- 
pose herself  to  them  unnecessarily,  is  incomprehensible,  unless  we  suppose  her 
willing  to  add  to  the  painful  sacrifice  which  the  giving  up  of  her  child  to  a  wet- 
nurse  imposes  upon  her.  Besides,  we  must  not  believe,  as  some  physicians  do, 
that  nursing  protects  women  from  puerperal  diseases.  We  have  but  too  often 
occasion  to  know  from  experience  in  our  hospitals,  that  puerperal  fever,  for  ex- 
ample, attacks  with  equal  violence  those  who  nurse  and  those  who  do  not. 

In  civil  practice,  where  the  minutest  attentions  are  bestowed  upon  the  child, 

Gl 


062  HYGIENE    OF    CHILDREN. 

I  can  discover  but  few  advantages  for  it,  and  many  inconveniences  for  the  motlier, 
in  beginning  to  nurse,  ■wben  she  has  no  expectation  of  continuing  to  do  so.  The 
case  is  different  in  our  large  lying-in  hospitals.  However  carefully  conducted,  it 
has  never  yet  been  possible  to  provide  a  supply  of  nurses  equal  to  the  demands  of 
all  the  children.  In  the  clinic  of  the  Faculty,  for  example,  there  are  but  five  or 
six  nurses  for  twenty  children,  and  the  number  of  ordinary  or  ward  nurses  being 
too  small  to  give  the  little  unfortunates  the  most  necessary  attentions,  a  great 
number  pei-ish,  we  are  bound  to  acknowledge,  of  cold  and  hunger.  Under  these 
circumstances,  the  physician  is  perfectly  right  in  requiring  the  mother  to  suckle 
her  child  until  it  can  be  provided  with  a  nurse. 

For  the  first  twenty-four  hours  after  birth,  the  child  will  take  nothing  but  a 
little  sweetened  water  as  a  substitute  for  the  colostrum ;  and  if  it  should  seem 
difficult  to  expel  the  meconium,  a  few  spoonfuls  of  compound  syrup  of  chiccory 
may  be  administered.  By  this  time  the  bowels  will  be  sufficiently  emptied,  and 
it  may  be  put  to  the  breast.  But  for  the  first  five  or  six  days,  or  rather  longer 
if  the  child  is  feeble,  it  will  not  depend  exclusively  upon  the  nurse's  milk,  but 
the  latter  is  to  be  alternated  with  sweetened  water  during  the  first  three  or  four 
days;  after  the  fifth  or  sixth,  it  will  be  allowed  to  suck  for  a  short  time,  and  the 
nursing  be  immediately  followed  by  the  administration  of  a  few  dessert-spoonfuls 
of  sugar  and  water;  lastly,  about  the  tenth  day,  it  will  be  confined  to  the  breast 
altogether. 

The  new-born  child  is  rarely  able  to  take  enough  milk  to  empty  the  nurse's 
breasts;  therefore,  it  is  well  to  keep  her  own  child  near  her  for  some  days,  in 
order  to  avoid  extreme  distension  of  the  mammse.  She  ought  then  to  be  ad- 
vised always  to  give  the  first  milk  to  the  nursling.  If  separated  from  her  child, 
she  should  endeavor  to  decrease  the  flow  of  milk  by  a  very  moderate  diet  and 
diluent  drinks;  and  if,  notwithstanding  these  precautions,  the  breasts  become 
painful,  they  must  be  emptied  by  a  breast-pump. 

The  precautions  which  it  is  necessary  for  the  mother  to  observe,  are  not  re- 
quired in  the  case  of  a  robust  nurse  who  is  accustomed  to  fatigue,  and  she  is 
expected  to  give  the  child  suck  during  the  night.  Upon  the  whole,  the  precepts 
in  regard  to  the  regulation  of  the  repasts,  are  as  applicable  here  as  to  nursing  by 
the  mother. 

Some  nurses  are  in  the  habit  of  taking  the  child  to  bed  with  them.  This 
ought  to  be  positively  prohibited,  as  terrible  accidents  might  result  from  it. 
Several  times  it  has  been  the  lot  of  nurses  to  find  only  a  dead  body  upon  waking, 
from  having  suffocated  the  child  whilst  asleep.  The  best  means  of  being  certain 
that  the  child  shall  be  laid  in  its  cradle  after  nursing,  is  to  give  the  nurse  so 
narrow  a  bed  as  to  make  it  almost  impossible  for  her  to  sleep  with  the  child  be- 
side her. 

§  3.  Regimen  of  Nurses. 

The  diet  of  nurses  should  be  moderate  but  substantial.  The  latter  quality 
ought  not,  however,  to  be  so  far  insisted  upon  as  to  give  them  a  food  which  is 
too  succulent  and  too  rich  in  azotized  matters.     They  should  certainly  partake  of 


NURSING.  963 

a  certain  amount  of  meat,  but  it  would  be  improper  to  confine  them  exclusively 
to  it.  Being  accustomed  from  childhood  to  indulge  freely  in  vegetables,  they 
would  not  long  support  a  merely  animal  diet  without  disadvantage. 

Nurses  brought  up  in  the  country  often  suifer  from  confinement  to  the  house 
in  cities,  and  their  condition  is  still  further  aggravated  by  the  indolence  which 
takes  the  place  of  their  previous  active  habits.  Therefore,  after  the  first  few 
days,  they  ought,  if  possible,  to  be  employed  in  some  light  household  duties,  and, 
even  when  the  child  is  unable  to  accompany  them,  they  should  be  made  to  take 
exercise  out  of  doors. 

The  nurse  may  at  any  time  lose  her  milk,  be  attacked  by  an  acute  disease,  or 
be  afi'ected  by  some  occurrence  which  lessens  or  alters  the  secretion.  It  is  a 
painful  thing  to  most  families  to  have  to  change  their  nurse,  and  it  is  important 
to  console  them  with  the  assurance,  that  the  change  is  not  so  serious  a  matter  as 
is  generally  represented.  Provided  the  child  receives  a  milk  of  good  quality  and 
enough  of  it,  it  will  suffer  nothing  in  this  respect.  Therefore,  all  that  we  have 
to  do,  is  to  choose  a  milk  equal  to,  if  not  better,  than  what  it  has  been  deprived 
of  Under  these  circumstances,  the  change  is  a  mt^tter  of  such  indifference, 
that  when  the  nurse's  disposition  is  too  disagreeable,  or  if  she  does  not  take 
proper  care  of  the  child,  I  do  not  hesitate,  whatever  the  qualities  of  her  milk 
may  be,  to  advise  a  change. 

The  only  precaution  to  be  observed  is,  that  when  once  decided  upon,  she  should 
not  be  informed  of  the  project  until  another  one  is  engaged  to  replace  her. 

The  only  difiiculty  is  to  get  the  child  to  take  the  breast  of  a  new  nurse.  If  it 
has  attained  the  age  of  from  sis  to  eight  months,  it  often  manifests  a  great  re- 
pugnance thereto.  It  should  then  be  left  for  some  time  without  nursing,  and 
advantage  be  taken  of  the  night  or  a  dark  place,  to  put  it  to  the  breast  for  the 
first  time. 

ARTICLE   yil. 

NURSING   BY   AN    ANIMAL. 

Nursing  by  a  female  animal  constitutes  the  transition,  so  to  speak,  between 
wet-nursing  and  artificial  nursing.  Though  much  in  vogue  in  some  countries,  it 
is  rarely  had  recourse  to  in  Paris  or  most  of  the  departments.  We  hardly  ever 
recommend  it,  except  when  a  child  who  has  been  weaned  for  a  long  time  be- 
comes suddenly  ill  and  requires  a  diet  composed  exclusively  of  milk,  and  in  cei'- 
tain  special  circumstances  making  it  necessary  to  administer  to  the  child  a  milk 
which  has  been  rendered  medicinal.  By  causing  animals  to  swallow  various 
remedies,  such  as  mercury,  iodine,  and  iron,  their  milk  becomes  imbued  with 
most  of  the  properties  of  these  substances.  It  would  be  unjustifiable  to  subject 
a  healthy  nurse  to  a  treatment  of  this  kind  for  the  benefit  of  the  child,  as  it  might 
readily  prove  injurious  to  her. 

The  animals  made  use  of  are  goats,  sheep,  she-asses,  and  cows ;  but  most  fre- 
quently the  she-goat.  The  shape  and  size  of  the  teats,  which  are  easily  seized 
by  the  child,  the  abundance  and  quality  of  its  milk,  the  docility  of  the  animal, 


964  HYGIENE    OF    CHILDREN. 

the  ease  with  which  it  is  trained  to  give  suck  to  the  child,  and  the  attachment 
which  it  is  capable  of  forming  for  it,  are  sufficient  reasons  for  the  preference. 
That  species  should  be  preferred  which  is  destitute  of  horns  and  which  have 
long,  thick,  and  white  hair,  because  they  possess  the  hircine  odor  in  a  slighter 
degree.  A  young  goat  which  has  nursed  several  times,  and  given  birth  recently 
to  her  kid,  ought  to  be  preferred. 

This  mode  of  nursing,  says  Desormeaux,  requires  at  the  outset  much  care  and 
attention  as  respects  the  presentation  of  the  mamma  to  the  child.  The  petulance 
and  impatience  of  the  animal  expose  it  to  frequent  accidents,  but  after  a  time  the 
goat  comes  of  its  own  accord  to  give  it  suck.  The  infont  should  be  laid  in  a  low 
cradle  placed  upon  the  floor. 

When  it  is  desired  to  communicate  medicinal  properties  to  the  milk,  they  are 
made  to  take  internally  or  to  absorb  by  the  skin  the  active  principles  of  these 
medicines.  Thus,  mercurial  ointment  is  rubbed  into  the  skin  of  goats  in  order 
to  communicate  antisyphilitic  properties  to  the  milk. 

ARTICLE    VIII. 

ARTIFICIAL   NURSING. 

I  have  but  little  to  say  of  artificial  nursing ;  for  it  is  admitted  by  all  to  be 
the  worst  of  the  various  methods  proposed  for  nourishing  a  child.  In  large  cities, 
where  it  is  a  difficult  matter  to  procure  good  milk,  and  where  the  bad  health  of 
the  cows  renders  useless  all  the  precautions  taken  with  this  object,  most  of  the 
unfortunate  children  subjected  to  this  regimen  die  within  the  year.  In  the 
country,  however,  the  chances  are  far  more  in  favor  of  artificial  nursing;  for 
there  it  is  possible  to  be  almost  certain  as  to  the  health  of  the  animal,  the  food  it 
takes,  and  the  good  qualities  of  its  milk.  Besides,  the  excellent  atmospheric 
conditions  in  which  the  child  is  placed,  compensate,  to  a  certain  extent,  for  the 
imperfection  of  the  mode  of  alimentation.  Although  a  woman's  milk  is  always 
preferable  to  any  other,  the  artificial  nursing,  which  I  proscribe  unconditionally 
for  large  cities,  may  be  tolerated  in  the  country,  with  the  understanding,  how- 
ever, that  it  shall  be  pursued  with  intelligence. 

Cow's  milk  is  generally  employed,  but  its  administration  demands  some  pre- 
cautions. Being  too  rich  for  a  new-born  child,  it  requires  to  be  diluted  with 
pure  water,  barley  water,  a  decoction  of  crumbs  of  bread,  of  rice  slightly  sweet- 
ened, or  gruel.  Pure  water  should,  I  think,  be  preferred  in  most  cases,  and  the 
proportions  of  the  mixture  must  necessarily  vary  with  the  age  and  digestive 
powers  of  the  child.  During  the  first  week,  three  parts  of  water  should  be  added 
to  one  part  of  cow's  milk,  and  during  the  early  months  the  latter  should  be 
diluted  one-half;  after  which,  unless  the  digestion  is  feeble,  but  one-fourth  of 
water  may  be  added  until  the  sixth  month,  when  the  milk  may  be  given  pure. 

Desormeaux  advises,  when  the  children  are  feeble,  that  the  milk  be  diluted 
with  chicken-water,  or  a  fluid  containing  animal  matter.  I  have  seen  some,  says 
he,  whose  stomachs  were  better  suited  by  weak  decoctions  of  meat  than  by  milk, 


NURSING.  965 

and  I  am  convinced  by  a  multitude  of  practical  observations  tbat  the  matters 
ingested  irritate  less  in  consequence  of  their  being  azotized,  than  because  they 
are  digested  with  difficulty.  I  think  this  regimen  proper  after  the  sixth  month, 
but  would  not  advise  it  in  the  earlier  months,  when,  if  used  at  all,  it  should  be 
with  great  caution. 

It  is  well  to  sweeten  slightly  the  children's  drink.  Although  sugar  has  not 
the  heating  qualities  which  the  women  attribute  to  it,  it  must  be  used  moderately, 
for  it  is  not  always  digested  easily.  I  have  seen,  says  Desormeaux,  feeble  chil- 
dren throw  up  unchanged  the  sweetened  water  and  solutions  of  gum  and  starch 
which  had  been  given  them  as  drink. 

The  drinks  ought  to  be  rather  more  than  lukewarm.  When  pure  milk  is  used, 
it  should  be  brought  by  the  water-bath  to  the  temperature  it  would  have  had  if 
just  drawn  from  the  cow;  if,  on  the  contrary,  it  is  to  be  diluted,  only  the  fluid 
to  be  mixed  with  it  should  be  heated.  In  no  case  ought  the  milk  to  be  boiled; 
for  ebullition  deprives  it  of  a  part  of  its  aroma,  and  of  the  air  which  renders  it 
more  digestible. 

The  mixture  of  milk  with  one  of  the  above  mentioned  substances  soon  fer- 
ments and  spoils,  especially  in  summer,  or  in  warm  rooms  in  winter.  It  ought, 
therefore,  to  be  prepared  only  when  about  to  be  administered. 

We  have  before  stated  that  a  child,  whose  alimentary  canal  has  been  habitu- 
ated by  mixed  nursing  to  more  substantial  nourishment  than  the  mother's  milk, 
is  able  to  take  paps  and  solid  food  rather  sooner  than  it  otherwise  would.  The 
same  is  true  after  artificial  nursing.  There  is  no  occasion  to  revert  to  the  pre- 
cautions laid  down  in  the  article  on  Weaning. 

The  instruments  used  for  giving  children  drink  are  numerous.  The  spoon  and 
drinking  cups,  by  whose  assistance  the  milk  is  poured  into  the  mouth,  are  sub- 
ject to  some  inconveniences ;  so  that,  unless  they  are  unable  to  suck  at  all,  I  pre- 
fer the  nursing-bottle  as  most  nearly  affording  the  conditions  of  natural  nursing. 
It  can  be  readily  procured  everywhere,  and  were  it  on  that  account  alone,  it 
deserves  to  be  mentioned.  It  is  either  an  ordinary  four-ounce  medicine  vial  or 
one  of  those  small  flattened  bottles  used  by  the  wine  merchant  for  exhibiting 
their  specimens;  into  the  neck  is  introduced  a  sponge  cut  for  the  purpose,  and 
which  projects  about  an  inch  and  a  half  beyond  it;  the  whole  is  covered  with 
a  piece  of  muslin,  and  fastened  by  a  thread.  The  thread  ought  also  to  be  drawn 
with  a  moderate  degree  of  tightness  around  the  sponge  at  its  exit  from  the  bottle, 
so  as  to  compress  it,  and  prevent  the  milk  from  flowing  too  rapidly.  Care  should 
be  taken  to  keep  the  sponge,  muslin,  and  thread,  always  in  fresh  clean  water,  and 
before  using,  pass  a  little  milk  through  it  and  squeeze,  so  as  to  drive  out  the  cold 
water,  and  replace  it  by  warm  milk. 

With  all  these  precautions,  this  bottle  has  still  some  imperfections,  which 
many  instrument-makers  have  sought  to  avoid.  The  nursing-bottle  manufac- 
tured by  M.  Charrifere,  I  think  merits  special  recommendation. 

In  terminating  this  chapter,  I  cannot  recommend  too  highly  to  physicians  a 
little  work  by  Dr.  Donn6,  which,  under  the  modest  title  of  Advice  to  3Iothers, 
will  furnish  them  with  an  abundance  of  useful  hints  in  relation  to  the  education 
of  children. 


966  HYGIENE     OF    CHILDREN. 


CHAPTER   III. 

GENERAL    CONSIDERATIONS    ON    CERTAIN    POINTS   RELATING   TO 
INFANTILE    HYGIENE. 

1.  Of  Clothing. — The  clothes  of  the  new-born  child  should  be  so  loose  as  not 
to  obstruct  its  motions.  The  swaddling-clothes,  which  are  still  in  general  use, 
and  which  were  formerly  drawn  much  too  tight,  may  be  retained,  but  only  on 
the  condition  of  leaving  sufficient  freedom  of  motion  to  the  limbs  of  the  child. 
I  confess  that,  for  the  first  weeks,  they  seem  to  me  to  have  some  advantages  over 
what  is  called  the  English  style,  by  protecting  the  children  better  from  the  cold, 
especially  when  they  are  wet  with  urine,  and  also  by  aiFording  greater  facilities 
to  those  who  have  to  take  them  up  and  carry  them  about.  I  therefore  approve 
of  swaddling,  but  would  have  the  clothes  so  loose  as  to  allow  the  extremities,  the 
lower  ones  especially,  sufficient  freedom  of  motion. 

After  the  umbilical  cord  has  fallen  off,  a  folded  compress,  as  large  as  a  dollar, 
should  be  applied  upon  the  navel,  and  kept  in  place  by  a  moderately-drawn  circu- 
lar bandage.  It  serves  to  prevent  the  rubbing,  and  consequent  irritation  of  the 
umbilical  cicatrix,  and  perhaps,  also,  the  formation  of  a  hernia. 

Pins  should  be  used  as  little  as  possible  in  dressing  the  child.  They  may 
become  loose,  and,  by  sticking  it,  give  rise  to  serious  accidents,  such  as  convul- 
sions and  death. 

It  is  important,  also,  that  the  little  cap  string  or  ribbon,  which  passes  under 
the  jaw,  should  be  sufficiently  loose,  for  the  cap  is  liable  to  be  displaced,  and  the 
neck  might  be  subjected  to  constriction.  To  avoid  this,  the  string  should  be 
attached  to  one  end  of  a  band,  the  other  end  of  which  is  fastened  in  front  of  the 
chest. 

After  the  second  or  third  month,  the  swaddling-clothes  should  be  replaced  by 
long  dresses;  from  this  time  the  style  of  garment  is  subject  to  the  fancy  of  the 
parents,  and,  provided  the  child  is  protected  from  the  cold  and  sufficiently  at  its 
ease,  the  physician  need  concern  himself  no  further  about  it. 

2.  Of  Washing,  Bathing,  and  Cleanliness. — Perfect  cleanliness  is  indispen- 
sable to  the  health  of  children,  and  nurses  cannot  be  watched  too  closely  for  the 
purpose  of  preventing  their  allowing  them  to  remain  in  their  urine  or  faecal  mat- 
ters ;  they  should  be  changed  as  soon  as  they  become  soiled.  They  ought  to  be 
washed  with  warm  water,  and  not  merely  wiped,  as  is  done  by  some  nurses.  It 
is  difficult  to  do  otherwise  when  out  walking;  but  the  omission  should  be  sup- 
plied immediately  on  reaching  home.  In  some  countries,  cold  water  is  used  in 
these  washings ;  I  think,  however,  that  it  is  rather  hazardous  within  the  first 
year,  and  I  do  not  recommend  it  before  the  child  is  eighteen  months  or  two  years 
of  age. 

I  am  in  the  habit  of  directing  the  children  to  be  bathed  every  other  day ;  but 
when  they  seem  to  be  rather  more  fatigued  and  enervated  on  the  day  of  the  bath, 


INFANTTLE    HYGIENE.  967 

I  advise  it  to  be  performed  but  twice  a  week,  and  am  content  with  a  simple  im- 
mersion, or  washing  all  over,  every  morning.  The  temperature  of  the  water 
should  be  from  77°  to  86°  F.  The  bathing  ought  to  be  short  in  proportion  to 
the  fatigue  of  the  child,  but,  as  a  general  rule,  it  ought  not  to  be  longer  than  five 
minutes  in  the  first  month,  and  rarely  ten  minutes  in  the  subsequent  ones.  When 
the  children  are  restless  at  night,  and  sleep  little  or  badly,  it  is  a  good  plan  to 
bathe  them  in  the  evening  before  going  to  bed.  When  the  restlessness  and  in- 
somnia are  very  great,  I  have  used  with  advantage  a  bath  prepared  with  a  decoc- 
tion of  lettuce  leaves. 

In  winter,  or  when  the  weather  is  cold  and  damp,  it  is  important  not  to  allow 
the  child  to  go  out  for  several  hours  after  bathing. 

Some  persons  are  afraid  to  wash  the  child's  head,  yet  it  should  be  done,  in 
order  to  remove  the  scurf  which  forms  there,  and  to  prevent  the  formation  of  the 
crusts  which  some  persons  are  glad  to  see  appear.  When  they  are  already  formed 
they  ought  not  to  be  respected,  but  after  rubbing  the  head  gently  with  a  warm 
cloth,  they  may  be  removed  by  a  soft  brush.  If  this  is  not  sufficient,  the  head 
may  be  greased,  and  the  next  morning  they  will  be  found  to  come  off  readily. 

3.  Talcing  the  air,  walkiiuj. — The  child  should  be  placed  immediately  after 
its  birth,  in  a  large,  airy  chamber,  kept  for  the  first  week  at  a  rather  elevated 
temperature.  If  the  child  is  weak  or  born  prematurely,  it  is  important,  in 
winter,  to  surround  it  with  bottles  of  warm  water  :  one  at  its  feet,  and  one  at  each 
side.  The  head  of  the  cradle  should  be  turned  towards  the  windows,  in  order  to 
protect  the  child's  eyes  from  the  too  bright  light.  The  omission  of  this  precau- 
tion has  seemed  to  me  to  favor  the  development  of  purulent  ophthalmia. 

In  winter,  especially,  the  children  should  not  be  taken  out  before  the  fifteenth 
day.  During  the  intense  heats  of  summer,  this  rule  need  not  be  adhered  to  so 
strictly,  provided  they  are  strong  and  well.  But  after  the  first  going  out,  they 
should  be  promenaded  every  day  for  several  hours,  and  at  three  months,  they 
ought  to  remain  for  the  greater  part  of  the  day  exposed  to  the  air;  in  winter, 
autumn,  and  spring,  they  will  be  kept  out  for  at  least  three  or  four  hours.  The 
air  and  sun  are  almost  as  necessary  as  good  nourishment,  and  it  is  perfectly  use- 
less to  consult  barometer  and  thermometer  to  know  whether  it  is  proper  for  a 
child  to  go  out.  Even  in  the  worst  days,  a  favorable  hour  can  always  be  found 
and  made  available ;  only  when  it  is  cold  and  freezing,  the  walk  will  be  shortened. 
There  is  no  occasion  to  fear  disturbing  their  sleep  whilst  promenading,  for  they 
never  sleep  more  soundly  than  then. 

Of  latter  time,  some  philanthropic  physicians,  at  the  head  of  whom  I  am 
pleased  to  name  my  colleague  and  friend,  M.  Loir,  have  insisted  strongly,  that 
the  recording  of  births  should  be  done  at  home,  and  that  there  should  be  no 
obligation  to  carry  the  poor  children  at  every  season  to  the  mayoralty  within  the 
first  three  days.  This  law  has  fallen  into  neglect  in  most  of  the  provinces ;  but 
in  Paris  it  is  still  observed  quite  rigorously,  unless  the  accoucheur  certifies  that 
the  child  is  in  poor  health,  and  that  it  is  impossible  to  transport  it  thither.  I 
am  happy  to  unite  my  feeble  voice  with  those  of  my  colleagues,  to  solicit  from 
the   authorities   a   modification   of  the   existing  laws.     The  same  motives   of 


968  HYGIENE     OF    CHILDREN. 

humanity  induce  me  to  express  the  desire  that  Catholic  families  should  cause 
their  children  to  be  baptized  at  home,  unless  the  ceremony  be  put  ofiF  to  a  some- 
what remote  period  from  birth.  Undoubted  advantages  would  result  from  it  as 
respects  both  mother  and  child. 

4.  Of  Sleep. — For  the  first  days  subsequent  to  birth,  children  do  nothing 
but  suck  and  sleep.  Whilst  asleep,  they  should  be  laid  upon  the  side — some- 
times upon  one  and  sometimes  upon  the  other,  in  order  to  avoid  bad  habits.  At 
first,  they  almost  always  fall  asleep  whilst  suckling,  so  that  it  is  nearly  impossible 
to  lay  them  awake  in  the  cradle ;  but  rather  later,  care  should  be  taken  not  to 
allow  them  to  go  to  sleep  in  the  arms  or  on  the  lap.  Having  once  acquired  this 
habit,  it  becomes  a  necessity,  and  on  awakening  at  night,  they  will  not  go  to 
sleep  again  except  in  their  nurse's  arms.  They  ought  to  be  put  in  the  cradle 
whilst  awake,  and  allowed  to  go  to  sleep  there ;  for  when  once  allowed  to  acquire 
bad  habits  in  this  respect,  it  is  very  difiicult  to  break  them.  It  requires  great 
firmness  to  hear  them  cry  for  a  long  time ;  but  with  courage  and  perseverance, 
and  by  a  temporary  removal  of  the  nurses,  of  whose  weakness  they  are  aware,  a 
complete  reform  is  finally  obtained.  The  same  remarks  apply  to  the  habit  which 
some  nurses  have  of  rocking  children. 

Most  children  at  the  breast  sleep  during  the  day  until  they  are  twenty  months 
or  two  years  old.  This  sleep,  which  is  almost  constant  at  the  outset,  becomes 
shorter  and  less  frequent  as  they  advance  in  age ;  but  it  is  very  rare  for  them  not 
to  take  three  or  four  hours  of  sleep  daily  during  this  early  period  of  life.  This 
repose,  is,  therefore,  a  necessity,  but  there  is  no  occasion  to  avoid  the  least  sound 
for  fear  of  wakening  them,  as  they  very  readily  become  accustomed  to  sleeping 
in  the  midst  of  motion  and  noise;  some  children  sleep  but  lightly,  because  they 
have  always  been  accustomed  to  solitude  and  silence.  Though  it  is  well  not  to 
be  too  scrupulous  in  this  matter,  they  ought  not  to  be  awakened  too  suddenly  for 
fear  of  alarming  them. 

5.  Exercise. — The  only  exercise  of  new-born  children,  consists  in  slight  mo- 
tions of  their  arms  and  legs,  which,  as  we  have  said,  ought  not  to  be  confined  too 
closely.  Rather  later,  they  may  be  moved  about  in  the  arms ;  toward  the  fifth  or 
sixth  month,  they  may  be  exercised  in  standing  on  a  carpet  or  coverlet,  and  left 
to  themselves  in  order  to  try  their  strength ;  they  begin  first  to  drag  themselves, 
then  to  creep  on  all  fours,  and  soon  get  up  by  taking  hold  of  furniture;  after 
which,  they  make  a  few  steps.  As  a  general  rule,  I  do  not  think  it  advisable  to 
encourage  children  to  walk  too  soon  by  supporting  them  with  belts  of  listing, 
wagons,  &c. :  we  ought  always  to  await  the  first  promptings  of  nature. 


APPENDIX. 

ON  THE  USE  OF  ANESTHETICS  IN  OBSTETRICAL 
PRACTICE. 


In  view  of  the  -wonderful  results  obtained  by  the  use  of  ether  in  surgical 
practice,  it  was  altogether  natural  to  inquire  whether  so  efficient  a  means  of 
avoiding  the  pain  of  operations,  might  not  be  employed  with  advantage  against 
the  physiological  pain  which  accompanies  labor  in  the  human  species.  But  be- 
fore speculating  upon  the  probable  advantages  to  be  derived  from  its  use  in  this 
way,  prudence  suggested  the  endeavor  to  foresee  the  disadvantages  also.  Might 
not  the  torpid  condition  of  the  voluntary  muscles  produced  by  etherization,  ex- 
tend to  the  muscles  of  organic  life,  and  might  not  that  action  of  the  womb  which 
is  indispensable  to  a  prosperous  termination  of  labor,  be  paralyzed  thereby? 
Supposing,  even,  that  the  uterus  should  preserve  its  contractile  powers  in  the 
midst  of  the  general  paralysis,  would  not  the  want  of  that  assistance  which  it 
receives  from  the  voluntary  contractions  of  the  abdominal  muscles,  and  of  that 
synergic  action  which  is  so  useful  in  the  termination  of  labor,  render  the  expul- 
sion of  the  foetus  very  difficult,  or  even  impossible  ?  Might  not  the  health  and 
even  the  life  of  the  child  be  endangered  by  the  vapor  inhaled  ?  and  might  not 
the  latter,  which  has  occasioned  some  serious  accidents  in  surgical  practice,  prove 
an  addition  to  the  dangers  which  threaten  the  female  during  labor  and  the  lying- 
in  ?  The  previous  solution  of  all  these  questions  is  of  the  highest  importance, 
and  we  may  readily  understand  the  effect  they  must  have  had  in  inspiring  with 
prudence  those  who  were  the  first  to  employ  anaesthetics  against  the  pains  of 
childbirth.  Some  of  these  questions  are  capable  of  elucidation  by  the  applica- 
tion of  certain  pathological  facts,  others  could  be  solved  only  by  experiment,  and 
this  experiment  had  yet  to  be  performed. 

Professor  Simpson,  of  the  University  of  Edinburgh,  was  the  first  to  venture 
upon  the  administration  of  ether  in  labor.  The  opportunity  presented  on  the 
19th  of  January,  1847.  The  woman  had  a  deformed  pelvis,  and  having  decided 
to  turn,  he  thought  the  occasion  a  favorable  one  for  determining  the  influence  of 
inhalation  of  ether  upon  the  contractions  of  the  uterus ;  for,  supposing  the  con- 
tractility of  the  organ  to  be  paralyzed  by  the  anaesthesia,  the  introduction  of  the 
hand  and  evolution  of  the  foetus  would  only  be  facilitated  thereby.     The  result 


970  ■  APPENDIX. 

was  so  satisfactory  as  to  convince  Dr.  Simpson  that,  notwithstanding  the  complete 
abolition  of  sensibility,  the  action  of  the  womb  might  continue  intact.  Encou- 
raged by  the  first  trial,  he  repeated  the  experiment  in  several  cases  of  natural 
and  of  difficult  labor,  and  on  the  10th  of  February  communicated  the  results  to 
the  Obstetrical  Society  of  Edinburgh. 

Almost  immediately  after  becoming  acquainted  with  his  observations,  several 
English  accoucheurs.  Murphy  (of  London),  Protheroe  Smith,  and  Landsdown, 
administered  ether  with  a  like  success.  Fournier  Deschamps  was  the  first  to  use 
it  in  France,  and  that,  only  eight  days  subsequent  to  the  publication  of  Dr.  Simp- 
son's first  observation.  In  the  month  of  February,  in  the  same  year,  Professor 
P.  Dubois  laid  before  the  Academy  of  Medicine  the  result  of  its  administration 
in  six  cases  of  labor  under  his  own  notice.  In  March,  it  was  used  by  Stoltz,  at 
Strasbourg,  and  by  Delmas,  at  Montpellier.  In  August,  I  made,  in  connection 
with  Mr.  Smith,  some  experiments  at  the  Clinique  d'accouchments,  then  under 
my  charge,  but  the  first  trials  did  not  seem  to  me  encouraging.  Still  later,  MM. 
Chailly,  Colrat,  Villeneuve,  Roux,  Male,  and  several  others,  published  their  ob- 
servations. In  Germany,  Professor  Martin  (of  Jena),  and  afterward,  Professors 
Siebold  and  Grenser  (of  Liepzig),  used  ether  in  several  cases  of  natural  and  of 
difficult  labor.  Lastly,  in  America,  Drs.  Channing,  Clark,  Putnam,  and  others, 
were  the  first  to  make  known  the  results  of  their  experiments. 

In  November,  1847,  the  substitution  for  ether  of  chloroform,  as  proposed  by 
Dr.  Simpson,  gave  a  fresh  impulse  to  the  use  of  anaesthetics  in  obstetrics.  The 
rapid  action  of  the  new  preparation  and  its  easy  administration,  were,  perhaps, 
the  occasion  of  a  too  ready  forgetfulness  of  the  dangers  to  which  it  might  give 
rise,  and  were  certainly  the  cause  of  its  enthusiastic  reception  by  at  least  a  large 
number  of  English  accoucheurs.  At  present,  notwithstanding  some  opposition, 
chloroform  is  employed  almost  exclusively  in  obstetrical  as  well  as  in  surgical 
practice. 

Amongst  the  questions  which  would  naturally  present  themselves  to  the  mind 
of  whoever  first  entertained  the  idea  of  using  anaesthetics  in  labor,  there  are 
some,  which,  as  we  have  said,  receive  a  degree  of  light  from  known  physiological 
and  pathological  facts.  Of  such,  are  those  having  reference  to  the  probable  con- 
tinuance of  the  uterine  contractions,  notwithstanding  the  complete  torpor  of  the 
voluntary  muscles,  and  to  the  more  or  less  important  assistance  received  from  the 
abdominal  muscles  in  labor. 

Numerous  facts  at  present  authorize  the  belief  that  the  momentary  paralysis  of 
sensation  and  voluntary  motion,  does  not  sensibly  interfere  with  the  action  of  the 
womb. 

Dr.  Simpson  was  acquainted  with  those  cases  of  complete  paraplegia,  in  which 
delivery  had  been  effected  with  its  normal  regularity  and  almost  without  pain ; 
nor  was  he  ignorant  of  the  many  instances  in  which  women  have  given  birth  to 
children  during  the  deep  stupor  of  drunkenness ;  he  had  often  seen  labor  termi- 
nated in  patients  affected  with  eclampsia,  during  the  period  of  coma  attending  or 
following  the  convulsive  paroxysm,  without  their  being  in  the  slightest  degree 
conscious  of  what  had  occurred,  as  also  the  astonishment  at  their  delivery  mani- 


AN-SIS  THE  TICS    IN    LABOR.  971 

fested  on  the  return  of  their  senses.  Nor  are  examples  rare  of  the  delivery  of 
women,  during  a  lethargy  so  profound  as  to  be  mistaken  for  death.  It  is  dis- 
tinctly proved  by  all  these  facts,  that  notwithstanding  the  momentary  or  perma- 
nent extinction  of  volition,  sensation,  and  voluntary  motion,  the  organic  contrac- 
tility may  not  only  continue,  but  be  equal  to  the  expulsion  of  the  foetus.  Hence 
it  was  quite  probable  that  the  condition  produced  by  the  inhalation,  resembling 
as  it  does  in  many  respects  the  sleep  of  drunkenness  or  the  coma  of  eclampsia, 
might,  like  the  latter,  have  its  influence  restricted  to  sensation  and  to  the  muscles 
of  animal  life. 

It  was  to  be  feared  lest  the  anterior  muscles  of  the  abdomen  should  be  para- 
lyzed like  those  of  the  extremities,  and  that  their  inaction  might  somewhat  retard 
the  expulsive  stage.  But  the  happy  delivery  of  paraplegic  women,  and  of  such 
as,  notwithstanding  a  complete  prolapsus  of  the  uterus,  have,  unaided,  been  deli- 
vered of  the  product  of  conception,  naturally  presenting  themselves  to  the  mind, 
allowed  of  no  hesitation  on  the  score  of  even  a  probable  paralysis  of  the  abdomi- 
nal muscles.  Besides,  in  the  case  in  which  Dr.  Simpson  employed  anaesthetics 
for  the  first  time,  version  was  to  be  performed,  and  he  would  be  able  to  supply 
by  ti'actions  any  deficiency  of  the  expulsive  powers. 

More  fortunate  than  Dr.  Simpson,  who  at  the  time  of  his  first  experiments  had 
only  the  rational  inductions  afforded  by  physiology  and  pathological  anatomy  to 
support  him,  we  now  are  able  to  appeal  to  experience.  Let  us,  then,  with  the 
assistance  of  the  numerous  facts  now  on  record,  endeavor  to  elucidate  the  various 
questions  connected  with  the  use  of  ancesthetics  in  obstetric  practice. 

1.  Of  the  effect  of  Ancestlietics  on  the  Uterine  Contractions. — On  this  point, 
as  on  many  others,  accoucheurs  entertain  various  opinions.  Some  regard  neither 
chloroform  nor  ether  as  possessing  any  power  to  suspend  the  uterine  action ; 
others  think  that  the  contractions  are  always  retarded  and  quite  frequently  even 
stopped  entirely.  AmidiJt  these  contradictory  assertions  and  facts,  it  is,  how- 
ever, possible  to  discover  the  truth.  A  careful  reading  of  all  the  observations 
will  show  that,  with  the  exception  of  Paul  Dubois,  almost  all  authors  are  unani- 
mous in  the  recognition  of  important  changes  impressed  by  the  inhalation  upon 
the  contractions.  These  modifications  are,  besides,  very  various :  thus,  whilst 
M.  Stoltz  believed  that  he  had  observed  an  increase  in  frequency  and  intensity 
and  Mr.  Murphy,  whilst  turning,  declared  that  he  had  never  before  found  the 
operation  so  difficult,  although  the  patient  was  under  the  full  influence  of  the 
agent,  we  find  MM.  Bouvier,  Siebold,  Montgomery,  &c.,  asserting  that  it  retards, 
and  sometimes  even  completely  suspends  the  labor.  Dr.  Denham  also  affirms, 
that  in  six  cases  in  which  chloroform  had  been  administered  before  turning,  the 
operation  was  rendered  easier,  and  that  its  happy  eS'ect  was  especially  evident  in 
one  case,  where  the  introduction  of  the  hand  having  been  fruitlessly  attempted 
before  inhalation,  it  was  efi"ected  very  easily  after  it.  We  shall  endeavor  to  ac- 
count for  this  dissidence  hereafter. 

Whatever  the  exact  truth  may  be,  in  an  unprejudiced  mind,  no  doubt  can 
exist  of  its  being  proved  by  numerous  facts,  that  when  chloroform  is  taken  so 
moderately  as  to  blunt  and  almost  extinguish  sensibility  without  entirely  depriv- 


972  APPENDIX. 

ing  the  patient  of  the  power  of  motion  or  of  self-consciousness,  it  has,  ordinarily, 
no  influence  over  the  contractile  power  of  the  uterus;  but  that  when  carried  to 
complete  anaesthesia,  the  contractions  may  be  diminished  both  in  frequency  and 
intensity  to  the  point  of  complete  extinction.  The  latter  fact  is  acknowledged 
by  Dr.  Simpson  himself,  and  he  regards  it  as  of  possible  occurrence  in  some  cases 
of  moderate  anassthesia.  The  degree  of  the  latter,  he  remarks,  which  some 
patients  are  able  to  bear  without  the  womb  being  affected  is  exceedingly  variable. 
Some,  are  thrown  into  a  profound  slumber  without  interference  with  the  uterine 
action.  Others,  on  the  contrary,  experience  interruption  of  the  contractions  by 
a  much  slighter  degree  of  anaesthesia.  These  individual  predispositions  explaia 
Mr.  Montgomery's  observations  of  the  manifest  diminution  of  the  uterine  con- 
tractions under  the  sedative  influence  of  chloroform  without  the  woman  being  in- 
sensible to  pain.  Besides,  according  to  the  majority  of  English  practitioners,  the 
retardation  or  the  suspension  of  labor,  is  the  indication  for  the  parfuidar  case, 
that  the  dose  of  the  agent  which  the  patient  might  have  supported  without  in- 
convenience has  been  exceeded,  and  the  best  means  according  to  Dr.  Simpson  of 
restoring  energy  to  the  uterus,  is  to  cease  the  inhalations  for  some  moments  and 
then  resume  them  in  more  moderate  proportions,  as  soon  as  the  patient  shall 
evince  sensibility.  It  is  stated  by  the  Edinburgh  accoucheur,  that  the  return  of 
the  contractions  on  withholding  the  chloroform  is  delayed  but  a  few  minutes 
only;  such,  also,  is  the  view  of  Denham,  Murphy,  and  others.  Mr.  Mont- 
gomery, however,  has  less  confidence  in  this  prompt  return  of  the  contractions. 
In  a  very  recent  case,  he  witnessed  an  interruption  of  the  labor  by  so  feeble  a 
dose  of  the  chloroform,  that  the  patient  was  all  the  while  expressing  with  volu- 
bility the  delicious  sensations  she  experienced;  and  notwithstanding  the  suspen- 
sion of  inhalation,  the  uterus  remained  inert  for  some  hours  before  resuming  its 
original  activity.     I  have  seen,  says  the  Dublin  professor,  several  similar  cases. 

1.  To  recapitulate  :  in  the  majority  of  instances,  the  contractions  are  unaffected 
by  the  inhalation  of  chloroform ;  2.  When  the  anaesthesia  is  pushed  too  far,  the 
labor  is  often  suspended ;  3.  In  certain  individuals,  the  same  result  may  be  pro- 
duced by  moderate  doses  of  the  agent,  and  that,  before  the  loss  of  sensibility  and 
consciousness. 

This  diff'erence  in  the  results,  setting  aside  certain  altogether  exceptional  and 
as  yet  inexplicable  idiosyncrasies,  is  manifestly  due  to  the  extent  and  duration  of 
the  etherization.  The  various  facts,  says  M.  Bouisson,  which  have  served  as  a 
basis  to  so  many  different  opinions,  are  but  the  simple  expression  of  greater  or 
less  degrees  of  anagsthesia,  and  the  phenomena  presented  by  the  uterus  in  regard 
to  sensibility  and  contractility,  are  themselves  included  in  the  general  laws  of 
ansesthesia.  We  are,  in  fact,  perfectly  well  aware,  that  the  participation  of  the 
organic  movements  in  the  depression  which  the  inhalations  produce  in  all  the 
powers  of  the  economy,  are  to  be  reckoned  amongst  the  ultimate  phenomena  of 
etherization. 

2.  Influence  of  Anccstlietics  upon  the  Contraction  of  the  Abdominal  Muscles. — 
It  is  well  known  that  in  the  last  stage  of  labor  the  womb  seems  to  call  to  its  aid 
the  action  of  the  voluntary  muscles,  and  that  the  efforts  of  the  female  assist  in 


ANiBSTHETICS    IN    LABOR.  973 

overcoming  the  obstacle  to  the  passage  of  the  foetus.  It  would  appear  as  though, 
being  dependent  upon  the  animal  life,  the  action  of  those  muscles  which  accom- 
plish the  eflfort,  would  be  destroyed  by  the  ether  or  chloroform,  as  is  that  of  the 
muscles  of  the  extremities.  Now,  according  to  the  majority  of  accoucheurs, 
such  is  not  usually  the  case,  but  that  unless  the  ansesthesia  be  carried  farther 
than  prudence  would  dictate,  the  auxiliary  power  of  the  abdominal  muscles  is 
not  wanting  to  the  uterine  contraction.  My  friend  M.  Longet  thus  attempts  to 
explain  this  singular  phenomenon.  He  first  calls  attention  to  the  fact,  that  in 
the  midst  of  the  complete  collapse,  the  respiratory  movements  are  still  accom- 
plished. Now  the  eflfort  in  general,  and  that  which  accompanies  labor  in  par- 
ticular, are  but  a  modification,  a  transitory  change  in  the  respiratory  act ;  it  is  a 
state  requiring  an  energetic  contraction  of  the  muscles  of  the  chest,  diaphragm, 
and  abdominal  parietes.  Since  in  etherization  the  respiration  is  maintained  in 
all  its  integrity,  volition  being  absent,  and  the  medulla  oblongata  continues  to 
excite  all  the  muscles  that  concur  in  its  accomplishment,  the  effort  which  is  the 
result  of  the  action  of  these  muscles,  those  of  the  abdomen  included,  should  also 
continue  to  be  produced.  I  would  also  willingly  add,  with  M.  Bouisson,  that 
since  it  is  at  the  present  day  demonstrated  that  the  reflex  or  excito-motor  power 
of  the  spinal  marrow,  which  produces  movements  without  the  participation  of  the 
will,  is  not  abolished  by  etherization  except  when  carried  to  an  extreme  degree, 
the  part  which  is  played  by  the  abdominal  muscles  in  parturition  may  properly 
be  regarded  as  reflex  in  its  nature.  Their  manifest  relatioji  with  the  viscera  of 
the  lower  part  of  the  abdomen,  leads,  naturally,  to  the  supposition  that  the  ex- 
citement emanating  from  the  uterus  during  the  act,  is  directly  reflected  by  the 
spinal  marrow  upon  the  muscular  planes  of  the  abdomen.  What  tends  to  prove 
it,  is  the  fact  that  the  abdominal  muscles  may  refuse  the  contingent  of  force 
which  they  contribute  to  this  act,  provided  the  etherization  be  carried  so  far  as 
to  abolish  the  reflex  power,  whilst  they  continue  to  act,  though  more  feebly,  it  is 
true,  as  muscles  of  respiration  (Bouisson).  I  was,  on  one  occasion,  enabled  to 
verify  the  correctness  of  this  observation  of  the  Montpellier  professor. 

Perhaps  it  would  have  been  proper  before  attempting  an  explanation  of  the 
contraction  of  the  abdominal  muscles  during  the  anaesthetic  slumber,  to  assure 
ourselves  whether,  in  fact,  such  contraction  really  occurs.  I  suggested  some 
doubt  of  it  in  a  communication  made  in  1848  to  the  medical  soceity  of  the 
department  of  the  Seine.  Whilst  admitting  that  women  under  the  influence 
of  ether  seemed  to  make  eflforts,  I  pointed  out  the  difl&culty  of  determining 
whether  the  contraction  of  the  anterior  muscles  of  the  abdomen  takes  place  simul- 
taneously with  that  of  the  uterus.  JMy  own  observations  had  failed  to  convince 
me  that  such  was  the  case.  It  seemed  to  me  that  nothing  could  be  more  difldeult 
in  the  distended  and  hard  condition  of  the  abdomen,  than  to  distinguish  the 
muscular  from  the  uterine  action,  and,  consetiuently,  to  feel  certain  whether  the 
organ  contracted  alone,  or  was  aided  by  the  action  of  the  abdominal  muscles. 
The  same  difficulty  has  also  presented  when  etherization  was  omitted. 

I  am  happy  to  find  that  Channing  also,  entertains  some  doubts  as  to  their 
simultaneous  action  in  etherized  patients.  He  says,  the  opinion  of  M.  P.  Dubois, 
appears  to  me  to  be  founded,  in  many  cases  at  least,  upon  an  erroneous  interpre- 


974  APPENDIX. 

tation  of  the  phenomena  of  etherization  in  labor.  The  women  appear  to  make 
an  effort,  but  this  symptomatic  expression  is  a  result  of  the  forced  or  embarrassed 
respiration  which  accompanies  uterine  contraction.  In  imperfect  etherization, 
the  abdominal  muscles  contract  in  different  degrees ;  but  when  the  anaesthesia  is 
complete  the  effort  is  only  apparent. 

3.  Influence  of  Ancestlietics  on  the  Resistance  of  the  Perineum. — One  of  the 
advantages  usually  attributed  to  the  use  of  ether  or  chloroform,  is  such  a  dimi- 
nished resistance  of  the  perineum  as  to  facilitate  the  expulsion  of  the  foetus,  and 
to  prevent  almost  certainly  the  ruptures  which  it  so  often  suffers  in  labor.  In 
the  few  observations  which  I  have  had  occasion  to  make,  I  was  in  no  degree  con- 
scious of  this  vaunted  relaxation ;  on  the  contrary,  it  seemed  to  me  that  the  dis- 
engagement of  the  head  took  place  with  its  habitual  slowness.  I  therefore  believe 
that  the  fact  has  yet  to  be  substantiated,  for  although  the  observations  of  Dubois, 
Chailly,  and  others,  seem  to  establish  it,  others  have  known  the  perineum  to 
maintain  all  its  resistance,  and  even,  as  in  the  case  noticed  by  Villeneuve,  of 
Marseilles,  to  be  extensively  lacerated.  The  verification  is  much  more  difficult 
than  is  supposed,  for  the  resistance  varies  so  much  in  different  individuals,  as  to 
render  it  almost  impossible  to  foresee  what  it  will  amount  to  in  any  given  case. 
How  often  in  practice  do  we  find  our  previsions  refuted  by  the  results  ? 

Again,  supposing  that  under  the  influence  of  the  pressure  which  these  muscles 
have  to  sustain,  the  reflex  action  of  the  spinal  marrow  is  unable  to  produce  their 
contraction  in  the  efforts,  involuntary  though  they  be ;  supposing,  we  repeat,  that 
they  are  paralyzed  in  the  etherized  female,  it  is  not  to  be  credited  that  the  entire 
resistance  of  the  perineum  is  on  that  account  ever  suspended.  The  flict  is,  that 
the  resistance  is  ordinarily  due  quite  as  much  to  the  aponeurotic  planes  of  the 
pelvic  floor,  and  to  the  sometimes  very  large  amount  of  fatty  tissue  situated 
between  the  different  layers,  as  to  the  muscular  fibres  themselves.  In  those  who 
have  borne  children,  and  in  whom  the  perineum  presents  but  slight  resistance, 
the  muscles  of  this  region  are  at  least  quite  as  fully  developed  and  as  strong,  as 
in  primiparous  females.  To  what,  then,  can  be  due  the  facility  with  which  the 
foetus  is  expelled,  if  not  to  the  greater  elasticity  of  the  aponeurotic  planes,  which, 
having  suffered  distension  in  previous  labors,  have  their  suppleness  increased 
thereby  ?  Since  the  chloroform  can  have  no  effect  upon  them,  it  is  no  cause  for 
astonishment  that  after  its  administration  the  resistance  of  the  perineum  should 
continue. 

Hence  we  may  conclude  that :  1.  When  properly  administered  and  in  mode- 
rate doses,  anaesthetic  agents  do  not  interfere  with  the  regular  course  of  the 
uterine  contractions, ;  and  that  whenever  their  administration  is  followed  by  the 
cessation  or  weakening  of  the  efforts,  the  effect  ought  not  to  be  attributed  to  the 
agent,  but  to  the  abuse  which  has  been  made  of  it;  2.  That  it  is  not  yet  suffi- 
ciently shown  that  during  the  ana3Sthetic  slumber,  the  abdominal  muscles  con- 
tinue to  aid,  by  their  contraction,  the  expulsive  efforts  of  the  womb;  3.  That 
fresh  observations  are  necessary  to  settle  definitely  the  influence  of  chloroform 
upon  the  resistance  of  the  perineum. 

Before  determining  what  cases  indicate  or  contraindicate  the  use  of  chloro- 


AN-aaSTHETICS    IN    LABOR.  975 

form,  it  remains  for  us  to  state  what  is  proved  by  experience,  regarding  the 
influence  of  chloroform  upon  the  health  of  both  mother  and  child. 

1.  Effect  upon  the  mother's  health. — Accoucheurs  who  have  often  used  chloro- 
form, are  almost  unanimous  in  the  declaration  that  it  has  never  had  the  least 
mischievous  effect  upon  the  mother's  health,  whilst  in  all  cases,  it  has  spared 
them  the  sufferings  of  the  last  expulsive  pains.  None  of  my  patients,  says  Dr. 
Simpson,  have  been  conscious  of  them ;  and  several,  through  their  confidence  in 
etherization,  have  been  spared  the  fears  which  they  usually  suffered  toward  the 
end  of  their  preceding  pregnancies,  in  anticipation  of  the  coming  labor.  By 
exempting  women  from  the  terminal  sufferings,  the  anresthesia  husbands  their 
strength,  and  avoids  the  nervous  exhaustion  which  follows  a  painful  labor.  Some 
who  were  already  mothers,  declared  in  grateful  terms,  their  condition  to  be  in- 
comparably better  than  after  their  previous  labors.  Their  recovery,  continues 
the  same  author,  is  more  rapid,  and  consecutive  inflammations  are  much  rarer  or 
less  serious  than  usual. 

I  am  not  yet  convinced,  so  far  at  least  as  regards  natural  labor,  thai  this  last 
proposition  is  fairly  demonstrated ;  and  nothing  in  the  facts  yet  known,  those 
even  of  Dr.  Simpson  included,  appear  to  me  of  a  character  to  prove  its  exactness. 
In  natural  labor  the  fatigue  is  moderate,  and  the  remembrance  of  it  soon  abolished 
by  the  happiness  of  maternity.  The  lying-in  demands  always  the  same  precau- 
tions, whether  chloroform  be  used  or  not,  and  the  time  of  getting  up  is  nearly 
always  the  same.  Finally,  in  an  epidemic  of  puerperal  fever  at  Edinburgh,  the 
women  who  had  used  inhalations  were  not  more  exempt  from  the  disease  than 
those  who  had  not. 

I  would  even  add,  that  in  tedious  labors  the  gravity  of  consecutive  acci- 
dents has  not  been  sensibly  diminished  by  the  use  of  chloroform.  Its  only 
incontestable  effect  is  to  abolish  pain,  and  prevent  the  considerable  nervous  dis- 
turbance sometimes  consequent  thereto.  This  result  is,  doubtless,  of  importance, 
but,  except  in  some  very  exceptional  cases,  the  pain  is  not  fatal  of  itself,  and  the 
nervous  shock  is  generally  avoided.  Metritis,  deep-seated  suppurations,  inflam- 
mations, and  gangrenous  eschars  of  the  soft  parts  of  the  pelvis,  are  consequences 
of  the  violent  uterine  efforts.  Now,  as  Montgomery  has  shown,  the  only  effect 
of  chloroform  is  to  remove  the  pain,  leaving  intact  all  the  other  consequences  of 
difficult  labors. 

Another  incontestable  advantage  of  chloroform  is  that  of  facilitating  certain 
obstetrical  operations.  The  uncontrollable  and  disordered  movements  of  the 
agonized  female,  hinder  the  operator  greatly ;  but  the  sleep  which  she  enjoys 
during  the  inhalation,  and  the  complete  insensibility  of  all  the  organs,  enable 
her  quietly  to  bear  the  most  painful  operations. 

The  annihilation  of  pain  in  all  cases,  the  prevention  of  the  nervous  shock  which 
is  sometimes  the  consequence  of  too  painful  or  too  prolonged  a  labor,  and  the 
facilitation  of  obstetrical  manoeuvres,  are,  therefore,  the  only  indisputable  advan- 
tages to  be  derived  from  the  use  of  chloroform. 

Are  not  these  advantages  counterbalanced  by  serious  inconveniences?  Such 
is  the  opinion  of  some  accoucheurs,  though  they  have,  in  my  opinion,  exagge- 


976  APPENDIX. 

rated  both  tlieir  frequency  and  gravity.  We  are  now  able  to  estimate  its  power 
of  suppressing  the  pains  of  hxbor  :  prudently  administered,  it  in  no  respect  alters 
the  regularity  and  power  of  the  contractions;  but  is  it  altogether  the  same  as 
regards  the  contractility  of  the  tissue,  and  may  not  the  retraction  of  the  womb 
after  labor,  be  in  some  degree  modified  by  the  previous  use  of  anesthetics  ?  I 
confess  the  want  of  an  entire  assurance  upon  this  point,  and  am  inclined  to 
believe  that  they  have  not,  in  some  cases  at  least,  been  altogether  without  in- 
fluence in  the  production  of  subsequent  inertia  and  hemorrhage.  Two  cases  of 
slight  hemorrhage  are  quoted  by  Duncan,  one  of  which,  it  is  true,  occurring  in  a 
twin  labor  with  extreme  distension  of  the  uterus,  is  thereby  sufficiently  accounted 
for ;  but  the  other  took  place  six  hours  after  delivery,  without  any  appreciable 
cause.  Dr.  Channing  has  met  with  4  cases  of  hemorrhage  in  78  of  anesthesia. 
In  one  case  it  was  internal,  and  happened  one  hour  after  delivery;  in  another, 
the  woman  half  fainted  immediately  upon  the  termination  of  labor,  and  he  found 
the  uterus  much  enlarged  and  filled  with  clots,  upon  the  removal  of  which,  the 
organ  contracted,  and  there  was  no  further  loss.  In  a  third  case,  a  serious 
hemorrhage  occurred  immediately  after  delivery.  The  fourth  observation  is  less 
conclusive,  on  account  of  the  patient  having  experienced  losses  after  previous 
labors,  and  because  the  delivery  of  the  placenta  was  made  difficult  by  adhesion. 
Dr.  Montgomery  declares,  as  his  personal  experience,  that  when  the  influence  of 
the  chloroform  is  kept  up  until  the  labor  is  ended,  the  patient  is  more  or  less 
exposed  to  hemorrhage  from  inertia  and  to  retention  of  the  placenta.  The  expe- 
rience of  several  of  my  brother  practitioners,  he  adds,  has  been  similar  to  my  own. 

I  am  well  aware  that  in  all  these  instances  the  hemorrhage  may  have  been 
due  to  various  circumstances,  and  there  is  nothing  to  show  that  chloroform  was 
necessarily  the  cause ;  still,  it  is  well  to  be  aware  of  them,  were  it  only  to  excite 
prudence  in  the  use  of  the  agent;  for,  since  by  too  large  a  dose,  the  exercise  of 
the  organic  contractility  has  sometimes  been  suspended,  why  may  not  the  same 
dose  diminish  the  contractility  of  the  tissue  ?  In  practice,  these  facts  ought  not 
to  be  lost  sight  of,  and  I  think  that,  immediately  after  delivery,  it  would  be 
prudent  to  administer  some  ergot. 

In  certain  surgical  operations,  death  has  resulted  immediately  from  the  admi- 
nistration of  chloroform.  Is  not  the  supposition  both  probable  and  reasonable, 
says  Mr.  Montgomery,  that  a  similar  misfortune  might  happen  to  a  woman  in 
labor  ?  Doubtless  it  is  possible;  but  happily,  although  a  great  number  of  women 
have  used  inhalation,  not  a  case  can  be  mentioned  in  which  sudden  death  can  be 
reasonably  attributed  thereto ;  for  I  cannot  accept  as  such  the  following  related 
by  Gream.  A  young  woman  had  just  been  delivered  of  one  child,  and  chloro- 
form was  administered  before  the  expulsion  of  the  second;  death  ensued  in 
half  an  hour.  No  further  detail  is  given.  In  two  other  cases  mentioned  by 
the  same  author,  death  occurred  at  a  still  later  period  after  delivery.  The 
patients  whom  the  surgeons  have  had  the  misfortune  to  lose,  did  not  die  in  this 
manner;  for,  in  their  cases,  it  was  during  the  administration  of  the  agent  that 
life  became  extinct;  it  is,  therefore,  because  in  the  observations  of  Gream  a 


ANiESTHETICS    IN    LABOR.  977 

longer  or  shorter  time  had  elapsed  between  the  cessation  of  inhalation  and  death, 
that  I  cannot  regard  the  chloroform  as  chargeable  with  the  fatal  result. 

With  still  less  reason  has  it  been  reproached  with  the  production  of  eclampsia, 
by  increasing  the  cerebral  congestion,  which  the  exertions  of  labor  have  of  them- 
selves a  tendency  to  produce.  For,  although  Wood  has  quoted  a  case  of  convul- 
sions occurring  in  an  etherized  woman  in  the  last  stage  of  labor,  we  are  now  in 
possession  of  enough  facts  to  prove  that  the  administration  of  chloroform  during 
convulsive  attacks,  lessens  their  frequency,  and  sometimes  puts  an  end  to  them 
altogether. 

Inhalation  has  also  been  accused  of  the  production  of  insanity;  of  which, 
says  Channing,  there  is  not  a  single  well-established  case.  In  reference  to  this 
point,  he  cites  the  following  observation  by  one  of  his  countrymen.  An  insane 
woman  had  in  a  preceding  labor  suffered  from  extreme  agitation,  which  was  the 
occasion  of  serious  difficulty.  In  her  last  labor,  ether  was  administered,  thanks 
to  which,  the  patient  was  perfectly  quiet,  and  all  passed  over  admirably. 

2.  Effect  of  Chloroform  upon  the  Life  and  Health  of  the  Foetus. — Whatever 
difference  of  opinion  may  still  remain  respecting  the  influence  of  chloroform  upon 
the  health  of  the  mother,  no  one  doubts  its  entire  innocence  as  regards  the  foetus. 
In  the  immense  majority  of  cases,  the  new-born  child  presents  its  usual  appear- 
ance ;  its  cries  are  neither  weaker,  nor  heard  less  promptly,  nor  does  its  viability 
appear  to  be  in  any  way  injured.  Thus  have  the  gloomy  previsions  of  certain 
physiologists  been  falsified  by  experience.  The  conclusions  which  M.  Amussat 
thought  himself  entitled  to  draw  from  his  experiments  were  contradicted  by  the 
ulterior  researches  of  M.  llenault. 

Indications. — In  what  cases  is  the  accoucheur  justified  in  the  employment  of 
chloroform  ?  This  question  is  variously  answered  in  different  countries.  Dr. 
Simpson,  and  with  him  quite  a  large  number  of  his  countrymen,  recommend  it 
unhesitatingly  in  all  Iabor,>,  whether  natural  or  difficult.  In  France,  on  the  con- 
trary, it  is  confined  almost  exclusively  to  cases  of  difficult  parturition.  We  adopt 
unhesitatingly  the  latter  position,  and  a  few  words  will  suffice  to  explain  the 
motives  of  our  preference. 

Whilst  regarding  the  use  of  chloroform  as  devoid  of  danger  in  the  majority  of 
cases,  we  cannot  entirely  forget  the  misfortunes  of  certain  surgeons,  who  had, 
nevertheless,  taken  the  best  precautions  to  avoid  them.  Now,  though  it  be 
allowable  to  subject  a  patient  to  some  danger,  in  order  to  spare  him  the  intense 
suffering  of  an  amputation  or  any  other  bloody  operation,  are  we  sufficiently  au- 
thorized to  do  so  when  the  regular  accomplishment  of  a  function  is  concerned  ? 
And,  after  all,  is  the  suffering  of  childbirth,  in  simple  cases,  so  grave  and  ter- 
rible ?  Do  we  not  see  women  delivered  almost  without  pain  ?  To  speak  only  of 
what  is  most  common,  do  they  not  often  preserve  their  calmness  and  gaiety  to  the 
end  of  the  labor?  Do  they  not  often  complain  of  the  repose  afforded  by  the  intervals 
between  the  pains,  and  ardently  desire  their  return,  in  the  conviction  that  each  is 
a  step  toward  delivery  ?  Why,  therefore,  with  the  simple  object  of  sparing  them 
some  suffering,  which,  after  all,  they  endure  courageously,  deprive  them  of  the 
caresses  of  the -husband,  the  condolence  of  their  relatives,  and  deaden  the  imagi- 

62 


978  APPENDIX. 

nation,  already  teeming  witli  the  joj'S  of  maternity  ?  Why,  especially,  should 
they  be  deprived  of  the  ineft'able  happiness  of  hearing  the  first  cry  of  the  new- 
born child  ?  Instead  of  the  pleasant  chatting  in  which  women  so  often  indulge, 
instead  of  those  maternal  aspirations  and  dreams  of  the  future  which  soothe  the 
young  mother,  what  do  we  observe  after  the  anaesthetic  inhalations  ?  A  deep 
sleep,  resembling  more  or  less  the  coma  of  inebriation,  or  concussion  of  the  brain, 
a  complete  annihilation  of  the  sensorial  and  intellectual  faculties,  is  the  lot  of  the 
mother;  an  always  increasing  solicitude  that  of  her  attendants.  Finally,  we  may 
add,  that  supposing  the  physician  to  be  devoid  of  all  fear,  he  is  obliged  to 
remain  constantly  by  the  side  of  his  patient  to  administer  the  agent  personally, 
and  to  watch  attentively  the  state  of  the  pulse,  of  the  breathing,  and  of  the 
heart. 

As  a  justification  of  the  use  of  anassthetics  in  ordinary  labors,  it  has  been  said 
that  they  favor  the  dilatation  of  the  mouth  of  the  womb,  and  by  lessening  the 
resistance  of  the  perineum  also  shorten  the  period  of  expulsion.  We  have  already 
seen  that  the  diminution  of  the  resistance  of  the  perineum  is  not  sufficiently 
proved ;  and  the  same  may  be  said,  I  believe,  of  the  rapidity  with  which  the 
dilatation  of  the  orifice  is  effected.  However  it  may  be,  upon  consulting  the 
published  observations,  it  is  not  discoverable  that,  in  the  cases  in  which  chloro- 
form has  been  employed,  the  duration  of  the  labors,  as  compared  with  preceding 
ones,  have  been  sensibly  shortened. 

Besides,  the  duration  of  a  labor  becomes  dangerous  for  either  mother  or  child 
only  as  it  exceeds  the  natural  limits,  and  of  the  latter  case  only  are  we  speaking 
at  present.  Indeed,  the  more  I  reflect  upon  it,  the  more  determined  do  I  feel 
to  exclude  anaesthetics  from  simple  labor  entirely. 

The  case  is  different  when  some  unfortunate  complication  disturbs  or  inter- 
feres with  the  course  of  nature.  It  will  have  been  seen,  on  reading  this  work, 
that  we  very  often  have  spoken  in  favor  of  the  use  of  chloroform,  and  we  shall 
now  proceed  to  recapitulate  the  diiferent  cases  in  which  we  feel  justified  in  recom- 
mending it. 

It  may  be  especially  useful :  1.  In  calming  the  extreme  agitation  and  mental 
excitement  which  labor  often  produces  in  very  nervous  women  (see  page  399). 
2.  In  those  cases  in  which  labor  appears  to  be  suspended  or  much  retarded  by 
the  pain  occasioned  by  previous  disease,  or  such  as  may  supervene  during  labor 
(vomiting,  cramps,  colic,  compression  of  the  sciatic  nerve,  page  523).  Mr. 
Montgomery,  who  certainly  is  no  enthusiast,  states  that  he  had  witnessed  a  case 
in  which  he  certainly  would  have  used  chloroform  had  he  been  acquainted  with 
it  at  the  time  :  the  sphincter  ani  muscle  was  aifccted  with  so  violent  a  spasmodic 
pain  as  almost  to  deprive  the  patient  of  reason.  3.  It  seems  to  us  particularly 
indicated  by  those  irregular  or  partial  contractions,  which,  notwithstanding  the 
intense  and  almost  constant  pain  which  they  occasion,  have  no  eflfect  to  advance 
the  labor  (page  525).  We  might  even  think,  with  M.  Bele,  that  chloroform, 
which  must  be  exhibited  in  very  large  doses  to  suspend  the  normal  and  rhythmi- 
cal contractions  of  the  uterus,  would  act  much  more  promptly  in  stopping  the 
irregular  contractions,     4.  Spasmodic  contraction  and  rigidity  of  .the  cervix  uteri 


ANiESTHETICS    IN    LABOR.  979 

have  sometimes  been  favorably  affected  by  inhalation  (page  622).  As  this  part 
of  the  uterus  receives  some  spinal  nerves,  it  becomes,  to  a  certain  extent,  a  por- 
tion of  the  muscular  apparatus  of  animal  life.  Facts  are,  however,  as  yet  too  few 
to  enable  us  to  determine  the  question. 

Amongst  the  accidents  which  so  frequently  complicate  labor,  there  is  one 
against  which  several  accoucheurs  have  thought  it  right  to  use  chloroform, 
namely,  eclampsia.  But  it  is  very  difficult  in  the  present  state  of  our  knowledge 
to  pass  a  definite  judgment  upon  its  utility  in  this  disease.  By  an  attentive 
reading  of  the  published  cases,  we  find  that  the  effect  produced  by  ether  or 
chloroform  is  very  variable,  and  that  although  they  have  appeared  to  ameliorate 
the  disease  in  some  cases,  in  many  others  they  have  had  no  influence  whatever, 
the  convulsions  recurring  with  the  same  frequency  and  intensity.  It  is  but  just, 
however,  to  state,  that  the  inhalations  have  never  been  manifestly  hurtful ;  and 
yet,  a  priori,  their  influence  might  be  dreaded  in  a  disease  which  is  so  often 
complicated  with  cerebral  congestion  and  sometimes  even  with  apoplexy.  The 
question  therefore  remains  open,  and  until  we  shall  possess  more  ample  informa- 
tion, I  think  it  prudent  to  abstain,  unless  the  eclampsia  appear  manifestly  due  to 
the  local  irritation  of  an  organ  (see  page  718)  whose  extreme  sensibility  had 
excited  the  reflex  action  of  the  spinal  nerves. 

Obstetrical  Operations. — Not  only  does  chloroform  abolish  the  great  pain  pro- 
duced by  various  obstetrical  operations  and  relieve  the  patient  from  the  dread 
which  they  inspire,  but  by  rendering  her  motionless,  greatly  facilitate  the  ma- 
noeuvre. It  is,  therefore,  no  despicable  auxiliary,  provided  the  nature  of  the 
services  required  of  it  be  well  understood.  Turning,  for  example,  would  cer- 
tainly be  facilitated  by  the  immobility  and  insensibility  of  the  patient,  but  not  at 
all  by  any  fancied  suspension  of  the  physiological  contractions;  only  the  sensibi- 
lity and  irritability  of  the  organ  being  destroyed,  it  is  not  irritated  by  the  pre- 
sence of  the  hand,  and  the  usual  spasmodic  contraction  does  not  occur.  To 
expect  other  assistance  from  the  chloroform,  to  propose,  for  example,  overcoming 
by  its  aid  the  difficulties  sometimes  presented  by  a  long  and  strongly-contracted 
uterus,  would  be,  as  we  have  said  (see  page  785),  exposing  ourselves  to  the 
danger  of  carrying  the  anaesthesia  to  the  third  degree, — a  circumstance  to  be 
dreaded  on  account  of  the  terrible  accidents  which  some  surgeons  have  had  to 
deplore. 

When  instruments  are  employed,  it  is  very  often  useful  to  interrogate  the  sen- 
sations of  the  female,  in  order  to  be  sure  that  no  part  of  the  uterus  or  vagina; 
is  caught  between  the  branches  of  the  instrument.  Now,  during  the  anaes- 
thetic slumber,  the  patient  can  reply  to  no  question,  and  thus  is  the  surgeon- 
deprived  of  a  source  of  useful  information.  Whatever  may  be  the  process  em- 
ployed, it  is  impossible  to  render  the  patient  too  secure,  therefore,  as  the  intro- 
duction of  the  blades  of  the  forceps  or  of  the  cephalotribe,  is  generally  attended 
with  but  moderate  pain,  I  would  recommend  that  the  patient  be  not  etherized; 
until  this  first  stage  of  the  operation  is  over.  The  extraction  of  the  child  may 
then  be  effected  without  causing  any  pain. 

If  ever  symphyseotomy  or  the  Capsarean  operation  be  decided  upon,  I  should. 


980  APPENDIX. 

think  the  administration  of  chloroform  as  likely  to  be  useful  as  in  any  other  great 
surgical  operation.  Finally,  the  difficulties  attendant  upon  the  delivery  of  the 
placenta  from  its  abnormal  adhesions,  and  from  irregular  contraction  of  the  uterus, 
sometimes  require  proceedings  which  are  very  painful  to  the  female.  Anaesthe- 
tics may  here  render  the  same  services  as  in  version.  It  is,  however,  necessary 
not  to  administer  them  too  freely,  for,  independently  of  the  dangers  of  which  we 
have  spoken,  it  might  be  feared  lest  by  paralyzing  the  contractile  powers  of  the 
womb,  they  should  expose  the  patient  to  inertia  and  consecutive  hemorrhage. 

31ode  of  Administration. — The  plan  described  by  Dr.  Simpson  is  the  one 
usually  followed.  It  consists,  as  is  well  known,  in  placing  near  the  nostrils  and 
mouth,  a  concave  sponge,  or  a  handkerchief  folded  into  a  cone,  after  having 
poured  into  the  concavity  a  drachm  or  two  of  chloroform.  The  handkerchief 
ought  to  be  held  rather  above  the  opening  of  the  nostrils,  for  the  weight  of  the 
chloroform  being  rather  greater  than  that  of  the  air,  it  would  otherwise  fall,  and 
not  enter  the  mouth  or  the  nostrils.  The  sponge  should  be  held  at  some  dis- 
tance from  the  face,  so  as  to  allow  a  free  passage  to  air,  and  prevent  contact  of 
the  fluid  with  the  skin  and  mucous  membrane.  If  this  precaution  be  not  taken, 
little  vesicles,  and  even  small  superficial  eschars  will  be  formed.  During  the 
interval  of  the  inhalations,  the  evaporation  of  the  chloroform  is  prevented  by 
closing  the  hollow  of  the  handkerchief  by  the  corners  or  with  the  hand. 

Dr.  Simpson  recommends  beginning  with  a  strong  inhalation,  and  at  the  out- 
set, to  cause  enough  to  be  breathed  to  produce  complete  somnolence.  He  attri- 
butes the  loquacity,  delirium,  spasms,  and  extreme  agitation  observed  in  certain 
subjects,  to  beginning  with  too  small  a  dose.  This  advice,  which  is  very  proper 
if  ether  be  employed,  is  not  of  equal  value  if  chloroform  be  used.  The  latter 
generally  produces  much  less  excitement,  and  throws  the  patient  at  once  into  a 
tranquil  sleep.  The  cough  and  pulmonary  irritation  which  they  sometimes 
occasion,  depend  either  upon  the  bad  quality  of  the  agent,  or  the  holding  of  the 
sponge  too  near  the  nostrils  at  the  outset,  thus  causing  too  much  of  the  vapor  to 
be  respired  at  a  time. 

When  an  operation  to  last  but  a  few  minutes  is  to  be  performed,  it  is  proper, 
as  in  surgical  practice,  to  induce  profound  slumber,  and  to  continue  inhalation 
whilst  the  operation  is  going  on.  But  if  it  be  intended  merely  to  moderate  the 
general  excitability  of  the  female,  to  abolish  a  pain  which  is  foreign  to  the  labor, 
or  to  modify  partial,  irregular,  or  tetanic  contractions,  it  is  necessary,  after  quiet- 
ness is  obtained,  to  remove  the  sponge  in  order  to  allow  of  free  respiration,  and 
to  be  content  with  a  few  slight  inhalations  at  the  beginning  of  every  contraction. 
Three  or  four  pains  may  sometimes  be  allowed  to  pass  without  applying  the 
sponge,  having  recourse  to  it  only  when  the  patient  complains  of  sufi'ering. 
These  repeated  inhalations  are  sufficient  to  keep  the  patient  in  a  state  in  which 
self-consciousness  is  lost,  and  which  may  thus  be  prolonged  for  several  hours 
without  inconvenience.  What  we  have  to  avoid,  adds  Dr.  Simpson,  is  either  too 
much  or  too  little.  By  too  large  a  dose,  the  contractions  may  be  suspended ;  by 
too  feeble  a  one,  much  excitement  is  produced.     To  calm  the  latter,  increase  the 


ANESTHETICS    IN    LABOR.  981 

dose ;  to  remedy  the  suspension  of  the  pains,  withhold  the  chloroform  for  some 
time. 

It  is  a  singular  fact,  that  large  inhalations  are  less  likely  to  suspend  the  con- 
tractions in  the  second  than  in  the  first  stage  of  labor,  and,  consequently,  there 
is  then  less  inconvenience  in  administering  them  to  a  smaller  extent.  Let  it  not 
be  imagined,  however,  that  in  order  to  produce  complete  anaesthesia,  it  is  neces- 
sary to  carry  the  inhalations  so  far  as  to  produce  noisy  respiration,  as  in  surgical 
practice.  It  is  rarely  needful  to  go  so  far.  The  amounts  required  to  produce 
sleep  and  immobility  also  vary  greatly  in  different  individuals. 

The  patients  are  calm  during  the  intervals  between  the  pains ;  at  the  return 
of  the  contractions  they  indicate  to  the  accoucheur  by  more  or  less  motion  and 
by  slight  groaning,  that  sensation  is  not  completely  abolished,  and  that  it  is 
proper  to  repeat  the  inhalation. 

So  long  as  the  etherization  is  continued,  the  greatest  silence  should  be  main- 
tained about  the  bed  of  the  patient,  for  the  general  excitement  and  loquacity 
produced  by  the  first  doses,  are  sometimes  augmented  by  noise. 


INDEX. 


A. 


Abdomen,  enlargement  of,  in  pregnancy,  132. 

palpation  of,  143. 
Abdominal  pains  during  pregnancy,  314. 
Abnormal  pregnancies,  238. 
Abortion,  329. 

causes  of,  330. 
symptoms,  336. 
diagnosis,  340. 
prognosis,  344. 
delivery  of  after-birth  in,  345. 
production  of,  846. 
Abscesses  in  lips  of  cervix  uteri,  628. 
Adhesion  of  the  labia,  588. 
After-pains,  491. 

After-birth,  natural  delivery  of,  877. 
Aflective   faculties,   lesions   of,  during  preg- 
nancy, 31 1. 
Asshuination  of  external  orifice  of  uterus, 

626. 
Agalactia,  950. 
Allantoid,  of  the,  175. 
Albuminuria  during  pregnancy,  288. 
symptoms.  293. 

progress,  duration,  and  termina- 
tion, 293. 
mode  of  detecting,  295. 
as  a  cause  of  puerperal  convul- 
sions, 716. 
Alimentation  of  children,  922. 
Amnion,  of  the,  173,  191. 

dropsy  of  the,  302. 
Amniotic  fluid,  173. 

amount   of,   and   composition, 
193. 
Anorexia  in  pregnancy,  263. 
Animal  diet  in  functional  disorders  of  preg- 
nancy, 282. 
Ante  version  of  the  uterus,  327. 
Anchylosis  of  foetal  articulations,  644. 
Anomalies  in  the  mechanism  of  labor,  663. 
Aneurisin  complicating  labor,  767. 
Aorta,  compression  of,  to  arrest  hemorrhage, 

907. 
Apparent  death  of  the  child,  505. 

treatment,  511. 
insufflation  for, 
513. 
Appendages,  foetal,  189. 
Appendix.       On    the    use   of  anaesthetics    in 

obstetrical  practice,  969. 
Apoplexy  and  asphy.xia  of  the  child,  504. 

placental,  692. 
Articulations  of  the  pelvis,  22. 


Articulation,  sacro-vertcbral,  25. 
Arm,  presentation  of,  795. 
Ascites  during  pregnancy,  299. 
treatment  of,  301. 
of  foetus,  642. 
Asphyxia  of  the  child,  504. 
Asthma  complicating  labor,  767. 
Attentions  to  the  woman  during  labor,  467. 
child  during  labor,  477. 
woman    immediately    after 

delivery,  484. 
lying-in  woman,  500. 
child      immediately      after 
birth,  502. 
Auscultation,  applied  to  pregnancy,  150. 
mode  of  performance,  164-. 
determination     of    position    of 

child  by.  154. 
determination    of    twin    preg- 
nancy by,  153. 
determination  of  child's  health 
by,  155. 


B. 


Bag  of  waters,  394. 
Ballotiement,  147. 
Battledoor  placenta,  210. 
Baudelocque's  cephalotribe  forceps,  861. 
Bellows  murmur,  156. 
Bile,  secretion  of,  in  foetus,  232. 
Blastodermic  membrane,  171. 
Blindness,  caused  by  hemorriiage,  700. 
Blood,  composition  of,  in  pregnancy,  278. 

alteration   of,    as    cause   of   secondary 
hemorrhage,  915. 
Bodies  of  Rosenmuller,  63. 
Blunt  hook,  792. 
Blot's  perforator,  8r,7. 
Botal,  foramen  of,  212,  233. 
Bony  tumors  of  pelvis  resulting  from  defor- 
mities, 597. 
Breasts,  changes  in,  from  pregnancy,  129. 
Breech  presentation,  444. 
Broad  ligaments,  62. 

cysts  of,  63. 

C. 

Cavity  of  the  pelvis,  33. 

dimensions  of.  33. 
diameters  of,  33. 
general  arrangement  of,  34. 
axis  of,  34. 


984 


INDEX. 


Caninculae  myrliformes,  45. 
Catheter,  mode  of,  introduction  of,  43. 
Canal  of  Nuck,  64. 

Caulifliiwer  tumors  of  the  uterus,  611. 
Callipers,  Baudelocque's,  568. 
Cancer  of  neck  of  uterus,  629. 
Ca2sarean  operation,  859. 

mode  of  operating,  864. 
vaginal,  865. 
Cervix  uteri,  induration  with  hypertrophy  of, 
628. 
obliteration  of,  630. 
Cephalalgia,  caused  by  hemorrhage,  700. 
Cephalic  version,  772. 
Chorion,  195. 

villi  of,  203. 
Chlorosis  in  pregnancy,  280,  364. 
Child,  healthy,  management  of,  502. 

diseased  or  feeble,  management  of,  504, 
attentions  to,  immediately  after  birth, 

502. 
apparent  death  of,  505. 
apoplexy  of,  504. 
asphyxia  of,  505. 
lesions  of  respiration  of,  508. 
circulation,  510. 
nervous  centres,  511. 
debility  of,  516. 
Chloroform,  used  to  facilitate  version,  7S4. 
Circulation  of  foetus,  232. 

changes  in,  after  birth, 
235. 
lesions  of,  during  pregnancy,  275. 
Clitoris,  42. 
Coccyx,  20. 
Coxal  bone,  20. 
Corpora  lutea,  76. 

discrimination  bet\veen,in  preg- 
nancy or  otherwise,  79. 
Conception,  95. 

opposing  causes  of,  99. 
Constipation  in  pregnancy,  274. 
Congestion,  uterine,  in  pregnancy,  283. 

as    cause   of    hemorrhage 
alter  delivery,  913. 
Cough  and  dyspnoea  during  pregnancy,  274. 
Colostrum,  497,  923. 
Congenital  luxation  of  the  femur,  551. 
Convulsions,  puerperal.  713. 

statistical  table  of,  714. 

causes  of,  715. 

proportional   occurrence   in  pri- 

miparffi,  717. 
local  causes  of,  718. 
symptoms,  720. 
phenomena  of  attack,  721. 
suppression  of  urinary  secretion 

in,  723. 
terininations  of,  725. 
ruptures  of  uterus,  from,  727. 
meningitis  from,  727. 
intestinal  inflammation  from,  727 
diagnosis,  728. 
prognosis,  729. 
dangers  to  foetus  from,  731. 
pathological  anatomy  of,  732. 
nature  of,  733. 
treatment,  736. 
tartar  emetic  for,  737. 
bleeding  for,  737. 
chloroform  for,  738. 
general  measures  for,  738. 
use  of  Junod's  apparatus  for,  740, 


Convulsions,  special  measures  for,  742. 

treatment  of,  during  gestation, 
742. 
during  labor,  744. 
after  delivery,  747. 
Complicated  positions,  670. 
Cord,  prolapsus  of,  652. 
shortness  of,  657. 

constriction  of  neck  of  child  by.  657. 
rupture  of  one  of  its  vessels,  685. 
hejnorrhage  from,  915. 
Cramps  during  labor,  523. 
Craniotomy,  867. 
Cystocele,  619. 


D. 


Decidua,  of  the,  177. 
reflex,  178. 

external  or  uterine,  178. 
serotina    or    inter-utero-placental, 

180. 
theory  of,  180. 
Death,  sudden,  during  or  after  labor,  400. 

of  loBtus  from  hemorrhage,  697. 
Debility  of  the  child.  516. 
Deformities  of  the  pelvis,  533. 

pathological  anatomy  of,  536. 
causes  and  mode  oi  production, 

546. 
dependent  on  previous  deformity 
of  another  part  of  the  skeleton, 
550. 
influence  of,  upon  pregnancy  and 

parturition,  557. 
rational  signs  of.  564. 
sensible  signs  of,  567. 
indications  presented  by,  582. 
indications  presented    by,   when 
the  smallest  diameter  is  at  least 
three  and  three-quarter  inches, 
583. 
indications  presented  by,  when 
the  largest    diameter  is    three 
and       three-quarter        inches, 
and     the    smallest     two     and 
a  half  inches,  585. 
indications    presented   by,  when 
the  diameterus    are   less    than 
two  and  a  half  inches,  587. 
of  the  foetus,  644. 
Decapitation  of  foetus  in  trunk  presentations, 

875. 
Delivery  of  the  after-birth,  877. 
Dentition,  941. 
Diameters  of  the  foetal  head  at  term.  220. 

of  foetal  head  from  the  32d  to  the 

37th  week,  834. 
of  the  pelvis,  30.  33. 
Diseases  of  pregnancy,  261. 

of  the  ovum,  as  a  cause  of  abortion, 

331. 
of  the  womb  and  its  appendages,  as 

causes  of  abortion,  333. 
occurring  during  pregnancy,  356. 
and  accidents  that  may  coinplicate 
pregnancy  and  require  the  inter- 
vention of  art,  674. 
that  may  complicate  labor,  766. 
of  the  foetus,  639. 
Digestion,  lesions  of,  during  pregnancy,  263. 
Diarrhoea  during  pregnancy,  274. 


INDEX. 


9^'5 


Disposition  to  falling,  310. 
Displacements  ot  liie  uterus,  in  relation  to  the, 
accidents  they  mav  cause  during  pregnancy, 
317. 
Distension  of  bladder,  efi'ect  of,  upon  labor, 

524 
Dropsy  of  cellular  tissue  during  pregnancy, 
297. 
progress  and  symp- 
toms of,  297. 
terminations,  298. 
prognosis,  298. 
treatment,  299. 
of  the  amnion,  302. 
the  foetus,  305. 
Duct  of  Gartner,  68. 
Ductus  arteriosus,  233. 

venosus,  234. 
Dyspncea  during  pregnancy,  274. 
Dystocia,  517. 

E. 

Eclampsia.  713. 

Effect  of  bleeding  and  a  debilitating    regimen 

upon  the  development  of  the  child,  850. 
Embryonic  spot,  172. 
Emphysema  occurring  during  labor,  400. 
Emphysematous  condition  of  fcEtus,  643. 
Embryotomy,  866. 

forceps,  Baudelocque's,  869. 

Cazeau.\'s    modifica- 
tion of,  870. 
Endochorion,  195. 
Epilepsy  during  pregnancy,  364. 
Eruptive  fevers  during  pregnancy,  358. 
Ergot,  natural  history  of,  526. 

therapeutical  action  of,  527.J 
External  parts  of  generation,  39. 

secretory  apparatus  of,  45. 
Examination,  anal,  150. 
Exochorion,  195. 
Extra  uterine  pregnancy,  244. 
Exhaustion  in  labor,  symptoms  of,  519. 

from    disease,    as    complicating 
labor.  769. 
Excavation,  tumors  in,  595. 
Exostosis  in  cavity  of  pelvis, '^596. 


Fallopian  tubes,  65. 

structure  of,  65. 
fimbriated  extremities,  super- 
numerary, 66. 
changes  of,  during  gestation, 

66. 
tumors  of,  615. 
False  kidneys,  213. 
waters.  307. 
pains,  <J68. 
labor,  469. 
Falling,  disposition  to,  310. 
of  the  womb,  317. 
of  the  cord,  652. 

prognosis  of.  654. 
treatment,  655. 
Face  presentations.  431. 

inclined  positions  of,  665. 
Fecundation,  place  of  occurrence,  97. 
Fevers  during  pregnancy,  typhoid,  358. 
eruptive,  358. 
intermittent,  361. 


Flooding,  external,  691. 
internal,  691. 
seat  of  effusion  in,  691. 
Fossa,  navicularis,  45. 

Fcetal  opAiings,  period  of  obliteration  of  after- 
birth. 235. 
mode  of  obliteration  of,  236, 
appendages,  189. 
head,  at  term,  218. 

diameter  of,  220. 
circumference  of,  221, 
Foetus,  of  the,  210. 

dimensions  and  weight  of,  at  different 
periods  of  intra-uierine  life,  212-217. 
position  and  attitude  in  the  uterus,  223. 
functions  of,  226. 
respiration  of.  230. 
nutrition  of,  226. 
secretions  of,  232. 
circulation  of,  232. 
dropsy  of,  305. 
diseases  of,  639. 

emphysematous  condition  of,  643. 
tumors  of,  643. 
deformities  of,  644. 
excess  of  volume  of,  644. 
malpositions  of,  661. 
Foetuses,  multiple  and  adherent,  645. 

multiple  and  independent,  647. 
Foramen  of  Botal,  212,  233. 
Fontanelles,  218. 

anterior  and  posterior,  219. 
Forceps,  of  the,  790. 

Smellie's.  797. 

Levret's,  797. 

Simpson's;"799. 

use  of,  preliminary  precautions,  799. 

general  rules  of  application,  801. 

Hutin's  method  of  applying,  802. 

special  rules  of  application,  807. 

application  of,  in  vertex  positions,  at 

the  inferior  strait,  807. 
application   of,   in   vertex   positions, 
when  the  head  is  merely  engaged 
at  the  superior  strait,  812. 
application    of,    when    the    head    is 
movable  above  the  superior  strait, 
813. 
application  of,  in  face  positions,  815. 
when     the    head     re- 
mains after  the  body 
isexpelled,818. 
general  considerations  on  the  employ- 
ment of,  820. 
use  of,  in   inclined  vertex,  or  face 

positions,  820. 
use  of,  in  contracted  pelves,  821. 
use  of,  in  case  of  accident  requiring 

immediate  delivery,  825. 
use  of,  on  account  of  resistance  of 

muscles  of  the  perineum,  825. 
statistics  of  use  of,  and  general  views 

of  the  operation,  827. 
dangers  to  the  foetus  from  use  of, 
828. 
Fourchette,  40. 

G. 

Gartner,  duct  of,  68. 
Galactorrhoca,  950. 
Generation,  external  organs,  39. 
internal  organs,  49. 


986 


INDEX. 


Generation,  95. 
Germinal  vesicle,  72. 

spot,  72. 
Gestation,  ]01. 

displacement  of  bladder    during, 
127. 

vesical  tenesmus  during,  127. 

pathology  of,  261. 
Giddiness  during  pregnancy,  312. 
Glans  clitoridis,  42. 
Gland  vulvo-vaginnl,  46. 
Glairy  discharges  during  labor,  393. 
Graafian  vesicle,  69. 
Granular  vaginitis,  296. 

H. 

Hand  or  arm  presentation,  795. 
Hernia,  congenital,  208. 

intestinal  or  omental,  618. 
vaginal,  618. 
vagino- labial,  618. 
vulvar  or  perineal,  619. 
vesical  or  cystocele,  619. 
of  the  womb,  637. 
complicating  labor,  768. 
Head  of  foetus  at  term,  218. 

presentation,  cause  of,  224. 
Hemorrhoids  during  pregnancy,  285. 
Hemorrhage,  puerperal,  675. 

causes,  675. 

predisposing  causes,  675. 
determining  causes,  680. 
special  causes,  682. 
symptoms,  690. 
general  symptoms,  691. 
local  symptoms,  691. 
diagnosis,  692. 
internal,  diagnosis  of,  696. 
prognosis,  697. 
^  treatment,  701. 

general  treatment,  702. 
special  treatment,  702. 
moderate,  occurring  in  the  three 

last  months,  702. 
proiuse,    occurring  in   the   last 

three  months,  703. 
rupture    of    membranes    as    a 

remedy  for,  706. 
internal  treatment  of,  708. 
moderate,  during  labor,  709. 
profuse,  during  labor,  709. 
table  showing  treatment  of,  be- 
fore and  after  labor,  711. 
complicating    delivery    of    the 

after-birth,  899. 
causes,  899. 
symptoms,  900. 
diagnosis,  902. 
treatment,  903. 
compression  of  aorta  for,  907. 
transfusion  for,  910. 
secondary,  912. 

from  congestion  of  uterus,  913. 
from  alteration  of  the  blood,  915. 
from  the  umbilical  cord,  915. 
Hemoptysis  complicating  labor,  767. 
Hematemesis  complicating  labor,  767. 
Heart,  chronic  diseases  of,  complicating  labor, 

767. 
Hour-glass  contraction  of  the  uterus,  886. 
Hymen,  43. 

varieties  of,  44. 
persistence  of,  589. 


Hydrorrhoea,  306. 

Hysteria  during  pregnancy,  364. 

Hygiene  of  the  lying-in  woman.  500. 

of  children   from   birth    to   time   of 
weaning,  922. 
Hydrocephalus,  639. 

Hydrothorax  and  ascites  of  the  fcEtus,  642. 
Hysterotomy,  864. 


Icterus  during  pregnancy,  360. 
Ilium,  22. 

Iron,  use  of,  in  functional   disorders  of  preg- 
nancy, 282. 
Inferior  strait,  31. 

plane  of,  32. 

variations  in  plane  of,  32. 
axis  of,  32. 

variations  in  a.xis  of,  33. 
diameters  of,  33. 
extremities,  lesions  of,  555. 
Innervation,  lesions  of,  during  pregnancy,  311. 
Intellectual  faculties,  lesions  of  during  preg- 
nancy, 311. 
Inguinal  pains  during  pregnancy,  314. 
Intermittent  fever  during  pregnancy,  361. 
Inflammation  of  the  pelvic  articulations  dur- 
ing pregnancy,  310. 
Inflammations  caused  by  hemorrhage,  700. 
Inspiration,  cause  of  the  first  act  of,  506. 
Inclined  positions  of  the  vertex,  662. 
of  the  pelvis   665. 
of  the  face,  665. 
Insertion  of  the  placenta  upon  the  lower  seg- 
ment of  the  uterus,  682. 
Induction  of  premature  labor,  831. 
Inertia  of  the  womb,  884. 

secondary,  912. 
Inversion  of  the  uterus,  916. 

spontaneous  reduction 
of,  919. 
Infants,  hygiene  of,  922. 
feeding  of,  922. 
nursing  of,  929. 
clothing  of,  966. 
bathing  of.  966. 
aeration  of,  967. 
sleep  of,  968. 
exercise  of,  968. 
Ischium,  22. 
Itching  of  the  skin  during  pregnancy,  313. 


J. 

Junod's  apparatus,  740. 

application  of,  for  convul- 
sions, 740. 

K. 

Kidneys,  false,  213. 

Kiwisch's  method  of  inducing  premature  la- 
bor by  use  of  injections,  8H. 

Kluge's  method  of  dilating  tlie  os  uteri  for 
inducing  premature  labor,  841. 

Kyesteine,  136. 


Labia  majora,  structure  of,  40. 

peculiar  pouch  in,  40. 


INDEX. 


987 


Labia  interna,  41. 

adhesion  of,  588. 
externa,  oedema  of,  598. 
Labor,  in  general.  371. 
premature.  37L 
retarded,  374. 
natural,  at  term,  376. 
causes  of,  37(i. 
duration  of,  396. 

physiological  phenomena  of,  384. 
pain  or  contraction,  388. 
glairy  discharges  during,  393. 
effect  of,  on  mother  and  child,  399. 
mechanical  phenomena  of,  402. 
false,  469. 

pains,  true,  characters  of,  468. 
preternatural  and  painful,  517. 
tedious,  520. 

rendered  difficult,  impossible,  or  dan- 
gerous, by  deficiency  or   excess  of 
action  of  the  expulsive  forces,  518. 
extreme  slowness  of,  518. 
exhausiion  in,  symptoms  of,  519. 
too  rapid,  530. 
treatment  of,  532. 

rendered  difficult,  irhpossible,  or  dan- 
gerous, by   obstacles   opposing  the 
ready  e.xpulsion  of  the  fcetus,  533. 
anomalies  in  the  mechanism  of,  663, 
premature,  induction  of,  831. 
Lactation,  923. 

Leucorrhea  during  pregnancy,  296. 
Levret's  forceps,  797. 
Ligaments,  pubic,  23. 

sacro-scialic,  24. 
sacro-iliac,  24. 
sacro-coccygeal,  25. 
softening  of,  25. 
broad,  62. 
round,  64. 
vesico-uterine,  64. 
utero-sacral,  64. 
Line  traversed  by  fnmus,  38. 
Locomotion,  lesions  of,  308. 
Lochia,  of  the,  493. 

absence  of,  495. 
effect  of  lactation  upon,  495. 
substituted  by  hematemesis,  495. 
long-continued,  496. 
profuse  and  purulent,  497. 
Lumbar  pains  during  pregnancy,  314. 
Luxation  of  the  femur,  congenital,  551. 

non-congenital,  555. 

M. 

Mammae,  changes  in,  from  pregnancy,   129, 
130. 
changes  of,  as  a  sign  of  pregnancy, 
134. 
JVIalacia,264. 
Malformations  of  the  vulva  and  vagina,  588, 

of  ihe  vagina,  588. 
Malpositions  of  the  I'ceIus,  661. 
Maternal  nursing,  661. 
Meatus  urinarius,  43. 
Menstruation,  82. 

time  of  beginning,  83. 

premature,  86. 

duration  of,  87. 

amount  of,  87. 

seat  of,  87. 

from  vagina,  case  of,  88. 


Menstruation,  cause  of,  90. 

cessation  of,  93. 
effect  of,  upon    the  quality  of 
the  milk,  927. 
Menses,  suppression  of,  in  pregnancy,  131. 

continuation  in  pregnancy,  131. 
Membrane,  blastodermic,  171. 

intermediate    or  utero-epichorial, 

185. 
epichorial,  155. 
anhistous,  188. 
Meconium,  232. 
Measles  during  pregnancy,  359. 
Mental  diseases  during  pregnancy,  364. 
Milk  fever,  497. 

cause  of,  499. 
suppression  or  prevention  of  the  secre- 
tion, 499. 
qualities  of,  923. 
induced  secretion  of,  925. 
quantity  of,  925. 

influence  of  health  of  mother  upon,  926. 
moral  afl'ections  upon,  926. 
genital  functions  upon,  927. 
alimentary    or    medicinal, 
substances  upon,  929. 
affected  by  general  health  of  the  mo- 
ther, 926,  950. 
alterations  in  the  quality  of,  926,  950. 
poor,  effects  of,  952. 
over-rich,  effects  of,  952. 
altered  by  colostrum,  953. 
altered  by  pus,  953. 
Mons  veneris,  39. 
Monstrosity  by  inclusion,  243. 
Monstrosities,  645.    ■ 
Movements  of  the  child  in  utero,  146. 

passive,  of  child,  in  utero,  147. 
Mucous  membrane  of  uterus,  hypertrophied, 
182. 
utero-epichorial,  204. 
Multiple  and  adherent  foetuses,  645. 

independent  fiaetuses,  647. 


N. 


Nipple,  affections  of,  945. 
Nuck,  canal  of,  64. 
Nutrition  of  foetus,  226. 
Nursing  of  children,  929. 
maternal,  930. 

obstacles  to,  944. 
rules  to  be  observed  dur- 
ing, 932. 
accidents  liable  to  inter 
fere  with,  950. 
mixed,  954. 
by  wet  nurses,  956. 
by  a  female  animal,  963. 
artificial,  964. 
children,  food  for,  940. 
mothers,  regimen  of,  943. 
Nurses,  selection  of,  9.i7. 

regulation  of  nursing,  by,  961. 
regimen  of,  962. 
Nymphse,  41. 


O. 


Obturator  membrane,  26, 
Obliquities  of  the  uterus,  329. 


988 


INDEX. 


Oblique-oval  pelvis,  540. 
Obliquity  ot  uterine  orifice,  624. 
of  the  uterus,  631. 
anterior,  631. 
posterior,  632. 
lateral,  635. 
Obliteration  of  neck  of  uterus,  630. 
Obstacles  to  delivery  dependent  on  the  body 
of  the  womb,  631. 
dependent  on  the  foetus 
or  its  appendages, 639. 
maternal  nursing,  944. 
Obstetrical  operations,  769. 
(Edema  of  labia  externa,  598. 
Omphalo-mesenteric  vessels,  175. 
Operations  for  producing  premature  labor,  838. 
Outrepont  and  Ritgen'sme- 

thod,  838. 
Dr,  Hamilton's  method.  838. 
Dr.  Cohen's  method,  839.1 
by  puncture  of  membranes, 

839. 
Meissner's  plan,  840. 
Kluge's  method,  841. 
Schoeller's  method,  843. 
Kiwisch's  method,  844. 
Os  tincae.  56. 

Osteo-sarcoma  of  pelvis,  597. 
Ovula  Nabothi,  61. 
Ovaries,  the,  67. 

ligaments  of,  67. 
structure  of,  69. 
Ovarian  vesicles,  69. 

modifications  of,  73. 
Ovule,  70. 

size  of  the,  71. 
Ovulation,  spontaneous,  81. 
Ovum,  human,  after  fecundation,  168. 
development  of,  169. 
changes  of,  in  the  tube,  169. 
modifications  of,  in  the  womb, 
until  after  the  development 
of  the  allantoid,  171. 
modifications  of,  from  develop- 
ment of  the   allantoid,  until 
end  of  gestation,  188. 
diseases  of,  as  a  cause  of  abor- 
tion, 331. 
Ovary,  tumors  of,  612. 


Padjeras,  92. 

Pathology  of  gestation,  261. 
Pains  during  pregnancy,  abdominal.  314. 
inguinal,  314. 
lumbar,  314. 
uterine,  315. 
of  labor,  388. 
^^       slowness  or  feebleness  of,  520. 
relaxation  or  suspension  of,  523. 
irregularity  of,  524. 
Paralysis,  lacial,  of  new-born  children,  from 

use  of  forceps,  828. 
Pelvis,  17. 

in  general,  26. 
external  surface  of,  26. 
internal  surface  of,  27. 
greater,  27. 
lesser,  27. 

inclined  planes  of,  28. 
straits  of,  29,  31. 
cavity  of,  33. 


Pelvis,  base  of,  35. 

differences  of,   according  to  age   and 

sex,  35. 
uses  of,  36. 

covered  by  soft  parts,  36. 
deformities  of,  533. 

deformed,  by  excess  of  amplitude,  533. 

retraction,  535. 

simple  contracted,  without   curvature 

or  malformation  of  the  bones,  536. 
contracted  by  curvature  and  malforma- 
tion of  the  bones,  537. 
oblique-oval,  540. 
degrees  of  contraction  of,  546. 
variations  in  depth  of,  546. 
causes  and  mode  of  production  of  de- 
formities of,  546. 
deformed  by  rachitis  or  mollities  os- 

sium,  547. 
deformity  of,  dependent  on  previous 
deformity  in    another    part    of  the 
skeleton,  550. 
;  deformed  by  absolute  narrowness, 556. 
influence  of  deformities  of,  upon  preg- 
nancy and  parturition,  557. 
having  at  least  three  and  three-quarter 

inches  in  its  contracted  part,  560. 
having  at  least  two  and  a  half  inches 

in  its  contracted  part,  561. 
in  which  the   contracted   diameter  is 
less  than  two  and  a  half  inches,  562. 
deformities  of,  diagnosis,  564. 
indications  presented  by  deformities 

of,  582. 
exostosis  of  excavation,  596. 
osteo-sarcoma  of,  597. 
bony  tumors  of,  resulting  from  defor- 
mities, 597. 
inclined  position  of  the,  665. 
Pelvic  canal,  outlet  of.  38. 

articulations,  relaxation  of,  308. 

inflammation  of,  310. 
version,  necessary  conditions  for,  776. 
general  rules  of  the  operation, 

777. 
introduction  of  the  hand,  777. 
evolution  of  the  foetus,  779. 
extraction  of  the  foetus,  780. 
difficulties    that   may  be   met 
with  in  its  performance, 783. 
smallness  of  the  vulva,  783. 
resistance  of  the  uterine  orifice, 

783. 
insertion  of  the  placenta  on  the 
neck  of  the  uterus,  784. 
Pelvimetry,  567. 

by  the  finger,  578. 
Pelvimeter,  internal.  570. 

Couiouly's,  570. 
Stein's,  570. 
Wellenberg's,  571. 
Van  Huevel's,  571. 
Perineum,  extent  of,  37. 

rigidity  or  resistance  of,  591. 
Perforator,  Blot's,  867. 
Phthisis,  during  pregnancy,  363. 
Phenomena  appertaining  to  the  lying-in  state, 

485. 
Pica  or  malacia,  264. 
Placental  murmur,  156. 
apoplexy,  692. 
adhesions,  890. 
Placenta,  195. 


INDEX. 


989 


Placenta  baltledoor,  195,  210.  I 

multiple,  1%. 
structure  oi,  197. 
arteries  of,  199. 
veins  of,  199. 
insertion  of,  upon  lower  segment  of 

uterus,  682. 
perforation  of,  by  head  of  the  foetus, 

697. 
expulsion  of,  before  birth  of  child, 698. 
natural  delivery  of,  877. 
mode  of  e.xtraciing,  880. 
delivery  of,  in  twin  labor,  883. 
artificial  delivery  of,  883. 
excessive  volume  of,  885. 
encystment  of,  888. 
encasement  of,  888. 
abnormal  adhesions  of,  890. 
partial  or  complete  retention  of,  894. 
putrid  absorption  of,  895. 
late  expulsion  of,  896. 
complete  absorption  of,  897. 
accidents  that    may    complicate    its 
delivery — hemorrhage,  899. 
Pneumonia  during  pregnancy,  359. 
Positions  of  fcetus,  determined  by  ausculta- 
tion, 154. 
of  the  trunk,  669. 
complicated,  670. 
Position  left  anterior  occipiio-iliac — mechan- 
ism of  natural  labor  in,  415. 
right  anterior  occipito-iliac — mechan- 
ism of  natural  labor  in,  421. 
Polypus  of  the  body  and  neck  of  the  uterus, 

610. 
Pregnancy,  diagnosis  of,  130. 

rational  signs  of,  131. 
sensible  signs  of,  140. 
abnormal,  238. 
multiple,  statistics  of,  238. 

causes  of,  239. 
extra-uterine,  244. 

varieties  of,  244,  249. 
pathological  changes  in, 

249. 
progress  of,  252. 
causes  of,  25.'>. 
terminations  of,  253. 
treatment  of,  259. 
diseases  of,  261. 
lesions  of  respiration  during,  274. 

circulation,  275. 
composition  of  the  blood  during, 

278.  _ 
chlorosis  during,  mistaken  for  ple- 
thora   as   producing   functional 
disorders,  280. 
plethora  during,  282. 
uterine  congestion  during,  283. 
varices  during,  285. 
hemorrhoids  during,  285. 
lesions  of  secretion  and  excretion 

during,  286. 
ptyalism  during,  286. 
secretion  and  excretion  of  urine 

during,  287. 
albuminuria  during,  288. 
uraemia  during,  288. 
leucorrhcRa  during,  296. 
dropsy  of  cellular  tissue  during, 

297. 
ascites  during,  299. 
lesions  of  locomotion  during,  308. 


Pregnancy,  relaxation  of  pelvic  articulations 
during,  308. 
disposition  to  falling  during,  310, 
lesions  of  innervation  during,  311. 
lesions  oi  sensorial  faculties  dur- 
ing, 311. 
lesions  of  affective  faculties  dur- 
ing, 311. 
lesions  of  intellectual  faculties  dur- 
ing, 311. 
vertigo  during,  312. 
giddiness  during,  312.  • 

syncope  durint;,  312. 
pruritus  of  vulva  during,  313. 
itching  of  skin  during,  313. 
abdominal  pains  during,  314. 
lumbar  pains  during,  314. 
inguinal  pains  during,  314. 
uterine  pains  during,  315. 
displacements  of  the  uterus,  in  re- 
lation to  the  accidents  they  may 
occasion  during,  317. 
diseases  occurring  during,  356. 
epidemic  diseases  during,  356. 
spasmodic  diseases  during,  356. 
chronic  diseases  during,  360. 
surgical  diseases  during,  365. 
typhoid  fever  during,  358. 
eruptive  fevers  during,  358. 
intermittent  fever  during,  361. 
pneumonia  during,  359. 
icterus  during,  360. 
syphilis  during,  361. 
phthisis  during,  363. 
hysteria  during,  364. 
epilepsy  during,  364. 
mental  diseases  during,  364. 
chlorosis  during,  364. 
tumors  in  the  abdomen  and  pel- 
vis during,  365. 
ulceration  of  neck  of  uterus  dur- 
ing, 366. 
efTect  of,  upon  the  lacteal  secre- 
tion, 928. 
Presentations  and  positions,  classification  of, 

by  various  authors,  402-412. 
Presentation  of  the  face,  431. 

frequency  of,  431. 
causes,  432. 
diagnosis,  433. 
inclined  or  irregular, 

441. 
prognosis  of,  442. 
pelvic  extremity,  444. 
causes  of,  445. 
•^  diagnosis,  446. 

mechanism,  448. 
prognosis,  453. 
trunk,  456. 

causes  of,  457. 
diagnosis,  459. 
mechanism,  461. 
prognosis,  466. 
Preternatural  and  painful  labor,  517. 
Premature  labor,  cases  requiring  it,  832. 

on  account  ot  abdominal  tu- 
mors, 836. 
on  account  of  smallness  of 

abdominal  cavity,  836. 
on  account  of  nervous  dis- 
orders, 836. 
on  account  of  intercurrent 
acute  diseases,  837. 


990 


INDEX. 


Premature  labor,  on  account  of  death  of  fcEtus 
in  preceding  pregnancies, 
837. 
operai  ions  for  inducing,  838. 
Precautions  to  be  observed  by  nursing  wo- 
men, 931. 
Pruritus  of  the  vulva  during  pregnancy,  313. 
Prolapsus  uteri,  317,  638. 

oi  the  cord,  652. 
Production  of  abortion,  846. 

modes  of  operating  for, 
848. 
Ptyalism,  286. 
Pubis,  22. 

arch  of,  31. 
symphysis  of,  22. 
Pubic  ligaments,  23. 
Puerperal  hemorrhage,  675. 
convulsions,  712. 

R. 

Rapid  contraction  of  the  uterus  as  a  cause  of 

hemorrhage,  693. 
Respiration  of  foetus,  230. 

lesions  of,  daring  pregnancy,  274. 
Relaxation  of  the  pelvic  articulations,  308. 
Retroversion  of  the  uterus,  321. 

treatment  of,  324. 
Regimen  of  the  woman  in  labor,  482. 
the  nursing  mother,  943. 
Rectum,  tumors  of  the,  615. 

scirrhus  of,  615. 
Rheumatism  of  the  uterus,  469,  762. 
causes,  762. 
symptoms,  763. 
influence  of,  upon  the  progress 

of  gestation,  764. 
influence    of,    upon  the  labor, 

764. 
influence  of,  upon  the  puerperal 

functions,  765. 
prognosis,  766. 
treatment,  766. 
Rigidity  or  resistance  of  the  perineum,  591. 

of  the  neck  of  the  uterus,  621. 
Rosenmuller,  bodies  of,  63. 
Round  ligaments,  64. 
Rotation  of  the  head,  421,  424,  428. 
Rupture    of  the    respiratory    organs   during 
labor,  400. 
uterus,  747. 
causes,  748. 

predisposing  causes,  748. 
determining  causes,  750. 
external  or  traunjiiifc  causes, 

750.  ^^ 

internal  causes,  751. 
symptoms,  752. 
prognosis-   and  terminations, 

754. 
pathological  anatomy,  756. 
treatment,  758. 
vagina,  760. 
Rupture  of  the  cord  or  of  one  of  its  vessels, 
685. 


S. 


Sacrum,  18. 

Saw  forceps,  Van  Huevel's,  872. 

Sanguineous  tumors  or  thrombus,  598. 


Scarlatina  during  pregnancy,  359. 

Scirrhus  of  the  rectum,  615. 

Secretions  of  fcEtus,  232. 

Secretion   and  excretion,    lesions  ^of,  during 

pregnancy,  286. 
Sensorial  faculties,  lesions    of,  during  preg- 
nancy, 311. 
Secale  cornutum,  526. 
Secondary  hemorrhage,  912. 
Sexual  intercourse,  effect  of,  upon  the  quality 

of  the  milk,  928. 
Shoulder  presentation,  457. 
Shortness  of  the  cord,  ()57. 

labor  delayed  by,  658. 
Signs  of  life  or  death  of  the  child  during  labor, 

470. 
Simpson's,  Prof.,  plan  of  removing  placenta 
for  arresting  hemorrhage 
in  placentalpresentations, 
709. 
substitute  for  forceps,  799. 
Skin,  itching  of,  during  pregnancy,  313. 
Smellie's  scissors,  867. 
forceps,  797. 
Sound  of  the  foetal  heart,  151. 
Souffle,  abdominal,  156. 
uterine,  156. 

seat  and  mode  of  production,  158-164. 
Soft  parts,  tumors  appertaining  to,  598. 
Spontaneous  ovulation,  SI. 
version,  461. 
evolution,  463. 
Spermatozoa,  96. 

office  of,  98. 
Spermatic  granules,  96. 

fluid,  characters  of,  95. 
Spasmodic  contraction  of  the  neck  of  the  ute- 
rus, 622. 
Superior  strait,  29. 

plane  and  axis  of,  29. 
inclination  of,  29. 
diameters  of,  30. 
Sutures,  219. 

Suckling,  when  to  be  commenced,  932. 
means  of  facilitating,  933. 
obstruction   to,  from    shortness   of 
the    fraenum    linguae,    sublingual 
tumors,hare- lip, facial  hemiplegia, 
debility  of  child,  933-935, 
regulation  of,  935. 
regular  times  for,  936. 
Swelling  and  elongation  of  anterior  lip  of  cer- 
vix, 627. 
Symphysis  pubis  22. 

sacro-iliac,  23. 
sacro-coccygeal,  24. 
Syncope,  during  pregnancy,  312. 
complicating  labor,  768. 
Syphilis  during  pregnancy,  361. 
Symphyseotomy,  853. 

eff'ects  of,  854. 
indication  for,  855. 
operation,  857. 
Stoltz's  method,  858. 
Imberi's  method, 858. 

T. 

Table  of  the  signs  of  pregnancy  at  various 
periods,  165. 
showing  treatment  of  external  hemor- 
rhage before  and  after  labor,  711. 
statistical,  of  convulsions,  114. 


INDEX. 


991 


Tampon,  701. 
Tlirombus,  598. 

irciUinent  of,  602. 
of"  lips  of  the  neck  of  the  uterus, 
60(i. 
Touch,  of  the,  140. 

vaginal,  140. 
Tongue-tie,  operation  for,  934. 
Trunk  presentation,  456. 

positions  of  the,  669. 
Transfusion  for  hemorrhage,  911. 
Tumor  of  the  scalp,  as  means  of  determining 

the  life  or  death  of  the  child,  470. 
Tumors  in  tlie  excavation,  595. 

abdomen    and    pelvis  during 
pregnancy,  365. 
appertaining  to  the  soft  parts,  598. 
sanguineous,  598. 
various,  (>07. 
appertaining  to  the  neck  or  body  of 

the  uterus,  607. 
fibrous,  of  the  cervix  uteri,  608. 
fungous,  or  cauliflower  of  the  uterus, 

611. 
of  parts  adjacent  to  the  uterus,  61'^. 
of  the  ovary,  612. 
of  the  Fallopian  tube,  615. 
of  the  rectum,  615. 
hernial,  618. 
of  the  foetus,  643. 
Twin  pregnancy,  238. 

pregnancies,  table  of  presentations  in, 
647. 
delayed    delivery    of    the 
second  child,  648. 
difficultiesofdelivery  in,  650. 
Typhoid  fever  during  pregnancy,  358. 


U. 


Ulceration  of  the  neck  of  the  uterus  during 

pregnancy,  3i)6. 
Umbilical  vesicle,  175. 

arteries  and  vein,  175,  233. 
cord,  19-2.207. 

length  of,  208. 

nerves  and  lymphatics  of,  208. 
prolapsus  of,  652. 
weakness  of,  885. 
hemorrhage  from,  915. 
Urethra,  43. 

dilatation  of,  43. 
Urine,  alterations  of,  during  pregnancy,  134. 
secretion  and  excretion  of,  during  preg- 
nancy, 287. 
alteration  of,  in  Bright's  disease,  295. 
mode  of  delecting  albumen  in,  295. 
secretion  of,  in  foetus,  232. 
Urachus,  190. 

Uraemia,  as  cause  of  convulsions,  734. 
Uterus,  the,  53. 

cavity  of  body,  58. 

anteflexion  of,  54. 

cavity  of  the  neck,  58. 

external  surface  of,  55. 

structure  of,  59. 

neck  of,  56. 

internal  surface  of,  58. 

internal  or  mucous  membrane,  60. 

structure  of  mucous  membrane  of,  61, 

development  of,  62, 


Uterus,  ligaments  of,  62. 
vessels  of,  62. 
nerves  of,  62. 

changes  in  l)ody  of,  by  pregnancy,  102. 
in  neck  of,  by  pregnancy,  108, 
in  te.xture  and  pioperties  of, 
by  pregnancy,  113. 
serous  coat  of,  114. 
mucous  coat  of,  1 14. 
middle  or  muscular  coat  of,  115. 
vessels  of,  1 18. 
nerves  of,  120. 
properties  of,  121. 
organic  contractility  of,  122. 
contractility  of  tissue  of,  124. 
relations  of,  at  term,  125. 
changes  in  neighboring  parts,  126. 
hypertrophied  mucous  membrane  of, 

182. 
displacements  of,  317. 
prolapsus  of,  317,  638. 
faulty  directions  of,  321. 
retroversion  of,  321. 
anteversion  of,  327. 
obliquities  of,  329. 

ulceration  of  neck  of,  during  preg- 
nancy, 366. 
changes  in,  after  delivery,  487. 
sanguineous  tumors,  or  thrombus  of 

lips  of  neck,  606. 
tumors  appertaining  to  neck  or  body 

of,  6u7. 
fibrous  tumors  of  cervix,  608. 
polypus  of  body  or  neck,  610. 
fungous  or  cauliflower  tumors  of,  611. 
tumors  of  parts  adjacent,  612. 
obstacles  presented  by  neck  and  body 

of,  621. 
rigidity  of  neck  of,  621. 
spasmodic  contraction  of  neck,  622. 
obliquity  of  orifice,  624 
agglutination  of  external  orifice,  626. 
swelling   and  elongation  of  anterior 

lip,  627. 
abscesses   in  the  lips  of  the  cervix, 

628. 
indurated  and  hypertrophied  cervix  of, 

628 
cancer  of,  neck  of,  629. 
complete  obliteration  of  cervix,  630. 
hernia  of,  637 

rapid  contraction  of,  as  cause  of  he- 
morrhage, 690. 
rupture  of,  747,  920. 
rheumatism  of,  762. 
ifMjia  of,  884. 

spMmodic  contraction  of  internal  ori- 
fice, 886. 
hour-glass  contraction,  886. 
spasmodic  contraction  of  whole  organ, 

889. 
congestions  of,  as  cause  of  secondary 

hemorrhage,  913. 
inversion  of,  916. 
Uterine  congestion,  during  pregnancy,  283. 

as  cause  of  secondary  he- 
morrhage, 913. 
pains  during  pregnancy,  313. 
rheumatism,  ')69. 
obliquity,  631. 
hemorrhage,  675. 
Utero-epichorial  mucous  membrane,  204. 


992 


INDEX. 


Vagina,  49. 

length  of,  50. 

mode  of  attachment  to  uterus,  51. 
congenital  shortening  of,  50. 
structure  of.  51. 
mallbrmationsof,  592. 
inversion  of,  595. 
rupture  of,  760. 
Vaginal  pulse,  127. 

Caesarean  operation,  865. 
Vaginitis,  granular,  291). 
Van  Huevel's  new  pelvimeter,  575. 

saw  forceps,  872. 
Varices,  during  pregnancy,  285. 
Variola,  during  pregnancy,  358. 
Vesicle,  allantoid,  189. 
umbilical,  190. 
ovarian,  69. 
Vertigo,  during  pregnancy,  312. 
Vertex,  presentation,  412. 

causes  of,  413. 
diagnosis  of,  414. 
mechanism  of,  expulsion 

in,  415. 
inclined     or    irregular, 

428,  662. 
prognosis  of,  428. 
inclined  positions  o(,  662. 
Vestibule,  43. 
Version,  769. 

general  considerations  upon,  769, 
cephalic,  772. 
pelvic,  776. 

difficulties  of,  from  mobility  of  body 
of  uterus,  786. 
from  shortness  of  cord, 

786. 
from  volume  of  shoul- 
ders, 786. 


Version,  difficulties  of,  from  crossing  of  arms 
behind  the  neck,  787. 
from  arrest  oi  the  head, 
787. 
appreciation  of,  in  vertex  presenta- 
tions, 790. 
in  face  presentations, 

791. 
in  pelvic    presenta- 
tions, 79J. 
in    trunk    presenta- 
tions, 792. 
Vectis,  of  the,  829. 
Villi,  of  chorion,  203. 
Vomiting,  during  pregnancy,  265. 
treatment  of,  268. 

induction  of  premature  labor  for, 
271. 
Vulva,  39. 

pruritus  of,  during  pregnancy,  313. 
and  vagina,  maltbrmaiions  of,  588. 
contraction  and  rigidity  of,  589. 
Vulvo-vaginal  gland,  46. 

excretory  duct  of,  47. 

organization  of,  48. 

uses  and  functions  of,  48. 


W. 


Weaning,  940. 
Wharton's  gelatine,  209. 
Wolffian  bodies,  213. 

Womb,  and  appendages,  diseases  of,  as  causes 
of  abortion,  333. 

hernia  of  the,  637. 

inertia  of,  884. 

hour  glass  contraction  of,  886. 

irregular  contraction  of  the  body,  8S6. 


I 


THE    END 


f6f^  '3 


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